Colitis Trouble up High: A Case of Gastroduodenal Ulcerative Colitis and Literature Review.

Background and aims: The presence of backwash ileitis, post-colectomy pre-pouch ileitis, or pouchitis has been widely described in the presentation of ulcerative colitis [UC]. However, over the years, a few cases of upper gastrointestinal [UGI] inflammation in patients with UC have been reported, most commonly post-colectomy.  The aim of this review was to conduct an analysis of the current literature to identify the prevalence, risk factors and current treatment of UGI UC.  Methods: Case report and review of the literature. An electronic search of five bibliographic databases [Pubmed, Cochrane, DOAJ, Science Direct, and JSTOR], was conducted. A combination of keywords and medical subject headings [MeSH] related to "small intestine" and "inflammation" or "enteritis" and "colectomy" or "post operative complications" or "ileostomy" or "stoma" and "ulcerative colitis" or "inflammatory bowel disease" were used. Referenced papers not fully available in English text were excluded from the study.  The manuscripts were analysed for age, gender, extent of colonic and UGI disease, timing of UGI presentation, surgical history, treatment and follow-up.

Results: We present the case of a 59-year-old woman with diffuse upper gastrointestinal (UGI) ulcerative colitis (UC) that was refractory to steroid treatment, occurring nine years after a panproctocolectomy for medical treatment failure Upon initiation of an anti-TNFɑ [adalimumab], she achieved remission. We then systematically reviewed the literature to analyse previous reports of patients presenting with UGI UC to understand the prevalence and identify risk factors for developing this condition. To date, 43 cases have been published describing UGI UC with a male to female ratio 5:4 with a mean age of 37.52 years [IQ range 27 years] The majority [85.7%] of these patients were post-colectomy secondary to pancolitis. The mean time post-colectomy for UGI UC to occur is 14 months [range 0-12 years]. The prognosis of these patients were generally good; however, severe complications including haemorrhage, perforation and death have been reported. The inflammatory distribution affected the duodenum [74%] > ileum [57%] > jejunum [31%] > stomach [4%]. The majority of patients with reported changes in the stomach had a pangastritis pattern, with only one case describing isolated antral inflammation. No standardised treatment strategy is available, however, intravenous and oral corticosteroids, 5-aminosalicylates, thiopurines, calcineurin-inhibitors, and TNFα-inhibitors, have been found to be effective in treating UGI UC. Only one other case report reported the successful use of adalimumab to attain remission in UGI UC.

Conclusion: This review sheds light on a rare presentation of UC. This highlights the need for further research into the pathogenesis of UC and treatment strategies for patients presenting with UGI UC. Our case further strengthens the use of anti-TNFɑ, particularly adalimumab for UGI UC and highlights the need for further research into the pathogenesis of inflammatory bowel disease.