Experience in the treatment of severe bleeding in Crohn’s disease with anti-TNF therapy

Czech version

Authors: J. Ulbrych ¹; K. Šlapalová ¹; A. Ondrejková ¹; J. Drábková ²; J. Vaníček ²; Bohuslav Kianička ¹
Authors‘ workplace: II. interní klinika LF MU a FN U sv. Anny v Brně ¹; Klinika zobrazovacích metod LF MU a FN u sv. Anny v Brně ²
Published in: Gastroent Hepatol 2018; 72(3): 251-256
Category:
doi: https://doi.org/10.14735/amgh2018251

Overview

Massive bleeding into the gastrointestinal tract (enterorrhagia) is a rare and life-threatening complication of Crohn’s disease (CD) and occurs in up to 4% of patients. The most common cause of enterorrhagia is a deep ulceration caused by inflammation of a part of the gastrointestinal tract. Risk factors for enterorrhagia have not yet been identified. Determination of the source of the bleeding and the extent of the inflammatory disorder are vital for successful treatment. Based on the results of examinations, a decision on the optimal treatment can be made. In this work, we describe two CD cases who were hospitalized at our workplace in 2016–2017. The first case was a patient who required hospitalization because of CD relapse in the colon area. The patient did not respond to conventional therapy and did not enter remission. Despite treatment, enterorrhagia propagated. The second case was a patient with massive enterorrhagia that appeared as the primary manifestation of CD relapse in the terminal ileum and colon. Conventional therapy did not lead to cessation of bleeding or remission. Instead, enterorhagia propagated. Using these selected case studies, we aim to demonstrate the efficacy of anti-TNF therapy in preventing gastrointestinal bleeding in CD patients. We note that anti-TNF therapy has the advantage of rapid onset in cases where conventional therapy has failed or in cases where other therapeutic methods such as mini-invasive procedures or surgical treatment cannot be used due to the high risk of “short-bowel syndrome”.

Key words: Crohn’s disease – enterorrhagia – anti-TNF – infliximab

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted: 29. 1. 2018

Accepted: 24. 4. 2018

Sources

1. Bortlík M, Ďuricová D, Kohout P et al. Doporučení pro podávání biologické terapie u idiopatických střevních zánětů: třetí, aktualizované vydání. Gastroent Hepatol 2016; 70 (1): 11–26. doi: 10.14735/amgh201611.

2. Podugu A, Tandon K, Castro FJ. Crohn’s disease presenting as acute gastrointestinal hemorrhage. World J Gastroenterol 2016; 22 (16): 4073–4078. doi: 10.3748/wjg.v22.i16.4073.

3. Kim JH, Kim WH, Choi CH et al. A case of Crohn‘s disease with iliac arterio-enteric fistulae. Korean J Gastroenterol 2003; 42 (1): 77–80.

4. Belaiche J, Louis E, D’Haens G et al. Acute lower gastrointestinal bleeding in Crohn’s disease: characteristics of a unique series of 34 patients. Belgian IBD Research Group. Am J Gastroenterol 1999; 94 (8): 2177–2181. doi: 10.1111/j.1572-0241.1999.01291.x.

5. Kim KJ, Han BJ, Yang SK et al. Risk factors and outcome of acute severe lower gastrointestinal bleeding in Crohn’s disease. Dig Liver Dis 2012; 44 (9): 723–728. doi: 10.1016/j.dld.2012.03. 010.

6. Falt P et al. Doporučené postupy České gastroenterologické společnosti ČLS JEP pro diagnostickou a terapeutickou koloskopii. Gastroent Hepatol 2016; 70 (6): 523–538. doi: 10.14735/amgh2016csgh.info19.

7. Yamaguchi T, Manabe N, Hata J et al. The usefulness of transabdominal ultrasound for the diagnosis of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2006; 23 (8): 1267–1272.

8. Olds GD, Cooper GS, Chak A et al. The yield of bleeding scans in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol 2005; 39 (4): 273–277.

9. Fidler JL, Goenka AH, Fleming CJ et al. Small bowel imaging: computed tomography enterography, magnetic resonance enterography, angiography, and nuclear medicine. Gastrointest Endosc Clin N Am 2017; 27 (1): 133–152. doi: 10.1016/j.giec.2016.08.008.

10. Vaníček J, Hruška L, Kianička B. Vyšetření tenkého střeva pomocí magnetické rezonance. Vnitř Lék 2015; 61 (2): 125–128.

11. Tachecí I, Lata J, Rejchrt S et al. Standard ČGS pro kapslovou endoskopii tenkého střeva. Gastroent Hepatol 2011; 65 (4): 195–201.

12. Girona E, Borrás-Blasco J, Conesa-García V et al. Successful treatment of severe gastrointestinal bleeding secondary to Crohn disease with recombinant factor VIIa. South Med J 2007; 100 (6): 601–604. doi: 10.1097/SMJ.0b013e 31804859a4.

13. Bauditz J. Effective treatment of gastrointestinal bleeding with thalidomide – chances and limitations. World J Gastroenterol 2016; 22 (11): 3158–3164. doi: 10.3748/wjg.v22.i11.3158.

14. D‘Haens G, Van Deventer S, Van Hogezand R et al. Endoscopic and histological healing with infliximab anti-tumor necrosis factor antibodies in Crohn‘s disease: a European multicenter trial. Gastroenterology 1999; 116 (5): 1029–1034.

15. Belaiche J, Louis E. Severe lower gastrointestinal bleeding in Crohn‘s disease: successful control with infliximab. Am J Gastroenterol 2002; 97 (12): 3210–3211. doi: 10.1111/j.1572-0241.2002.07143.x

16. Papi C, Gili L, Tarquini M et al. Infliximab for severe recurrent Crohn‘s disease presenting with massive gastrointestinal hemorrhage. J Clin Gastroenterol 2003; 36 (3): 238–241.

17. Tsujikawa T, Nezu R, Andoh A et al. Inflixmab as a possible treatment for the hemorrhagic type of Crohn’s disease. J Gastroenterol 2004; 39 (3): 284–287.

18. Ando Y, Matsushita M, Kawamata S et al. Infliximab for severe gastrointestinal bleeding in Crohn‘s disease. Inflamm Bowel Dis 2009; 15 (3): 483–484. doi: 10.1002/ibd.20635.

19. Meyer MM, Levine EJ. Acute hemorrhagic Crohn’s disease controlled with infliximab. Inflamm Bowel Dis 2009; 15 (10): 1456–1457. doi: 10.1002/ibd.20840.

20. Julián Gómez L, Atienza R, Barrio J et al. Infliximab treatment of severe bleeding complicating Crohn’s disease. Rev Esp Enferm Dig 2010; 102 (1): 57–58.

21. Alcalde Vargas A, Justiniano JM, Carnerero EL et al. Utility of infliximab therapy in severe enterorrhagia associated with Crohn’s disease. Report of three cases. Gastroenterol Hepatol 2011; 34 (1): 24–28. doi: 10.1016/j.gastrohep.2010.09.004.

22. Aniwan S, Eakpongpaisit S, Imraporn B et al. Infliximab stopped severe gastrointestinal bleeding in Crohn’s disease. World J Gastroenterol 2012; 18 (21): 2730–2734. doi: 10.3748/wjg.v18.i21.2730.