S28 Efficacy and Safety of Tofacitinib in Moderate and Severe Ulcerative Colitis in Real Clinical Practice: 3 Years of Observation

Abstract

Case: Hepatic abscesses are a rare extraintestinal manifestation of inflammatory bowel disease (IBD) with only 60 cases reported in the literature, the majority of which being in Crohn's disease (CD) patients. In ulcerative colitis (UC) patients, Streptococcus is the most common pathogen identified in hepatic abscesses followed by Escherichia coli, and Staphylococcus aureus is the most common cultured hepatic abscess aspirate from Crohn's disease patients. In extremely rare cases, however, no pathogen is isolated, and these so-called visceral aseptic hepatic abscesses represent part of the spectrum of neutrophilic disease and an extremely rare manifestation of IBD. Our case illustrates a middle-aged female with Crohn's disease on adalimumab presenting with an aseptic hepatic abscess. A 49-year-old female with a history of longstanding Crohn's disease on adalimumab status-post partial ileal resection, atrial fibrillation on apixaban, chronic obstructive pulmonary disease, lupus, and hypothyroidism presented for 2 days of cramping right hemi-abdominal pain, fever, and vomiting. Her vitals were within normal limits. Labs showed a mild leukocytosis of 11.1 with neutrophilic predominance, an erythrocyte sedimentation rate of 67, and a C-reactive protein of 20.64. The rest of her labs were unremarkable. Computed tomography (CT) of the abdomen/pelvis showed a subcapsular 2.4 x 2.3 x 1.7 cm rim-enhancing abscess within segment 5 of the liver with central and peripheral hypodensity. There was also a short segment of proximal ascending colon wall thickening most consistent with an inflammatory colitis. She was given ceftriaxone and metronidazole in the emergency department. Repeat CT the following day showed an increase in abscess size, now measuring 3.4 x 3.3 x 3.1 cm. The patient was switched to piperacillin-tazobactam per Infectious Disease recommendations due to concerns for hepatic inoculation from Crohn's colitis and underwent an ultrasound-guided placement of a percutaneous drainage catheter into the abscess by Interventional Radiology 2 days later. Fluid cultures were remarkably negative for any organisms. Post-procedure, with continued catheter drainage, the patient reported significant improvement of symptoms. She was discharged along with removal of her catheter on hospital day 14 with instructions to hold her adalimumab until follow-up in clinic. There are only 7 other reports of aseptic abscesses in the literature as the presenting manifestation of Crohn's disease. Multiple theories have been purported regarding the development of hepatic abscesses in IBD patients. One proposes that ulceration and loss of mucosal barrier integrity leads to microbial invasion of the portal venous system with parenchymal seeding. Another suggests that the increased incidence of cholelithiasis and primary sclerosing cholangitis in IBD patients leads to ascending cholangitis and dissemination of bacteria up the biliary tree to seed the liver. Biologics and other immunosuppressives have also been suggested to reactivate chronic inf...