Clinical Case Summary

Introduction: Up to 30% of patients with acute severe ulcerative colitis (ASUC) lack adequate response to intravenous corticosteroid therapy and rescue treatment with infliximab or cyclosporine. Despite rescue therapy, more than 30% of patients with ASUC require surgical intervention. Due to rapid action, tofacitinib may provide additional means for colectomy prevention in patients with ASUC. Rapid tofacitinib effect and clinical improvement may be observed within 3 days.
Case report: A 30-year-old man was presented with ulcerative proctitis endoscopically and histologically in May 2021. The remission is achieved with 5-ASA followed by endoscopic confirmation in May 2022.
In December 2022, the patient suffered another relapse. A colonoscopy revealed an extensive form of ulcerative colitis (Montreal classification E2S3) without clinical response to systemic corticosteroids. Repeated stool test for Clostridium dificile tested positive followed with oral vancomycin addition. Symptoms worsened with 7-8 bloody stools. The disease was classified as severe according to Truelove Witts criteria followed by hospitalization in January 2023. The initial partial Mayo score (pMayo score) was 9. The patient was offered a rescue regimen with inflixmab or tofacitinib. He preferred tofacitinb with corticosteroids, at a dose of 20 mg per day, with regular clinical and laboratory monitoring. On treatment day 3 , the pMayo score decreased to 6, due to less rectal bleeding (RB) Mayo subscore - RBS = 1. The next assessment on treatment day 7 revealed pMayo score 5 (RBS = 1) and stool frequency (SF) Mayo subscore - SFS = 2. The patient was discharged home for further treatment. After 8 weeks of treatment, the pMayo score was 2 with RBS 0 and SFS 1.
Conclusion: Tofacitinib could be considered a promising treatment in patients with steroid-refractory ASUC. Randomized clinical trials are required for further efficacy assesment, safety and optimal dosing tofacitinib in cases of ASUC.

Introduction

Perianal Crohn’s disease (pCD) represents a challenging phenotype of Crohn's disease (CD). While risankizumab (RZB) has demonstrated efficacy in luminal CD, its role in pCD remains unknown. We aimed to evaluate the effectiveness of RZB in pCD and compare the outcomes with other biologics including anti-TNF, ustekinumab (UST), and vedolizumab (VDZ).

Aims & Methods

This retrospective multicenter study performed at nine international centers included adult patients with pCD who initiated RZB as advanced-line (second or more) therapy between 2020 and 2024. Historical controls included pairwise propensity-scored matched pCD patients treated with anti-TNF, UST, or VDZ as second- or third-line therapies. The primary outcome was clinical remission in patients with active pCD, defined as complete resolution of perianal symptoms. Secondary outcomes included clinical response (any symptomatic improvement) in active perianal disease, and relapse rates among patients with inactive pCD at baseline, defined as new or recurrent signs or symptoms of perianal disease.

Results

A total of 214 patients with active pCD were included: 59 (27.6%) received RZB, 62 (29.0%) anti-TNF, 57 (26.6%) UST, and 36 (16.8%) VDZ. Clinical remission was achieved in 58% of patients treated with RZB, compared to 32.9% of those receiving non-RZB therapies (p = 0.01), including 27% for anti-TNF, 44% for UST, and 25% for VDZ. Clinical pCD response rates were 81% for RZB, compared to 71% for anti-TNF, 88% for UST, and 44% for VDZ; p < 0.001. In propensity score–matched comparisons, remission rates with RZB were numerically higher than anti-TNF (56% vs. 31%, p = 0.056) and VDZ (58% vs. 29%, p = 0.08), and comparable to UST (53% vs. 43%, p = 0.5). The median time to clinical response with RZB was three months [IQR: 2–3.5], comparable to anti-TNF (3 [IQR: 2–4], p = 0.4), but significantly shorter than UST (5 [IQR: 4–6], p < 0.001) and VDZ (6.5 [IQR: 4–8], p < 0.001).
Among 160 patients with inactive pCD at baseline, matched analysis showed significantly lower relapse rates with RZB compared to anti-TNF (2% vs. 22%, p = 0.004) and VDZ (0% vs. 28%, p = 0.004), with no significant difference compared to UST (3% vs. 15%, p = 0.2).

Conclusion

Risankizumab demonstrates favorable clinical response, faster time to response, and higher remission rates in active pCD, along with the lowest relapse rates in inactive disease. These results support RZB as an effective therapeutic option for pCD, warranting prospective validation.

Disclosure

No conflicts of interest were declared in relation to this study.

Introduction

In recent years, eosinophilic gastrointestinal disorders (EGIDs) have attracted attention due to an increase in their incidence. Although many reports have focused on eosinophilic esophagitis (EoE), there are relatively few reports of eosinophilic enteritis (EoN), which causes eosinophil infiltration of the small intestine. In addition, although the diagnostic criteria for EGID also specify that the number of eosinophils infiltrating the gastrointestinal tract other than the esophagus should be 20 or more, the small intestine has not been clearly defined. Furthermore, not even normal eosinophils have been clearly defined for the small intestine, it is necessary to establish the clinical features of EoN. using double-balloon Enteroscopy (DBE) to differentiate it from other small intestinal diseases such as IBD and IBS, which cause similar symptoms of EoN. Accordingly, we examined both the extent of eosinophilic infiltration in the small intestine using DBE and the associated clinical background in cases which EoN was suspected.

Aims & Methods

Patients who underwent DBE for examination of the small intestine at our hospital from January 2021 to December 2024 and had a biopsy from the small intestine were included. Biopsies were taken from 1 or more of the duodenum, upper jejunum, lower jejunum, upper ileum, lower ileum, or terminal ileum, and the number of eosinophils per 1HPF was counted. By using a × 40 objective and × 10 oculars the number of eosinophils per high power field (EOS / HPF) in up to two HPFs was counted in each biopsy specimens. Five patients who visited our hospital with abdominal symptoms, were suspected of EoN, and underwent DBE‑guided small‑intestinal biopsy revealing more than 50 eosinophils per high‑power field, after other diseases had been ruled out, were classified into the EoN group. (3 males and 2 females, mean age 58.3 years). The non-EoN group (7 males and 6 females, mean age 48.4 years) consisted of 14 patients who underwent small intestinal biopsy by DBE for other reasons during the study period, and the number of eosinophil infiltration in the small intestinal mucosa and clinical background were compared.

Results

All five patients in the EoN group presented to our hospital with a chief complaint of abdominal pain and diarrhea and four cases showed edema of the small intestine on CT. All five had an elevated peripheral blood eosinophil count (median 13%). In contrast, the non-EoN group showed no increase with a median of 2.4%. In total, 80 small intestine biopsy specimens were obtained from 18 patients using DBE, 25 specimens in the EoN group and 55 specimens in the non-EoN group. The median eosinophil count in the EoN group was 77 (15-213), which was elevated and significantly higher than the 23 (3-111) in the non-EoN group. (P < 0.01)(Table 1)(Figure 1)
Table 1. Characteristics of patients and biopsy specimens

Conclusion

Small intestinal biopsy using DBE may be useful for the diagnosis of EoN, as eosinophil counts are significantly increased in the small intestine in patients with suspected EoN.