2576 Terminal Ileitis: A Rare Gastrointestinal Complication of 5-Fluorouracil Therapy

Abstract

INTRODUCTION: Ileitis is often seen in Crohn's disease and infection. Less often, it is associated with other conditions, including vasculitides, neoplasia, ischemia and medication-related complications. Ileitis typically presents with right lower quadrant abdominal pain and diarrhea; in some cases, it causes a small bowel obstruction (SBO). There are very few case reports of 5-fluorouracil associated ileitis and it is not well-described in literature. CASE DESCRIPTION/METHODS: A 66-year-old male with stage IV gastroesophageal junction adenocarcinoma was started on radiation therapy to the upper esophagus along with continuous infusion of fluorouracil (5FU). On day four of 5-FU, the patient developed severe mucositis causing dysphagia and odynophagia, requiring hospitalization and PEG-tube placement. With initiation of tube feeds, patient developed nausea, vomiting and watery nonbloody diarrhea. CT abdomen/pelvis showed SBO, with thickening of the distal small bowel thickening suggestive of terminal ileitis (Figure 1). Despite cessation of tube feeds, he continued to have diarrhea. C. difficile PCR, enteric pathogen panel, GI pathogen panel, and Yersinia culture were negative. He remained afebrile and without leukocytosis. Colonoscopy revealed inflammation of the terminal ileum characterized by erythema and ulceration (Figure 2). Biopsies of the terminal ileum showed chronic active inflammation (Figure 3). The terminal ileitis was attributed to treatment with 5-FU. With supportive care, the patient's diarrhea resolved and he was discharged home. 5-FU was held and patient received radiation therapy alone. Repeat colonoscopy 2 months later showed endoscopically normal mucosa. Biopsies showed nonspecific chronic inactive ileitis. DISCUSSION: We report a case of diarrhea and SBO associated with terminal ileitis, which was likely related to 5-fluorouracil therapy. Histology showed chronic inflammation with crypt architectural distortion, which are similar to the findings associated with radiation induced enteritis. However, this patient received only radiation therapy to the upper esophagus, none to the abdomen or lower abdomen. Infectious etiologies of ileitis were ruled out, and the ileitis resolved with discontinuation of 5-FU. Terminal ileitis may be an important diagnostic consideration in patients receiving 5-FU. We suggest that colonoscopies performed for diarrhea associated with 5-FU should include intubation into the terminal ileum when possible.