by Hiral Patel, MD, Robert Moylan, MD and Klaus Klaus Mönkemüller, MD, PhD, FASGE, FJGES
Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA
A 70-year-old woman with history of metastatic melanoma on treatment with ipilimumab presented with acute onset abdominal pain and bloody bowel movements.
Figure 1. Immune checkpoint inhibitor induced colitis (“immune mediated colitis”). A. diffuse mucosal edema, loss of light reflex, erythema, granularity. B. Large amount of secretion and pus (“mucopus”). C. “Tubular” colon because of severe inflammation. D. Immune mediated colitis is associated with significant neutrophilic inflammation, hence pus. E. Descending colon stenosis due to massive edema and inflammation. F. IMC is often indistinguishable from inflammatory bowel diseases. G. Typical granularity of mucosa in IMC. NBI views of inflamed crypts (cryptitis, white spots).
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target cancer modulatory cells and immune processes such as cytotoxic T-lymphocyte antigen-4 (ipilimumab), and interaction between PD-1 and the ligands PD-L1 and programmed death ligand 2 (anti–PD-1 agents such as pembrolizumab, nivolumab) (1). Although ICIs have improved the treatment of several malignancies such as melanomas, their severe immune-related adverse events including hepatitis and colitis hamper their use in a significant proportion of patients (1, 2). Indeed, immune-mediated colitis (IMC) can occur in up to 25% (1, 2). On endoscopy, this iatrogenic colitis is very hard to differentiate from classical ulcerative colitis or Crohn’s disease. On histology there is more neutrophilic infiltration without chronic inflammation (1, 2). Therapy consists mainly on reducing or stopping the ICIs. In addition, corticosteroids are recommended for moderate and severe forms of colitis (1-3). Infliximab has also been shown to be beneficial, especially in those patients that do not respond to steroids (1-3. As ICIs are entering practice worldwide it is important to know about immune colitis.
References:
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Som A, Mandaliya R, Alsaadi D, Farshidpour M, Charabaty A, Malhotra N, Mattar MC. Immune checkpoint inhibitor-induced colitis: A comprehensive review. World J Clin Cases. 2019 Feb 26;7(4):405-418. doi: 10.12998/wjcc.v7.i4.405. PMID: 30842952; PMCID: PMC6397821.
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Hashash JG, Francis FF, Farraye FA. Diagnosis and Management of Immune Checkpoint Inhibitor Colitis. Gastroenterol Hepatol (N Y). 2021 Aug;17(8):358-366. PMID: 34602898; PMCID: PMC8475264.
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Dougan M, Wang Y, Rubio-Tapia A, Lim JK. AGA Clinical Practice Update on Diagnosis and Management of Immune Checkpoint Inhibitor Colitis and Hepatitis: Expert Review. Gastroenterology. 2021 Mar;160(4):1384-1393. doi: 10.1053/j.gastro.2020.08.063. Epub 2020 Oct 17. PMID: 33080231.
No COI by HP, RM or KM with any of the companies/utensils or products mentioned in this article.
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