Dense Colon Scarring After Infliximab for Acute Severe Ulcerative Colitis

Introduction: Infliximab is a monoclonal antibody against tumor necrosis factor alpha used in the treatment of ulcerative colitis. It has been shown to be efficacious in patients with moderate to severe ulcerative colitis and/or those who have failed intravenous steroids. We present a unique finding of profoundly dense colonic scarring after a year of infliximab therapy in a patient with acute severe ulcerative colitis. Case: A female in her early 60s presented to the hospital with a three month history of rectal bleeding and intermittent fevers. A colonoscopy was done which demonstrated severe Mayo 3 left-sided colitis, consistent with a diagnosis of acute severe ulcerative colitis. After failing mesalamine and intravenous methylprednisolone, she was started on infliximab resulting in marked symptom improvement. She then had a repeat colonoscopy one year later which showed no active ulcerative colitis with a mayo score 0 but profound scarring correlating to the severe initial ulcerations from the previous year. Discussion: During normal pathogenesis of ulcerative colitis, inflammation and ulceration causes the bowel walls to swell and thicken with scar tissue. After treatment with monoclonal antibodies, the mucosa should normally heal without evidence of scar tissue or fibrosis. Despite being at high risk for colectomy, this patient responded well to infliximab. However, further studies and follow ups are needed to determine if the scar tissue in this patient has long term effects. Research is ongoing on how to prevent fibrosis in inflammatory bowel disease.