Capecitabine-Induced Ileitis

Abstract

Capecitabine is an oral fluoropyrimidine commonly used in the treatment of colon cancer. Diarrhea, nausea, vomiting and hyperbilirubinaemia are the most common gastrointestinal side effects occurring in up to 50% of the patients receiving capecitabine. Ileitis is an extremely rare side effect of capecitabine and so far only few cases have been reported in the literature. All cases were noticed within first two cycles of chemotherapy. We report a case of capecitabine induced ileitis that developed late in the treatment course (after completing 4th cycle of chemotherapy). A 63-year-old Caucasian male was admitted to hospital with severe diarrhea. Patient was diagnosed with stage II colon adenocarcinoma (T3N0M0). Following surgical resection he was initiated on capecitabine as adjuvant chemotherapy, with plans to administer eight 3-week cycles. He completed 4 cycles of capecitabine at a total daily dose of 4000 mg (1000 mg/m2 twice daily on days 1-14 every 21 days). Two days after finishing his 4th cycle, he reported watery diarrhea (up to 8 bowel movements a day) associated with nausea and lightheadedness. Patient denied any fever, abdominal pain, vomiting, melena or hematochezia. Abdominal examination revealed normal active bowel sounds without tenderness. The skin on both palms was erythematous, dry and cracked consistent with capecitabine associated palmar-plantar erythrodysesthesia (hand-and-foot syndrome). Infectious workup for diarrhea was negative. Despite loperamide treatment, diarrhea and abdominal pain persisted. CT scan of abdomen was performed and showed thickening of ileal wall with adjacent fat stranding suggestive of ileitis. Colonoscopy was pursued and revealed diffuse terminal ileum erythema, edema associated with multiple scattered ulcerations. Histopathology showed moderate active ileitis. Fungal and CMV stains were negative. Patient was diagnosed with capecitabine induced ileitis and managed symptomatically with intravenous fluids and anti-emetics. Additional chemotherapy was withheld. One month later, patient reported complete resolution of diarrhea and abdominal pain. Ileitis is an extremely rare side effect of capecitabine and so far only few cases have been reported in the literature. This is the first reported case where ileitis developed after completing 4 cycles of chemotherapy. The timely diagnosis led to discontinuation of additional chemotherapy and prevention of additional toxicity.Figure 1