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P295. Treatment of acute or relapsing massive intestinal bleeding in Crohn's disease with anti-TNFα therapy

E. Archavlis, K. Papamichael, D. Tzivras, A. Smyrnidis, P. Konstantopoulos, G. Agalos, N. Kanellopoulos, I. Drougas, N. Kyriakos, D. Tsironikos, N. Raptis, G.J. Mantzaris

A' Gastroenterology Clinic, Evaggelismos Hospital, Athens, Greece

Background: Patients with Crohn's disease (CD) may develop occasional episodes or even relapses of massive spontaneous intestinal bleeding in the absence of any predisposing factors, such as ingestion of NSAIDs. These episodes may be due to erosions of intestinal vessels by deep penetrating ulcers in association or not with coagulation defects. The anti-TNFα agents infliximab (IFX) and adalimumab (ADA) being effective treatment of active CD and inducing rapid clinical remission and mucosal healing may be effective treatments for patients with relapsing severe intestinal bleeding.

Aim: To evaluate retrospectively the outcome of anti-TNFα treatment for severe relapsing intestinal bleeding in CD.

Methods: Files of patients with CD who were admitted for single or relapsing episodes of spontaneous massive intestinal bleeding between 2000–10 were reviewed. Demographic data, potential predisposing and/or triggering factors for intestinal bleeding, disease location, duration and severity, prior intestinal resections and therapeutic regimens were recorded. Patients who were treated conservatively with anti-TNFα agents were identified and included in the study. Patients on any treatment that could cause intestinal bleeding were excluded.

Results: We identified 7 patients with spontaneous massive intestinal bleeding [5 males, median age 28 (range 23–57) years, median disease duration 4.5 (range 1–12) years]. Five of 7 patients had relapsing episodes of bleeding. Four patients had undergone right hemicolectomy for ileocolonic CD and were on no maintenance therapy (n = 2) or on sub-therapeutic doses of mesalazine. Two patients had colitis and perianal disease despite azathioprine treatment; one patient had ileocolitis and was on mesalazine maintenance treatment. All patients had clinical and serological signs of active disease as judged on admission (Harvey-Bradshaw index >8, elevated WBCs, platelet counts and serum CRP). The median drop in haematocrit was 12 (range 9–15) points and patients received 3.5 (±2.2) units of concentrated RBCs. The focus of bleeding was identified by urgent colonoscopy in 6/7 and was attributed to extensive penetrating ulcers with signs of recent bleeding; these ulcers were both anastomotic and pre-anastomotic in patients with a prior intestinal resection. One patient with ileocolitis underwent urgent angiography which showed the source of bleeding in the distal terminal ileum. Five patients received urgent IFX induction treatment (5 mg/kg, weeks 0, 2, 6) and two patients received ADA (160 mg/80 mg, weeks 0, 2) followed by scheduled maintenance therapy. Bleeding ceased in 3 and did not relapse in any of the patients after a mean 3 (1–9) years. Coagulation defects were not detected. Ileocolonoscopy 26–52 weeks after treatment showed complete or near complete mucosal healing in 6 patients but persisting ulcers in a patient who opted for azathioprine maintenance therapy after 6 months of IFX scheduled treatment.

Conclusion: Anti-TNF treatment may be very effective in patients presenting with a first episode or relapsing massive intestinal bleeding due to active disease and deep/penentrating ulcerations.