Case description

A 28 year old male was diagnosed with moderate-severe colonic and perianal Crohn’s disease and commenced on combination therapy with adalimumab and azathioprine. After six years, the patient developed secondary loss of response, with severe distal colitis and recurrent perianal fistulae and was switched the intravenous infliximab. He was sequentially escalated to 10 mg/kg 4 weekly infusions over two years with resolution of active perianal disease but persistent distal colonic inflammation. He experienced severe bloody diarrhoea, iron deficiency anaemia, raised inflammatory markers and faecal calprotectin persistently greater than 2000. Outpatient colonoscopy was performed and demonstrated moderately active colitis to 35cm. At 35cm from the anus, there was a tight stricture, which could not be traversed with a paediatric colonoscope (Figure 1). Magnetic resonance enterography demonstrated 11 cm of active disease within which there were two strictures measuring 5 cm and 3 cm, extending from the distal descending colon to the sigmoid colon (Figure 2).

The patient was empirically commenced on dose-escalated ustekinumab, four-weekly, due to severity of disease. At two months after induction, he experienced clinical improvement with reduced frequency of stools and reduced per-rectal bleeding By six months, there was normalization of inflammatory markers, haemoglobin and iron stores. A repeat colonoscopy was performed 12 months after commencing ustekinumab. The rectal and sigmoid mucosa was markedly improved, with near complete resolution of inflammation. The previously seen stricture at 35 cm was widely patent and easily traversed with a paediatric colonoscope (Figure 3). This case highlights the efficacy of Ustekinumab in stricturing Crohn’s disease.

Disclosure statement

The authors do not have any disclosures or conflicts of interests.

Author contributions

George Tambakis: Writing of manuscript.

Emily Wright: Review and editing of manuscript.