Colectomy rate in acute severe ulcerative colitis in the infliximab era

Does intramesorectal proctectomy with rectal eversion affect postoperative complications compared to standard total mesorectal excision in patients with ulcerative colitis?

INTRODUCTION

Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal proctectomy with concomitant rectal eversion (IMP/RE) or total mesorectal excision (TME). No data exists comparing the outcomes of the two techniques.

METHODS

All UC patients undergoing J-pouch surgery at a single institution over 10.5 years were included. Postoperative complications with IMP/RE vs. TME were analyzed using univariable and multivariable statistics.

RESULTS

One hundred nineteen of 201 (59 %) patients underwent IMP/RE. Demographic and disease characteristics were similar between groups. On univariable analysis, IMP/RE had fewer total perioperative complications than TME (p = 0.02), but no differences in postoperative length of stay or readmissions. Multivariable regression accounting for patient age, comorbidities, disease severity, preoperative medications, operative technique, and follow-up time (mean 5.5 ± 0.2 years) suggested that both anastomotic leak rate (OR 0.32; p = 0.04) and overall postoperative complications (2.10 ± 0.17 vs. 2.60 ± 0.20; p = 0.05) were lower in the IMP/RE group.

CONCLUSIONS

IMP/RE may be associated with fewer overall postoperative complications compared to TME. However, further studies on functional and long-term outcomes are needed.

Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis

BACKGROUND & AIMS

Subcutaneous golimumab, a fully human monoclonal antibody to tumor necrosis factor-α (TNFα), was evaluated as maintenance therapy in TNFα antagonist-naive adults with moderate-to-severe active ulcerative colitis, despite conventional therapy, who responded to golimumab induction therapy.

METHODS

We performed a phase 3, double-blind trial of patients who completed golimumab induction trials (Program of Ulcerative Colitis Research Studies Utilizing an Investigational Treatment, eg, PURSUIT). Patients who responded to induction therapy with golimumab (n = 464) were assigned randomly to groups given placebo or injections of 50 or 100 mg golimumab every 4 weeks through week 52. Patients who responded to placebo in the induction study continued to receive placebo. Nonresponders in the induction study received 100 mg golimumab. The primary end point was clinical response maintained through week 54; secondary end points included clinical remission and mucosal healing at both weeks 30 and 54.

RESULTS

Clinical response was maintained through week 54 in 47.0% of patients receiving 50 mg golimumab, 49.7% of patients receiving 100 mg golimumab, and 31.2% of patients receiving placebo (P = .010 and P < .001, respectively). At weeks 30 and 54, a higher percentage of patients who received 100 mg golimumab were in clinical remission and had mucosal healing (27.8% and 42.4%) than patients given placebo (15.6% and 26.6%; P = .004 and P = .002, respectively) or 50 mg golimumab (23.2% and 41.7%, respectively). Percentages of serious adverse events were 7.7%, 8.4%, and 14.3% among patients given placebo, 50 mg, or 100 mg golimumab, respectively; percentages of serious infections were 1.9%, 3.2%, and 3.2%, respectively. Among all patients given golimumab in the study, 3 died (from sepsis, tuberculosis, and cardiac failure, all in patients who received 100 mg golimumab) and 4 developed active tuberculosis.

CONCLUSIONS

Golimumab (50 mg or 100 mg) maintained clinical response through week 54 in patients who responded to induction therapy with golimumab and had moderate-to-severe active ulcerative colitis; patients who received 100 mg golimumab had clinical remission and mucosal healing at weeks 30 and 54. Safety was consistent with that reported for other TNFα antagonists and golimumab in other approved indications. ClinicalTrials.gov number: NCT00488631.

Infliximab in patients with severe steroid-refractory ulcerative colitis: Indian experience

INTRODUCTION

The role of infliximab in the treatment of acute severe ulcerative colitis is established. However, all the data available in the literature are from western countries. This is the first report on the use of infliximab in patients with severe steroid-refractory ulcerative colitis from India.

METHODS

Retrospective analysis of 28 patients who had received infliximab therapy for induction of remission, with three doses of 5 mg/kg at 0, 2, and 6 weeks, was performed.

RESULTS

Twenty-four (85.6 %) patients had shown a clinical response by week 8 and, hence, avoided urgent colectomy. In 2 years of follow up, 9/16 (56 %) patients had not required colectomy.

CONCLUSION

Infliximab averted colectomy in a proportion of patients with severe steroid-refractory ulcerative colitis.

The positioning of colectomy in the treatment of ulcerative colitis in the era of biologic therapy

The position of surgery in the treatment of ulcerative colitis (UC) has changed in the era of biologics. Several important questions arise in determining the optimal positioning of surgery in the treatment of UC, which has long been a challenge facing gastroenterologists and surgeons. Surgery is life-saving in some patients and leads to better bowel function and better quality of life in most patients. The benefits of surgery, however, must be weighed against the potential surgical morbidity and compromised functioning that clearly can occur. The introduction of biologic therapy has added further complexity to decisions about medical management, surgery, and the relative timing of these choices. Appropriate medical management of UC may induce and maintain remission and may prevent surgery. However, medical management also carries risks of adverse effects, and recent data suggest that delay of surgery during ineffective medical therapy can increase the chances of negative surgical outcomes. To make individualized timely treatment decisions, early collaboration between gastroenterologists and surgeons is important and more data on predictors of treatment response and positive outcomes are needed. Early identification of patients who would benefit from biologic therapy or surgery is challenging.

Semi-urgent surgery in hospitalized patients with severe ulcerative colitis does not increase overall J-pouch complications

BACKGROUND

Surgeons frequently discourage patients with ulcerative colitis from having surgery in the midst of an acute flare for fear of complications and poor long-term outcomes.

METHODS

Outcomes of patients undergoing urgent versus elective surgery for ulcerative colitis were compared via retrospective review.

RESULTS

Patients undergoing urgent (n = 80) versus elective (n = 99) surgery were younger, were more malnourished, had more severe active disease, and had higher steroid use (P ≤ .05). During surgery, hemodynamic stability was similar, but urgent patients underwent more subtotal colectomies (5.1% vs 29%, P < .0001) and fewer laparoscopic procedures (8.8% vs 18%, P = .07). Multivariate regression suggested that short-term complications were increased with higher body mass index and urgency status (P ≤ .05). Anastomotic leaks and long-term complications were similar between groups. Surgeon inexperience and use of immunomodulators other than infliximab were associated with increased odds of long-term fistula/abscess (odds ratio, 5.56; P = .05] and pouch failure (odds ratio, 13.3; P = .01).

CONCLUSIONS

Surgery in patients with acute ulcerative colitis flares is associated with more short-term complications than elective procedures but does not appear to affect risk for anastomotic leak or long-term complications when performed by an expert.

Infliximab as rescue therapy in hospitalised patients with steroid-refractory acute ulcerative colitis: a long-term follow-up of 211 Swedish patients

BACKGROUND

Rescue therapy with infliximab (IFX) has been proven effective in a steroid-refractory attack of ulcerative colitis (UC). The long-term efficacy is not well described.

AIM

To present a retrospective study of IFX as rescue therapy in UC. Primary end points were colectomy-free survival at 3 and 12 months.

METHODS

In this multicentre study, 211 adult patients hospitalised between 1999 and 2010 received IFX 5 mg/kg as rescue therapy due to a steroid-refractory, moderate-to-severe attack of UC. Exclusion criteria were duration of current flare for >12 weeks, corticosteroid treatment for >8 weeks before hospitalisation, previous IFX therapy or Crohn's disease.

RESULTS

Probability of colectomy-free survival at 3 months was 0.71 (95% CI, 0.64-0.77), at 12 months 0.64 (95% CI, 0.57-0.70), at 3 years 0.59 (95% CI, 0.52-0.66) and at 5 years 0.53 (95% CI, 0.44-0.61). Steroid-free, clinical remission was achieved in 105/211 (50%) and 112/209 (54%) patients at 3 and 12 months respectively. Of 75 colectomies during the first year, 48 (64%) were carried out during the first 14 days, 13 (17%) on days 15-90 and 14 (19%) between 3 and 12 months. There were three (1.4%) deaths during the first 3 months.

CONCLUSIONS

Infliximab is an effective rescue treatment, both short- and long-term, in a steroid-refractory attack of UC. Most IFX failures underwent surgery during the first 14 days, which calls for studies on how to optimise induction treatment with IFX. Serious complications, including mortality, were rare.

Preoperative infliximab therapy does not increase morbidity and mortality after laparoscopic resection for inflammatory bowel disease

BACKGROUND

The impact of infliximab on the postoperative course of patients with IBD is under debate.

OBJECTIVE

The aim of this study was to evaluate the influence of infliximab on perioperative outcomes in patients undergoing elective laparoscopic resection for IBD.

DESIGN

This study is a retrospective analysis of a prospectively collected, institutional review board-approved database. SETTING, PATIENTS, INTERVENTIONS: Patients undergoing laparoscopic resection on preoperative infliximab (infliximab group) were compared with patients who did not receive infliximab (noninfliximab group).

MAIN OUTCOME MEASURES

The short-term and long-term morbidity and mortality rates were assessed.

RESULTS

Elective laparoscopic resection for IBD was performed on 518 patients from January 2004 through June 2011; 142 patients were treated with infliximab preoperatively. Both groups had similar demographics, type and severity of IBD, comorbidities, and type of surgery. A significantly higher number of patients in the infliximab group had been on aggressive medical therapy to control symptoms of IBD during the month preceding surgery, including steroids (73.9 vs 58.8%, p = 0.002) and immunosuppressors (32.4 vs 20.5%, p = 0.006). Operative time and blood loss were similar (p = 0.50 and p = 0.34). Intraoperative complication rate was 2.1% in both groups. No significant differences were observed in terms of the conversion rate to laparotomy (6.3% vs 9.3%, p = 0.36), overall 30-day postoperative morbidity (p = 0.93), or mortality (p = 0.61). The rates of anastomotic leak (2.1% vs 1.3%, p = 0.81), infections (12% vs 11.2%, p = 0.92), and thrombotic complications (3.5% vs 5.6%, p = 0.46) were similar. Subgroup analyses confirmed similar rates of overall, infectious, and thrombotic complications regardless of whether patients had ulcerative colitis or Crohn's disease.

LIMITATIONS

This study is subject to the limitations of a retrospective design.

CONCLUSIONS

Infliximab is not associated with increased rates of postoperative complications after laparoscopic resection.

Health-related quality of life in pediatric ulcerative colitis patients on conventional medical treatment compared to those after restorative proctocolectomy

PURPOSE

Health-related quality of life (HRQL) is not well studied in proctocolectomy patients with pediatric onset of ulcerative colitis (UC). We aimed to (1) compare the HRQL of proctocolectomy patients with those treated with conventional therapy and (2) determine factors that influence HRQL in UC patients < 18 years.

METHODS

Chart review was done on patients diagnosed with pediatric onset of UC (<18) at the Stollery Children's Hospital. HRQL was evaluated in 88 patients using disease- and age-specific questionnaires; IMPACT III (<18) and Inflammatory Bowel Disease Questionnaire (IBDQ; ≥18). Demographics, disease characteristics, disease index (PUCAI), HRQL EuroQoL visual analog scale (EQ-5D/VAS) were collected and analyzed from all patients.

RESULTS

Sixty-five respondents completed the IMPACT III (74 %) and 23 patients completed the IBDQ (26 %). Thirty-three surgical patients (34 %) responded (mean IMPACT III score = 148.9 ± 12.7; mean IBDQ = 171.2 ± 40.1). There was no significant difference in IMPACT III scores of surgical patients vs. medically treated patients (148.9 ± 12.7 vs. 140.6 ± 19.4, p = 0.09). Patients with high IMPACT scores (>143 points) were most likely to be in remission (p = 0.05), they were less likely to be on medication (p < 0.05), have parent/guardian with postsecondary education (p = 0.01), did not suffer from fatigue (p < 0.01), and did not report depression (p < 0.02). The IMPACT correlation with PUCAI (adjusted r (2) = 0.33) and EQ-VAS (adjusted r (2) = 0.45) was strong.

CONCLUSIONS

Surgical patients reported to have a HRQL comparable to or better than the nonsurgical patients. Depression, fatigue, parent/guardian education, and drugs influence HRQL.

Infliximab versus cyclosporine as rescue therapy in acute severe steroid-refractory ulcerative colitis: a systematic review and meta-analysis

PURPOSE

Acute severe colitis affects 25 % of patients with ulcerative colitis (UC). Up to 30-40 % of these patients are resistant to intensive steroid therapy and therefore require rescue therapy to prevent emergent colectomy. Data comparing rescue therapy using infliximab and cyclosporine are limited and equivocal. This study evaluates the outcomes of UC patients receiving infliximab or cyclosporine as rescue therapy in acute severe steroid-refractory exacerbations.

METHODS

Electronic databases (PubMed, EMBASE, and Cochrane database) were searched for studies directly comparing infliximab and cyclosporine in UC, and references of included studies were screened. Two independent reviewers identified relevant studies and extracted data. Meta-analyses were performed using the random effect model. Outcome measures included 3- and 12-month colectomy rates, adverse drug reactions, and postoperative complications.

RESULTS

Six retrospective cohort studies describing 321 patients met the inclusion criteria. The meta-analysis did not show significant differences between infliximab and cyclosporine in the 3-month colectomy rate (odds ratio (OR) = 0.86, 95 % confidence interval (CI) = 0.31-2.41, p = 0.775), in the 12-month colectomy rate (OR = 0.60, 95 % CI = 0.19-1.89, p = 0.381), in adverse drug reactions (OR = 0.76, 95 % CI = 0.34-1.70, p = 0.508), and in postoperative complications (OR = 1.66, 95 % CI = 0.26-10.50, p = 0.591). Funnel plot revealed no publication bias.

CONCLUSIONS

Infliximab and cyclosporine are comparable when used as rescue therapy in acute severe steroid-refractory UC. Randomized trials are required to further evaluate these agents.

Cyclosporine in patients with severe steroid refractory ulcerative colitis in the era of infliximab. Review article

Corticosteroids are the mainstay of therapy for severe ulcerative colitis. However, at least a third of patients fail to respond and face a colectomy. In these, rescue therapy with cyclosporine or infliximab (IFX), aimed at avoiding surgery, has been used in recent years. Of the two options, infliximab is largely preferred in both Sweden and Norway, whereas cyclosporine (CyA) is generally regarded as difficult to use, rather toxic and showing limited long-term efficacy. In light of some new recent data, herein, we provide an update of the literature in the field. It appears that there are theoretical and practical arguments on each side, and as of today, the choice between IFX or CyA for rescue therapy cannot be made on strong evidence. Thus, the best choice of medical rescue therapy will depend on the results of ongoing RCTs as well as future research in the field.

Prolonged preoperative hospitalization correlates with worse outcomes after colectomy for acute fulminant ulcerative colitis

BACKGROUND

Although total abdominal colectomy has long been considered definitive treatment for fulminant ulcerative colitis refractory to medical management, the optimal timing of surgery remains controversial. Early surgical intervention may be beneficial to patients with acute ulcerative colitis. Our goal was to compare outcomes after colectomy for fulminant ulcerative colitis and to identify preoperative factors that are predictive of poor outcome.

METHODS

The charts of 107 patients treated by total abdominal colectomy with ileostomy for fulminant ulcerative colitis between 2004 and 2009 were retrospectively reviewed. Twenty-nine patients sustained a major postoperative complication; 78 patients recovered uneventfully. Perioperative statistics, 30-day readmission/reoperation rates, and perioperative morbidity and mortality were compared using the Student t and Fisher exact tests and χ(2) analysis where appropriate.

RESULTS

White blood cell count at admission was significantly higher among patients who developed postoperative complications, but there were no differences in patient characteristics, other acute illness measures, or disease extent. Univariate analysis revealed that patients who developed postoperative complications underwent colectomy significantly later (3.6 vs 7.4 days; P = .01) than those who recovered uneventfully. Laparoscopic colectomy took significantly longer than open surgery, but did not affect postoperative morbidity. Multivariate analysis revealed duration of preoperative medical treatment to be the only significant predictor of increased risk of postoperative morbidity. Follow-up data revealed that similar percentages of patients in both groups eventually underwent ileal pouch anal anastomosis (IPAA; 68% vs 77%; P = .5).

CONCLUSION

Prolonged duration of preoperative medical treatment correlates with poor postoperative outcomes after total abdominal colectomy for fulminant ulcerative colitis. In addition, sustaining postoperative complications did not prevent patients from eventually undergoing IPAA.

Role of surgery in severe ulcerative colitis in the era of medical rescue therapy

Despite the growing use of medical salvage therapy, colectomy has remained a cornerstone in managing acute severe ulcerative colitis (ASC) both in children and in adults. Colectomy should be regarded as a life saving procedure in ASC, and must be seriously considered in any steroid-refractory patient. However, colectomy is not a cure for the disease but rather the substitution of a large problem with smaller problems, including fecal incontinence, pouchitis, irritable pouch syndrome, cuffitis, anastomotic ulcer and stenosis, missed or de-novo Crohn’s disease and, in young females, reduced fecundity. This notion has led to the widespread practice of offering medical salvage therapy before colectomy in most patients without surgical abdomen or toxic megacolon. Medical salvage therapies which have proved effective in the clinical trial setting include cyclosporine, tacrolimus and infliximab, which seem equally effective in the short term. Validated predictive rules can identify a subset of patients who will eventually fail corticosteroid therapy after only 3-5 d of steroid therapy with an accuracy of 85%-95%. This accuracy is sufficiently high for initiating medical therapy, but usually not colectomy, early in the admission without delaying colectomy if required. This approach has reduced the colectomy rate in ASC from 30%-70% in the past to 10%-20% nowadays, and the mortality rate from over 70% in the 1930s to about 1%. In general, restorative proctocolectomy (ileoanal pouch or ileal pouch-anal anastomosis), especially the J-pouch, is preferred over straight pull-through (ileo-anal) or ileo-rectal anastomosis, which may still be considered in young females concerned about infertility. Colectomy in the acute severe colitis setting, is usually performed in three steps due to the severity of the inflammation, concurrent steroid treatment and the generally reduced clinical condition. The first surgical step involves colectomy and constructing an ileal stoma, the second - constructing the pouch and the third - closing the stoma. This review focuses on the role of surgical treatment in ulcerative colitis in the era of medical rescue therapy.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

Pros and cons of medical management of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease characterized by diffuse mucosal inflammation limited to the colon and rectum. Although a complete medical cure may not be possible, UC can be treated with medications that induce and maintain remission. The medical management of this disease continues to evolve with a goal to avoid colectomy and ultimately alter the natural history of UC. Emergence of antitumor necrosis factor-α (TNF-α) agents has expanded the medical armamentarium. 5-Aminosalicylates continue to be used in mild to moderate UC and corticosteroids are mainly used for induction of remission with immunomodulators (6-mercaptopurine/azathiopurine/methotrexate) being applied as steroid-sparing agents for maintenance therapy. Infliximab has been approved by the U.S. Food and Drug Administration and used in the treatment of moderate to severe UC; nevertheless, its use may be associated with significant adverse effects and have a negative impact on the postoperative course should the patients undergo restorative proctocolectomy. In addition, there is always a concern about patients' compliance to medical therapy, cost of medications, and risk for UC-associated dysplasia. The authors discuss the pros and cons of medications used in the treatment of UC.

Safety and efficacy of Profermin® to induce remission in ulcerative colitis

AIM: To test the efficacy and safety of Profermin^® in inducing remission in patients with active ulcerative colitis (UC).

METHODS: The study included 39 patients with mild to moderate UC defined as a Simple Clinical Colitis Activity Index (SCCAI) > 4 and < 12 (median: 7.5), who were treated open-label with Profermin^® twice daily for 24 wk. Daily SCCAI was reported observer blinded via the Internet.

RESULTS: In an intention to treat (ITT) analysis, the mean reduction in SCCAI score was 56.5%. Of the 39 patients, 24 (62%) reached the primary endpoint, which was proportion of patients with ≥ 50% reduction in SCCAI. Our secondary endpoint, the proportion of patients in remission defined as SCCAI ≤ 2.5, was in ITT analysis reached in 18 of the 39 patients (46%). In a repeated-measure regression analysis, the estimated mean reduction in score was 5.0 points (95% CI: 4.1-5.9, P < 0.001) and the estimated mean time taken to obtain half the reduction in score was 28 d (95% CI: 26-30). There were no serious adverse events (AEs) or withdrawals due to AEs. Profermin^® was generally well tolerated.

CONCLUSION: Profermin^® is safe and may be effective in inducing remission of active UC.

Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements

OBJECTIVES

The objective of this study was to provide updated explicit and relevant consensus statements for clinicians to refer to when managing hospitalized adult patients with acute severe ulcerative colitis (UC).

METHODS

The Canadian Association of Gastroenterology consensus group of 23 voting participants developed a series of recommendation statements that addressed pertinent clinical questions. An iterative voting and feedback process was used to do this in conjunction with systematic literature reviews. These statements were brought to a formal consensus meeting held in Toronto, Ontario (March 2010), when each statement was discussed, reformulated, voted upon, and subsequently revised until group consensus (at least 80% agreement) was obtained. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence.

RESULTS

As a result of the iterative process, consensus was reached on 21 statements addressing four themes (General considerations and nutritional issues, Steroid use and predictors of steroid failure, Cyclosporine and infliximab, and Surgical issues).

CONCLUSIONS

Key recommendations for the treatment of hospitalized patients with severe UC include early escalation to second-line medical therapy with either infliximab or cyclosporine in individuals in whom parenteral steroids have failed after 72 h. These agents should be used in experienced centers where appropriate support is available. Sequential therapy with cyclosporine and infliximab is not recommended. Surgery is an option when first-line steroid therapy fails, and is indicated when second-line medical therapy fails and/or when complications arise during the hospitalization.

Thirty-day mortality after elective and emergency total colectomy in Danish patients with inflammatory bowel disease: a population-based nationwide cohort study

OBJECTIVES

The purpose of this investigation was to assess 30-day mortality among Danish inflammatory bowel diseases (IBD) patients and to examine the prognostic impact of hospital total colectomy volume, age, gender and comorbidity.

DESIGN

Cohort study.

SETTING

The authors compared 30-day survival over the period 1996-2010 among 2889 IBD patients with total colectomy identified in the Danish National Registry of Patients. This registry covers all hospitals in Denmark. Postoperative survival patterns for patients with ulcerative colitis and Crohn's disease were compared, using proportional hazard regression. The regression model accounted for the timing of surgery, hospital total colectomy volume, age, gender and comorbidity.

PARTICIPANTS

Patients were enrolled in the study if they had a hospital registry diagnosis of IBD, with accompanying procedure codes for total colectomy (see codes in online appendix table 1). Hospitalisations were described as elective or emergency, and patients were categorised as having Crohn's disease, ulcerative colitis or as a mixed group.

OUTCOME MEASURES

Primary outcome measure was 30-day mortality.

RESULTS

Among 2889 IBD patients with total colectomy, 1439 (50%) underwent surgery during an emergency hospitalisation. Thirty-day mortality was 5.3% (76/1439) among emergency cases compared with 1% (14/1450) among elective cases. The highest mortality (8.1%; 11 of 136) was observed among Crohn's patients undergoing emergency surgery. The mortality of patients with ulcerative colitis undergoing emergency surgery was 5.2% (55/1056). After elective surgery, the 30-day mortality was 0.9% (8/938) among patients with ulcerative colitis and 1.5% (3/201) among Crohn's disease patients. Low hospital total colectomy volume, comorbidity and high age were associated with increased 30-day mortality in ulcerative colitis patients undergoing emergency surgery.

CONCLUSION

Emergency total colectomy among patients with ulcerative colitis and particularly Crohn's disease is associated with substantial 30-day mortality.

A systematic review and meta-analysis of the effects of infliximab on the rate of colectomy and post-operative complications in patients with inflammatory bowel disease

INTRODUCTION

Use of biological therapies may reduce or delay the surgical procedures in patients with inflammatory bowel disease (IBD). The aim of this meta-analysis and systematic review was to determine the impact of pre-operative infliximab (IFX) use on the rate of surgical interventions in patients with IBD and also the effect of preoperative IFX therapy on post-surgical complications.

MATERIAL AND METHODS

Literature was searched for studies that investigated the efficacy of IFX on the rate of colectomy and post-operative complications/side effects in patients with IBD between 1966 and February 2011.

RESULTS

Twelve articles were included in the meta-analysis. In comparison to control groups, patients who received IFX had a relative risk (RR) of 1.17 (p = 0.65) for the rate of colectomy, odds ratio of 3.34 (p = 0.09) in seven observational studies and RR of 0.74 (p = 0.79) in clinical trials for mortality. Summary RR of hospitalization was 0.61 (p = 0.005). Infections and anastomotic leak, pouch-related complications, sepsis and thrombotic events were more common in the patients under IFX therapy but post-operational hospitalization was lower. The patients with IBD who were under IFX therapy were most of the times refractive to other therapies and their disease was more severe.

CONCLUSIONS

Although IFX does not decrease the rate of colectomy in patients with IBD, it would not increase most of the post-operational side effects in the patients.

Managing chronic disease in Ireland: hospital admission rates and clinical outcomes in a large ulcerative colitis population

BACKGROUND

Health care planning demands a detailed knowledge of the course of chronic diseases in the Irish population. This study describes hospital admission rates, medication use and outcomes in a large cohort of patients with ulcerative colitis attending a tertiary referral centre in Ireland.

METHOD

Four hundred and twenty-four patients who attended during the 18-year period from January 1991 to January 2009 were identified. Baseline demographics, hospital admission, medications required, extent of colitis and date of colectomy were recorded.

RESULTS

More than half (55.4%) of the patients were managed exclusively in an outpatient setting throughout diagnosis and follow-up. Systemic corticosteroids, thiopurines and infliximab were required by 70, 29.5 and 5% of the patients, respectively. Overall 5-year colectomy rate due to failure of medical therapy was 15.8%. Independent predictors of colectomy were hospital admission at first presentation (odds ratio 3.6, p < 0.0001) and pancolitis at diagnosis (odds ratio 2.3, p < 0.01).

CONCLUSIONS

The majority of patients with colitis have an uncomplicated disease course and do not require thiopurines, biologic agents or hospital admission. Principal management at a primary care level may be appropriate in many cases. Colectomy rates at a specialist centre in Ireland compare favourably with international figures.

Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care

BACKGROUND

New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically.

METHODS

A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges.

RESULTS

Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001).

CONCLUSIONS

The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.

A nationwide analysis of changes in severity and outcomes of inflammatory bowel disease hospitalizations

INTRODUCTION

The past decade has seen a change in inflammatory bowel disease (IBD; Crohn's disease (CD) and ulcerative colitis (UC)) treatment, with increasing use of immunomodulators and biologics. The impact of this on IBD hospitalization outcomes is unknown.

METHODS

We identified hospitalizations with a diagnosis of IBD using data from the Nationwide Inpatient Sample, a national US discharge database. We compared the proportion of hospitalizations resulting in surgery in the entire cohort and within each disease severity stratum for the years 1998, 2004, and 2007.

RESULTS

There were an estimated 89,673 hospitalizations for CD in 1998 increasing to 150,593 hospitalizations in 2007. UC hospitalizations increased from 56,911 in 1998 to 86,611 in 2007. This increase was primarily among low or intermediate severity hospitalizations not requiring surgery. For CD, the proportion of bowel surgeries during hospitalization decreased from 17.3% in 1998 to 12.4% in 2007 (p < 0.001) while for UC, the proportion of colectomy decreased from 9.5% in 1998 to 6.2% in 2007 (p < 0.001). For both diagnoses, this reduction was significant in those with a low severity of disease but not with in those with the highest severity stratum.

CONCLUSIONS

There continues to be an increase in the number of hospitalizations in patients with IBD. The numbers of non-elective bowel surgeries among those with the highest severity of disease continues to increase suggesting need for further research into improving outcomes in this cohort at high risk for adverse outcome.

Long-term effects and colectomy rates in ulcerative colitis patients treated with infliximab: a Danish single center experience

OBJECTIVE

Infliximab (IFX) is a well-established treatment for both acute, severe ulcerative colitis (UC) and chronic, refractory UC. However, data on the long-term clinical outcome and colectomy rates after IFX treatment in a routine clinical setting are sparse. The aim of this study was to provide further data on the long-term effect of IFX for acute, severe and chronic, refractory UC in unselected patients treated at a single center.

MATERIAL AND METHODS

A retrospective analysis of all patients (n = 52) treated with IFX for UC before February 2009 was performed. The material comprised 19 patients (37%) with acute, severe UC and 33 patients (63%) with chronic, refractory UC. The primary outcome was colectomy rate; the secondary outcome clinical response.

RESULTS

The overall colectomy rate was 27% (14/52 patients) after a median follow-up of 22 months (range 4-57 months). The colectomy rate was 37% (7/19 patients) in the group with acute, severe UC and 21% (7/33 patients) among those with chronic, refractory UC. In all, 77% of the patients had clinical response to IFX treatment with no difference between the two subgroups. Among those with an initial clinical response, 50% (20/40 patients) had sustained clinical response.

CONCLUSION

IFX is of long-term benefit as rescue treatment in selected patients with acute, severe UC with about two-thirds of the patients avoiding colectomy. The beneficial effect on colectomy rate in chronic, refractory UC seems less convincing although these patients may still achieve a sustained clinical response.

The pattern and outcome of acute severe colitis

BACKGROUND

The prognosis of acute severe ulcerative colitis (ASC) influences therapeutic decisions, but data on prevalence or long-term outcome are few.

METHODS

A systematic review of all patients with UC diagnosed in Oxford was performed to assess the prevalence of ASC defined by Truelove and Witts' (TW) criteria and determine whether outcome is related to disease activity on admission, likelihood of recurrence and long-term prognosis.

RESULTS

750 patients (median follow up 12.7 yr, range 0-648 mo) met inclusion criteria out of a total cohort of 1853 patients. 24.8% (186/750) had at least one admission for ASC (294 admissions in 186 patients). Overall, 12% (93/750) had a colectomy, compared to 39.8% (74/186) of patients with one or more episodes of ASC (p<0.0001) and 3.4% (19/564) in those with no admission. The colectomy rate on first admission (37/186, 19.9%) was lower than on the second or subsequent admissions (OR 2.35, 95% CI 1.33-4.14, p=0.003), being 29.0%, 36.6%, 38.2% after two, three, or subsequent episodes respectively. It was 8.5% (11/129) if patients had one TW criterion in addition to ≥6 bloody bowel motions/day, compared to 31% (29/94) if two additional criteria were present and 48% (34/71) if three or more additional criteria were present (p=1.4 × 10⁻⁵; OR 4.35, 95% CI 2.20-8.56 one criterion vs two or more).

CONCLUSIONS

A quarter of all patients with ulcerative colitis experience at least one episode of ASC; 20% come to colectomy on first admission, but 40% after two admissions. The likelihood of colectomy is related to biological severity on admission.

Clinical trial: colectomy after rescue therapy in ulcerative colitis - 3-year follow-up of the Swedish-Danish controlled infliximab study

BACKGROUND

The long-term efficacy of infliximab as rescue therapy in steroid-refractory ulcerative colitis is not well described.

AIM

To examine the long-term efficacy of infliximab as a rescue therapy through a 3-year follow-up of a previous placebo-controlled trial of infliximab in acute steroid-refractory ulcerative colitis.

METHOD

In the original study, 45 patients were randomized to a single infusion of infliximab 5 mg/kg or placebo, and at 3 months, 7/24 patients given infliximab were operated vs. 14/21 patients given placebo. Three years or later, patients were asked to participate in a clinical follow-up.

RESULTS

Another seven patients underwent colectomy during follow-up: five in the infliximab group and two in the placebo group. After 3 years, a total of 12/24 (50%) patients given infliximab and 16/21 (76%) given placebo (P = 0.012) had a colectomy. None of eight patients in endoscopic remission at 3 months later had a colectomy compared with 7/14 (50%) patients who were not in remission (P=0.02). There was no mortality.

CONCLUSION

The benefit of rescue therapy with infliximab in steroid-refractory acute ulcerative colitis remained after 3 years. The main advantage of infliximab treatment occurred during the first 3 months, whereas subsequent colectomy rates were similar in the two groups. Mucosal healing at 3 months influenced later risk of colectomy.

Simple score to identify colectomy risk in ulcerative colitis hospitalizations

BACKGROUND

Patients hospitalized for ulcerative colitis (UC) are at high risk for colectomy. Despite growing interest in research using administrative data in inflammatory bowel disease, there is no available tool in such research to stratify disease severity or identify patients at high risk for colectomy.

METHODS

Using the Nationwide Inpatient Sample (NIS) 2004, we identified patients hospitalized for UC flare through appropriate ICD-9-CM discharge diagnosis codes (556.x). Our primary outcome of interest was undergoing total colectomy (45.8). Multivariate logistic regression models were constructed to identify independent predictors of colectomy. From this, a cumulative risk score was developed. Hospitalizations were divided into 3 strata (low, intermediate, high) based on the odds of colectomy.

RESULTS

There were a total of 15,142 hospitalizations with a discharge diagnosis of UC included in our study among whom 366 patients underwent total colectomy (2.4%). Anemia (odds ratio [OR] 2.13), requirement for blood transfusion (OR 2.22), malnutrition (OR 4.53), and total parenteral nutrition (OR 4.30) were independent predictors of colectomy as were transfer in from another hospital (OR 2.06) and admission to a teaching hospital (OR 1.73). The cumulative colectomy risk score ranged from 0-8, with significantly higher risk of colectomy in the high-risk stratum (13.7%) compared to the intermediate-risk (4.2%, P < 0.001) and low-risk (1.3%, P < 0.001) strata. The risk score performed well in its discriminative ability with an area under the curve of 0.70.

CONCLUSIONS

We propose a simple and novel risk score to stratify the severity of UC hospitalizations and predict colectomy in this population.

Disease activity, ANCA, and IL23R genotype status determine early response to infliximab in patients with ulcerative colitis

OBJECTIVES

We analyzed the efficacy and safety of the antitumor necrosis factor-alpha antibody infliximab (IFX) for induction therapy in patients with moderate-to-severe ulcerative colitis (UC) in a large single-center cohort.

METHODS

A total of 90 UC patients treated with IFX for 14 weeks were analyzed retrospectively. Colitis activity index (CAI) and markers of inflammation were measured during IFX induction therapy. Genotyping for UC-associated variants in the IL23R gene and in the IL2/IL21 region was performed.

RESULTS

At week 2 (after the first IFX infusion), 64.1% of IFX-treated patients had clinical response to IFX and 52.6% were in remission. At week 14 (after three infusions), 61.0% showed clinical response and 52.5% were in remission. The mean CAI decreased significantly from 10.4 points at week 0 to 5.1 at week 2 (P<0.001), to 4.4 at week 6 (P<0.001), and to 5.0 at week 14 (P<0.001). Similarly, IFX therapy significantly decreased C-reactive protein levels and leukocyte counts (P=0.01 and P=0.001 at week 2 and week 0, respectively). Multivariate regression analysis identified high CAI before IFX therapy (P=0.01) and negative antineutrophil cytoplasmatic autoantibody (ANCA) status (P=0.01) as independent positive predictors for response to IFX. Homozygous carriers of inflammatory bowel disease (IBD) risk-increasing IL23R variants were more likely to respond to IFX than were homozygous carriers of IBD risk-decreasing IL23R variants (74.1 vs. 34.6%; P=0.001). No serious adverse IFX-related events requiring hospitalization were recorded.

CONCLUSIONS

Our findings suggest that IFX therapy is safe and effective in patients with moderate-to-severe UC. A high CAI before IFX therapy, ANCA seronegativity, and the IL23R genotype were predictors of early response to IFX.

Self-reported frequency and severity of disease flares, disease perception, and flare treatments in patients with ulcerative colitis: results of a national internet-based survey

OBJECTIVES

The purpose of this study was to better understand the characteristics and patterns of treatment of flares of ulcerative colitis (UC) from the patient's perspective. A secondary objective was to determine the predictive value of disease characteristics, particularly disease flares, on current use of biologic therapy.

METHODS

Study participants were recruited from an Internet panel of self-identified individuals with inflammatory bowel disease (UC or Crohn's disease). The present analysis was limited to individuals who reported having a diagnosis of UC, were aged >or=18 years, resided in the United States, and could speak and write English. Cross-sectional data (demographic characteristics, insurance coverage, incidence of flares, patient experiences, treatment patterns) were collected via a self-reported Internet-based questionnaire during the third quarter of 2008.

RESULTS

A total of 505 individuals with UC completed the survey (72.7% female; 16.6% non-white; 37.2% college graduates; mean [SD] age, 48.6 [2.8] years). The mean time since the diagnosis of UC was 11.9 (10.1) years, and 76.6% of respondents characterized their disease as controlled. Overall, 27.9% of the sample reported >or=1 flare per week, and an additional 25.1% reported >or=1 flare per month. Most disease flares (76.5%) lasted <or=7 days and were classified as moderate in severity (51.9%). Among those reporting >or=1 flare per week, 30.5% classified their overall disease severity as mild, 56.0% as moderate, and 13.5% as severe. The majority of respondents with >or=1 flare per week currently used 5-aminosalicylic acids (5-ASAs) (41.1%) or corticosteroids (49.6%), whereas 19.1% used immunomodulators and 17.0% used biologics. Disease flares were most commonly treated by increasing the dose of the current medication (60.4%) or adding a corticosteroid to the treatment regimen (34.5%).

CONCLUSIONS

More than half of these individuals with UC reported experiencing disease flares >or=1 time per week or month. The majority reported using 5-ASAs or corticosteroids as maintenance medications and increasing the dose or adding corticosteroids to control flares in the short term.

Impact of hospital institutional volume on postoperative mortality after major emergency colorectal surgery in English National Health Service Trusts, 2001 to 2005

PURPOSE

The aim of this study was to investigate the effects of institutional volume on postoperative mortality in patients undergoing emergency major colorectal surgical procedures in England between 2001 and 2005.

METHODS

All of the emergency excisional colorectal procedures performed between the above dates were included from the Hospital Episode Statistics data set. Institutions were divided into high-, medium-, and low-volume tertiles according to the total major emergency colorectal caseload.

RESULTS

During the study period, 37,094 emergency excisional colorectal procedures were performed in 166 English National Health Service institutions. Overall 30-day postoperative mortality was 15.49%, increasing to 29.18% at 1 year after surgery. Overall 30- and 365-day mortality rates were similar among institutional volume tertiles (P > .05) after adjustment for age, sex, social deprivation, diagnosis, procedure type, and comorbidity score.

CONCLUSION

Hospital Episode Statistics data suggest that institutions with high volumes of emergency colorectal caseload do not demonstrate lower mortality after emergency major excisional colorectal surgery.

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

Preoperative infliximab treatment and postoperative complications after laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis: a case-matched study

BACKGROUND

Infliximab offers promising new therapeutic options for treatment of moderate to severe ulcerative colitis. However, several studies suggest that it increases postoperative complication rates for patients who later require a restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). This study aimed to assess the postoperative course of patients after laparoscopic IPAA, comparing those who had and those who had not received infliximab before surgery.

METHODS

The authors identified patients from their institution's IPAA database, finding 13 patients who had received preoperative infliximab treatment. Using age, gender, and type of procedure (2 or 3 stages) as criteria, they matched these cases with infliximab-naive patients drawn from the same database. The differences in perioperative data between the two groups were analyzed. Complications and their severity were assessed using the Strasberg classification.

RESULTS

No significant difference was found between patients treated with and those treated without infliximab for each variable studied, namely, mean operative time (353 vs. 355 min), complication rate (23 vs. 38%), and mean hospital stay (22 vs. 25 days).

CONCLUSION

The study findings showed no adverse impact from previous infliximab therapy on the laparoscopic IPAA postoperative course.

Treatment of fulminant ulcerative colitis with cyclosporine A

OBJECTIVE. Fulminant ulcerative colitis not responding to high doses of corticosteroids remains a clinical challenge. Intravenous infusion of cyclosporine A (CyA) has shown an excellent short-term response, but its use has been restricted by potential serious adverse events and reports of high short- and long-term colectomy rates. The purpose of this study was to report on the Oslo experience with CyA in fulminant ulcerative colitis. MATERIAL AND METHODS. Between 1993 and 2006, intravenous CyA (5 mg/kg) was administered to 18 patients with fulminant ulcerative colitis. Responders were discharged under a 6 months' course of oral CyA. Patients were prospectively followed at 2, 6, 12 and 24 months after discharge. RESULTS. Fifteen patients (83%) responded to intravenous CyA treatment. On follow-up at 2, 6, 12 and 24 months, the colectomy-free rates were 72%, 67%, 61% and 56%, respectively. After a median follow-up of 60.3 months (range 1.7-146), 8 patients (44%) still had avoided having to undergo a colectomy. All patients had at least one relapse during follow-up. Only one patient had to discontinue CyA owing to adverse events. CONCLUSION. At our institution, CyA treatment of fulminant ulcerative colitis is an effective and safe treatment.

Colectomy rate comparison after treatment of ulcerative colitis with placebo or infliximab

BACKGROUND & AIMS

The efficacy of infliximab for treating patients with ulcerative colitis has been established.

METHODS

The Active Ulcerative Colitis Trial (ACT)-1 and ACT-2 randomized, double-blind, placebo-controlled studies evaluated infliximab induction and maintenance therapy in moderately to severely active ulcerative colitis. Overall, 728 patients received placebo or infliximab (5 or 10 mg/kg) intravenously at weeks 0, 2, and 6, then every 8 weeks through week 46 (ACT-1) or 22 (ACT-2). Colectomy, hospitalization, and surgery/procedure data through 54 weeks after the first infusion were obtained from ACT-1, ACT-2, and associated data sources. In the prespecified analysis, all data were combined to ascertain time to colectomy. Kaplan-Meier product-limit method was used to estimate the cumulative incidence of colectomy, and log-rank test was used to compare the combined infliximab group and placebo.

RESULTS

Eighty-seven percent (630 of 728) of patients had complete colectomy follow-up; 13% (98 of 728) of patients had a median follow-up of 6.2 months. The cumulative incidence of colectomy through 54 weeks was 10% for infliximab and 17% for placebo (P = .02), yielding an absolute risk reduction of 7%. Compared with placebo, fewer ulcerative colitis-related hospitalizations and surgeries/procedures per 100 patient-years of treatment occurred with infliximab therapy: 40 vs 20 (P = .003) and 34 vs 21 (P = .03), respectively. Serious adverse events occurring in infliximab-treated patients included serious infections, tuberculosis, histoplasmosis, listeriosis, and malignancy.

CONCLUSIONS

Patients with moderately to severely active ulcerative colitis treated with infliximab were less likely to undergo colectomy through 54 weeks than those receiving placebo.

Management of acute severe ulcerative colitis

Ulcerative colitis is a chronic relapsing and remitting inflammatory disorder that can generally be managed successfully with maintenance oral medications. However, approximately 15% of patients with ulcerative colitis will develop a severe exacerbation and require hospitalization. While many patients with acute severe ulcerative colitis will respond to a short course of intravenous corticosteroids, up to a third will fail to improve. In these patients with steroid-refractory colitis, the choice is between rescue medical therapy with ciclosporin or infliximab, or surgery. Well-timed rescue medical therapy is generally safe when administered by experienced physicians, and is effective in the majority of cases. Surgery is unavoidable in some cases, but is the treatment of choice in others. While ileal pouch-anal anastomosis offers the prospect of life without a permanent ileostomy, there are issues with its long-term functional outcome.

Lactobacillus plantarum attenuates up-regulation of adhesion molecules expression in IL-10 gene knockout mice with colitis

AIM: To investigate the effect of lactobacillus plantarum (LP) daily intragastric administration on lymphocyte homing and intestinal inflammation in IL-10 gene knockout mice colitis.

METHODS: Both two groups of 10 IL-10 KO mice and two groups of normal background controls were consecutively fed on phosphate buffered saline containing LP 1258 at 10¹² CFU/L, and unmodified phosphate buffered saline, respectively, from 4 to 8 wk. At sacrifice, the bowels were histologically scored under light microscope and observed under transmission electron microscope. Expression of CD3 and intestinal homing-related molecules MAdCAM-1, ICAM-1, α4β7 were detected by reverse-transcription polymerase chain reaction and Western blot.

RESULTS: At 8 wk, 100% of the IL-10 gene-deficient mice showed histological inflammation. CD3, adhesion molecules α4β7, ICAM-1 and MAdCAM-1 had a significantly higher expression of both mRNA and protein levels in KO than WT group (mRNA: t = 39.42, 8.83, 25.53, 45.78, all P < 0.01; CD3, ICAM-1, MAdCAM-1 protein: t = 19.04, 29.57, 12.29, all P < 0.01). After LP treatment, the expression of both mRNA and protein was significantly reduced in KO+LP, compared with KO mice (mRNA: t = 20.34, 4.95, 14.21, 22.31, all P < 0.01; CD3, ICAM-1, MAdCAM-1 protein: t = 6.82, 14.10, 7.03, all P < 0.01). The expression of mRNA was significantly reduced in WT+LP, compared with WT mice (t = 9.33, 10.55, 7.75, 6.69, all P < 0.01), however, protein expression was not significantly reduced.

CONCLUSION: LP can interfere with upregulation of adhesion molecules, attenuating colitis of IL-10 gene knockout mice.