Clinical Challenge: From Ulcerative Colitis to Crohn’s Disease-Like Pouch Inflammation

Abstract

A 30-year-old man with a history of medically refractory ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) for which he underwent three-stage total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) was evaluated for complaints of frequency, urgency of bowel movements, abdominal pain, and joint pain. He was originally diagnosed with UC in the setting of tenesmus and diarrhea. Since infliximab, adalimumab, and vedolizumab were trialed in succession without significant improvement, he ultimately underwent TPC three years after diagnosis at the Mount Sinai Hospital. Before proceeding to IPAA, colectomy pathology was confirmed to be consistent with extensive UC and ‘backwash’ ileitis, with no features of Crohn’s disease (CD). Approximately one year after IPAA, he developed recurrent episodes of acute pouchitis with symptoms of frequency (> 15 bowel movements per day including > 3 overnight), urgency, abdominal pain, and joint pain (knees and elbows). Though symptoms initially resolved with several two-week courses of ciprofloxacin and metronidazole, they became refractory to antibiotics over the course of six months. Pouchoscopy was notable for patchy erythema with scattered aphthous ulcerations involving 20 cm of the distal afferent limb (Fig. 1a) and diffuse erythema with large ulcerations, friability, and complete loss of vascular pattern in the pouch body (Fig. 1b). There was no evidence of stricture, fistulae, or cuffitis. Biopsies of the afferent limb and pouch body revealed severely active chronic ileitis with erosion. Given the extensive involvement of the afferent limb and the antibiotic-refractory nature of the pouchitis, he was diagnosed with Crohn’s disease-like pouch inflammation (CDLPI). After discussion with the patient, the decision was made to proceed with ustekinumab induction.