Capecitabine-Associated Ileocolitis Diagnosed on Colonoscopy

Abstract

Capecitabine is considered a first line agent in adjuvant therapy for colorectal cancer. One of its adverse effects however is that it can commonly be associated with GI side-effects such as diarrhea. When the diarrhea is severe and prolonged, capecitabine associated enterocolitis should be strongly considered in the differential. Herein, we present a rare case of capecitabine enterocolitis, specifically involving the distal ileum and ascending colon, demonstrating the role of colonoscopy in diagnosis. Additionally, this case is meant to demonstrate the disease course and provide our experience in treating this rare condition. We present a 72-year-old female with stage IIIC ascending colon adenocarcinoma who underwent laparoscopic right hemicolectomy started on adjuvant chemotherapy with capecitabine. She was initiated on capecitabine monotherapy for a planned 6 months, however after one month of tolerating the medication, she developed severe, prolonged, and painless diarrhea ultimately lasting 4 weeks. Infectious and ischemic workup was negative. Her initial CT abdomen and pelvis was significant for mildly dilated fluid-filled loops of small bowel with adjacent engorgement of vasa recta and mesenteric edema concerning for enteritis. This was followed up with colonoscopy with ileoscopy finding evidence of granular erythematous mucosa with ulceration both above and below the ileocolonic anastomosis in the distal ileum and ascending colon. Ileal biopsy showed mucosal erosion with acute and chronic inflammation and occasional atypical gland. Our treatment approach with anti-motility agents, cholestyramine, octreotide and oral steroids were largely ineffective in treating the diarrhea. The patient ultimately required TPN to address the patient's severe protein deficiency and malnutrition secondary to the ileocolitis.1570_A Figure 1. A. Axial CT of the abdomen demonstration vasa recta engorgement and mesenteric edema. B. Coronal CT of the abdomen with “comb sign” demonstrating vasa recta engorgement and mesenteric edema1570_B Figure 2. Colonoscopy showing granular erythematous mucosa of the ascending colon (2A and 2B) distal to the ileocolonic anastamosis. Ileoscopy reveals evidence of ulceration in the distal ileum (2C and 2D)To date, there have only been 8 cases published that describe Capecitabine associated enterocolitis, and only 2 of these cases documented colonoscopic evidence revealing ulceration of the ileum. Our case will be the 3rd case which utilized colonoscopic and pathologic evidence of ileal ulceration. In all the published cases, approach to management posed a significant challenge. It appears that a trial of cessation of Capecitabine, fluid and nutritional resuscitation with TPN have shown some benefit. With all cases it appears that capecitabine enterocolitis requires time to ultimately resolve itself.