Duodenal Crohn’s disease successfully treated with adalimumab

Table of Contents

Upper gastrointestinal involvement in Crohn’s disease is considered to be relatively infrequent (0.4 – 3 %) [1], and treatment mainly relies on the use of high doses of proton pump inhibitors, mesalazine (mesalamine), and steroids [2].

A 37-year-old woman was admitted for observation in November 2009 because of diarrhea, epigastric pain, iron-deficiency anemia, and weight loss (6 kg in 2 months). Gastroscopy found large ulcers in the second portion of the duodenum, with reduction of duodenal folds ([Fig. 1]). The result of histological examination of the specimens was compatible with active Crohn’s disease ([Fig. 2]), and computed tomography excluded any other gastrointestinal localization. The patient started treatment with azathioprine 2.5 mg/kg per day, pantoprazole 80 mg/day, and adalimumab (160 mg at week 0 and 80 mg at week 2 to induce remission, followed by maintenance treatment with 40 mg every 2 weeks). She responded immediately to the therapy, with immediate epigastric pain relief. Her weight recovered within 4 months, and all laboratory tests became normal within 3 months. At the first endoscopic follow-up (February 2010) we noted complete healing of the large ulcers and restoration of histology, which persisted until the last follow-up (August 2010) ([Fig. 3]). At the present date the patient is still taking pantoprazole 40 mg/day and adalimumab 40 mg every 2 weeks (azathioprine was discontinued after 6 months), and is in complete remission.

Fig. 1 Endoscopic appearance of the second portion of the duodenum before treatment, showing thickening of some duodenal folds which converge to a large ulcer with thickened margins and spontaneous bleeding.

Fig. 2 Histological specimen (hematoxylin & eosin, × 40). A marked transmucosal inflammatory infiltrate is visible, also involving the submucosal layer. A large noncaseous granuloma can be also seen in the middle of the picture, under the epithelial layer.

Fig. 3 Endoscopic appearance of the second portion of the duodenum, 6 months later, showing complete disappearance of the lesions and a normal appearance of the duodenal folds.

Anti-TNFα therapy has hitherto been regarded only as an alternative therapy for severe or refractory disease [2] [3] [4]. This is the first case report describing successful treatment of adult primary duodenal Crohn’s disease with adalimumab. The case is also interesting because we used adalimumab as the first therapeutic strategy on appearance of the disease. This “top-down” approach resulted in more rapid remission than the conventional “step-up” treatment, with a faster reduction in clinical symptoms, rapid decline in laboratory inflammatory markers, and rapid endoscopic mucosal healing without the use of steroids [5].

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AC

Competing interests: None

References

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