VIDEO CAPSULE ENDOSCOPY DIAGNOSIS OF OXALIPLATIN-INDUCED ENTERITIS IN A PATIENT WITH X-RAY NEGATIVE CROHNʼS DISEASE

Abstract

Advanced colorectal cancer (CRC) is commonly treated with fluorouracil, leukovorin and oxaliplatin (FOLFOX), but the effects in patients with Inflammatory Bowel Disease (IBD) are unknown. The treatment of IBD-associated CRC does not differ from sporadic cancers, yet Crohn's disease (CD) may present particular challenges to diagnosis and therapy. We present a case of small bowel series (SBS)-negative FOLFOX-induced enteritis, diagnosed by video capsule endoscopy (VCE). MS is a 30 year old man with longstanding perianal and ileocecal CD since age 8. He underwent an ileocolic resection in 2000 for stricturing ileitis with an ileocecal fistula. Preoperative colonoscopy showed only cecal CD. One year later, after a normal SBS, his prophylactic 6MP was discontinued. In 9/03, he presented with a new sensation of fleeting buttock pain. Colonoscopy revealed a friable rectal malignancy, and he underwent an abdominoperineal resection. Pathology revealed a moderately differentiated anorectal adenocarcinoma with 12 out of 12 lymph nodes involved and focal extra-nodal extension (Stage IIIc). He received external beam radiation therapy to the pelvis. Prior to receiving FOLFOX, a baseline SBS showed no evidence of CD. After chemotherapy, he developed melena with a hemoglobin of 5.4 g/dL. Colonoscopy showed mild ileitis. VCE showed an active enteritis with bleeding, edematous folds, and scattered erosions and ulcerations. Mesalamine (Pentasa) and budesonide (Entocort) were started, and his chemotherapy was suspended. The risk of developing CRC in patients with long-standing CD with more than 1/3 colonic involvement is similar to patients with ulcerative colitis. FOLFOX has not been reported to cause either gastrointestinal hemorrhage or exacerbation of IBD. In light of the diffuse hemorrhagic jejunoileitis and recent normal SBS, it is likely that this patient's GI hemorrhage is due to chemotherapy-induced enteritis rather than a CD flare. Conclusion: Patients with CD may be more likely to develop FOLFOX-induced eneritis. More than 2/3 of suspected of small bowel CD, undetected by conventional SBS, is correctly diagnosed by VCE. Patients with SBS-negative CD may warrant VCE to detect subclinical CD prior to initiation of oxaliplatin combination chemotherapy. In select VCE-positive CD patients, mesalamine and budesonide prevention therapy may be recommended prior to initiation of FOLFOX chemotherapy for IBD-associated CRC.