Risk factors and indications for colectomy in ulcerative colitis patients are different according to patient's clinical background

An Update on Current Pharmacotherapeutic Options for the Treatment of Ulcerative Colitis

The main goals of Ulcerative Colitis (UC) treatment are to both induce and maintain the clinical and endoscopic remission of disease, reduce the incidence of complications such as dysplasia and colorectal carcinoma and improve quality of life. Although a curative medical treatment for UC has not yet been found, new therapeutic strategies addressing specific pathogenetic mechanisms of disease are emerging. Notwithstanding these novel therapies, non-biological conventional drugs remain a mainstay of treatment. The aim of this review is to summarize current therapeutic strategies used as treatment for ulcerative colitis and to briefly focus on emerging therapeutic strategies, including novel biologic therapies and small molecules. To date, multiple therapeutic approaches can be adopted in UC and the range of available compounds is constantly increasing. In this era, the realization of well-designed comparative clinical trials, as well as the definition of specific therapeutic models, would be strongly suggested in order to achieve personalized management for UC patients.

Colectomy Incidence Rates in Five-Year Data From the Observational Postmarketing Ulcerative Colitis Study of Originator Infliximab

BACKGROUND

This analysis of the Observational Postmarketing Ulcerative Colitis Study examined incidence rates of colectomy in patients with ulcerative colitis who received originator infliximab (IFX) or conventional therapies (ConvRx) as per their treating physician.

METHODS

Cox proportional hazards models compared time to colectomy for both treatment groups. A secondary analysis examined colectomy incidence rates based on IFX exposure timing (defined by a 90-day window after the last IFX dose date).

RESULTS

Of 2239 patients with data, 1059 enrolled in IFX and 1180 enrolled in ConvRx (including 296 patients who switched to IFX). Patients in the IFX group had more severe disease at baseline vs the ConvRx group (percentage with baseline partial Mayo score 7-9: 46.0% vs 30.5%, respectively). During 5 years of follow-up, 271 patients (12.1% of enrolled patients) had colectomy. Enrollment in the IFX group was associated with a higher risk of colectomy (hazard ratio = 3.12; 95% confidence interval, 2.25-4.34; P < 0.001) compared with enrollment in the ConvRx group. A total of 174 colectomies occurred in the IFX group, but 97 of these colectomies occurred ≥90 days after the last IFX dose date.

CONCLUSIONS

Colectomy was reported at a higher rate in the IFX group than in the ConvRx group, although patients in the IFX group had more severe disease at baseline and most of the colectomies occurred after patients had been off of IFX for ≥90 days.

Twenty-five years of biologicals in IBD: What´s all the hype about?

Twenty-five years ago the field was revolutionized by the introduction of infliximab as the first hybrid anti-TNF-antibody. Subsequently, other humanized anti-TNFs were developed and marketed, followed by antibodies to new targets including integrins (vedolizumab) and interleukin 12/23 (ustekinumab). All these so-called biologicals were shown in registrational trials to induce remission superior to placebo but consistently were effective in only a minority of patients. Even though in most trials only the responders were selected to continue on the respective medication for maintenance, many experienced a secondary loss of response and only a minority of usually <25% of the initial cohort achieved long-term (1 year) remission. In 'real life studies', the outcome was somewhat better, probably due to proper selection of patients and open, mostly retrospective study designs. A clear benefit of biologicals is apparent in otherwise treatment refractory patients, in extraintestinal manifestations and in Crohn´s disease (CD) with fistulizing complications. Biologicals achieve mucosal healing (MH) more often than corticosteroids or thiopurines, and MH is associated with improved prognosis. However, this does not justify escalating treatment until MH is reached since controlled trials proving this point of 'treat to target' are lacking both in ulcerative colitis and CD. Surgical rates have decreased with increasing use of biologicals, but disease progression has not been proven to improve. With the exception of opportunistic infections, serious adverse events are rare. In conclusion, biologicals have changed the scene considerably and expanded our armamentarium, but there is also a marketing hype fostering expectations without evidence.

Rectal Cancer Risk and Survival After Total Colectomy for IBD: A Population-Based Study

BACKGROUND

Patients undergoing total colectomy for IBD may develop cancer in the rectal remnant, but the association is poorly understood.

OBJECTIVES

This study aimed to examine the risk and prognosis of rectal cancer after total colectomy for IBD.

DESIGN

This is a nationwide population-based study.

SETTING

Treatment of the patients took place in Denmark from 1977 to 2013.

PATIENTS

Patients with IBD undergoing total colectomy were included.

MAIN OUTCOME MEASURES

We examined the incidence of rectal cancer among patients with IBD and total colectomy and compared cancer stage to that of other patients with rectal cancer in Denmark. We used Kaplan-Meier methodology to estimate survival and Cox regression to estimate adjusted mortality rate ratios following a rectal cancer diagnosis, comparing patients with and without IBD and a rectal remnant.

RESULTS

We identified 4703 patients with IBD (1026 Crohn's disease; 3677 ulcerative colitis) who underwent total colectomy with a rectal remnant. During 29,725 years of follow-up, 30 rectal cancers were observed, compared with 8 rectal cancers expected (standardized incidence ratio = 3.6 (95% CI, 2.4-5.1)). Cancer stage distributions were similar. Risk of rectal cancer 35 years after total colectomy was 1.9% (95% CI, 1.1%-2.9%). Five years after rectal cancer diagnosis, survival was 28% (95% CI, 12%-47%) and 38% (95% CI, 37%-38%) for patients with and without IBD and a rectal remnant. The adjusted mortality rate ratio 1 to 5 years after a rectal cancer diagnosis was 2.5 (95% CI, 1.6-3.9). Median time from last recorded nondiagnostic proctoscopy to rectal cancer diagnosis for patients with IBD and total colectomy was 1.1 years.

LIMITATIONS

This study was limited by the few outcomes and the use of administrative and not clinical data.

CONCLUSION

Long-term risk of rectal cancer following total colectomy for IBD was low. Survival following a diagnosis of rectal cancer was poorer for patients with IBD and total colectomy than for patients who had rectal cancer without IBD and total colectomy. Endoscopic surveillance, as it appeared to be practiced in this cohort, may be inadequate. See Video Abstract at http://links.lww.com/DCR/B497. RIESGO DE CÁNCER DE RECTO Y SUPERVIVENCIA DESPUÉS DE UNA COLECTOMÍA TOTAL POR ENFERMEDAD INFLAMATORIA INTESTINAL: UN ESTUDIO POBLACIONAL: Los pacientes sometidos a colectomía total por enfermedad inflamatoria intestinal (EII) pueden desarrollar cáncer en el remanente rectal, pero la asociación es poco conocida.Examinar el riesgo y el pronóstico del cáncer de recto después de una colectomía total para la EII.Estudio poblacional a nivel nacional.Dinamarca 1977-2013.Pacientes con EII sometidos a colectomía total.Examinamos la incidencia de cáncer de recto entre pacientes con EII y colectomía total y comparamos el estadio del cáncer con el de otros pacientes con cáncer de recto en Dinamarca. Utilizamos la metodología de Kaplan-Meier para estimar la supervivencia y la regresión de Cox para estimar las tasas de mortalidad ajustadas (aMRR) después de un diagnóstico de cáncer de recto, comparando pacientes con y sin EII y un remanente rectal.Identificamos 4.703 pacientes con EII (1.026 enfermedad de Crohn; 3.677 colitis ulcerosa) que se sometieron a colectomía total con remanente rectal. Durante 29,725 años de seguimiento, se observaron 30 cánceres de recto, en comparación con los 8 esperados [razón de incidencia estandarizada (SIR) = 3.6, (intervalo de confianza (IC) del 95%: 2.4-5.1)]. Las distribuciones de las etapas del cáncer fueron similares. El riesgo de cáncer de recto 35 años después de la colectomía total fue del 1,9% (IC del 95%: 1,1% -2,9%). Cinco años después del diagnóstico de cáncer de recto, la supervivencia fue del 28% (IC del 95%: 12% -47%) y del 38% (IC del 95%: 37% -38%) para los pacientes con y sin EII y un remanente rectal, respectivamente. La aMRR 1-5 años después de un diagnóstico de cáncer de recto fue de 2,5 (IC del 95%: 1,6-3,9). La mediana de tiempo desde la última proctoscopia no diagnóstica registrada hasta el diagnóstico de cáncer de recto en pacientes con EII y colectomía total fue de 1,1 años.Pocos resultados, uso de datos administrativos y no clínicos.El riesgo a largo plazo de cáncer de recto después de una colectomía total para la EII fue bajo. La supervivencia después de un diagnóstico de cáncer de recto fue más pobre para los pacientes con EII y colectomía total que para los pacientes con cáncer de recto sin EII y colectomía total. La vigilancia endoscópica, como parecía practicarse en esta cohorte, puede ser inadecuada. Consulte Video Resumen en http://links.lww.com/DCR/B497. (Traducción-Dr. Adrian Ortega).

Low serum albumin at admission is a predictor of early colectomy in patients with moderate to severe ulcerative colitis

Background and Aim

Several studies have identified postinduction therapy predictors of long‐term outcomes of ulcerative colitis (UC) in patients who experienced the first attack of the disease or relapsed after therapy. We aimed to identify the preinduction therapy predictors at admission that predicted early colectomy in patients with moderate to severe UC.

Methods

Ninety‐five patients with moderate to severe UC who underwent induction therapy at the Kyoto Prefectural University of Medicine hospital between August 2008 and March 2020 were retrospectively included and categorized into two groups: the colectomy group (n = 27) and the noncolectomy group (n = 68). The clinical parameters (age, gender, disease extent, and disease activity on admission), induction therapies administered [including 5‐aminosalicylic acid, steroids, immunomodulators, calcineurin inhibitor, and anti‐Tumor Necrosis Factor (TNF)‐α antibodies], and laboratory data (hemoglobin, albumin, C‐reactive protein, and cytomegalovirus reactivation on admission) were evaluated and compared between the two groups. Multivariate logistic regression analyses were performed to identify significant predictors of early colectomy, and P < 0.05 was considered significant.

Results

All clinical parameters were not significant predictors of colectomy. Among laboratory parameters, the serum albumin level on admission was a significant independent predictor of colectomy (odds ratio: 6.097, 95% confidence interval: 1.8310–20.3047). Receiver operating characteristic curves were plotted for the serum albumin levels of the 95 patients at admission. The cut‐off value of serum albumin was 2.45 g/dL.

Conclusions

When the serum albumin level of UC patients at admission is below 2.45 g/dL, we should consider presenting the option of surgical treatment to patients.

Early Intervention in Ulcerative Colitis: Ready for Prime Time?

Growing evidence shows that ulcerative colitis (UC) is a progressive disease similar to Crohn’s disease (CD). The UC-related burden is often underestimated by physicians and a standard step-up therapeutic approach is preferred. However, in many patients with UC the disease activity is not adequately controlled by current management, leading to poor long-term prognosis. Data from both randomized controlled trials and real-world studies support early intervention in CD in order to prevent disease progression and irreversible bowel damage. Similarly, an early disease intervention during the so-called “window of opportunity” could lead to better outcomes in UC. Here, we summarize the literature evidence on early intervention in patients with UC, highlighting strengths and limitations of this approach.

Analysis of Outcomes by Extraction Site following Subtotal Colectomy in Ulcerative Colitis: A Retrospective Cohort Study

BACKGROUND

Ulcerative colitis frequently requires surgery as a definitive management strategy. The colonic specimen can be extracted from various sites including a midline incision, the stoma site, or a Pfannenstiel incision. It is unclear if one extraction site offers improved outcomes and fewer complications.

METHODS

A retrospective review of charts obtained of colorectal surgery patients was conducted for all patients with ulcerative colitis who underwent a subtotal colectomy between 2008 and 2016 at a single tertiary care institution. Demographic data and outcomes data including parastomal and incisional hernias, advanced wound/ostomy certified nurse referrals, surgical site infections, reoperations, and readmissions were collected. Univariate and multivariate analyses were completed to detect any significant differences in outcomes between groups based on extraction site (midline incision, stoma site, or Pfannenstiel incision).

RESULTS

Univariate analysis did not show any statistical differences between groups in regard to outcomes. Stoma site extraction did not statistically differ from midline extraction in regard to hernias, advanced ostomy referrals, infections, or reoperations, but midline incision extraction did have a lower risk of readmission (OR = 0.56, p = 0.0066). Pfannenstiel extraction had lower risk of incisional hernias (OR = 0.25, p = 0.0002), advanced ostomy referrals (OR = 0.45, p = 0.0164) and readmission (OR = 0.26, p < 0.0001) as compared to stoma site extraction.

CONCLUSIONS

While stoma site extraction can be successfully performed for most patients requiring subtotal colectomy for ulcerative colitis, Pfannenstiel extraction leads to the fewest number of complications and provides the most consistent results.

The Role of Early Biologic Therapy in Inflammatory Bowel Disease

The goals for treatment of inflammatory bowel diseases (IBDs) are changing from elimination of symptoms toward complete disease control-a process that demands both clinical and endoscopic remission. This new IBD treatment paradigm has been shifting from a conventional "step-up" approach toward a more "top-down" early intervention treatment strategy. Recent studies suggest that the use of biologic agents, specifically those targeting tumor necrosis factor alpha, earlier in the treatment course improves patient outcomes and can prevent progression to irreversible bowel damage. Although the strategy of early intervention has accumulating evidence in Crohn's disease, there is less evidence supporting its impact in ulcerative colitis.

Baseline risk assessment of patients with ulcerative colitis: does initial treatment selection influence outcomes?

BACKGROUND AND AIMS

Treatment of ulcerative colitis (UC) typically follows a step-up approach and targets colonic mucosal healing. Although mucosal healing reduces the risk of colectomy, whether or not early treatment of patients with 'high-risk' features using tumor necrosis factor (TNF) antagonists reduces the risk of colectomy is not clear. Accordingly, we aim to evaluate the effect of baseline treatment selection according to the risk profile on 5-year outcomes and identify predictors of poor outcomes.

PATIENTS AND METHODS

Adult patients with confirmed UC were retrospectively identified. Baseline clinical and endoscopic data were collected. Patients were assigned a risk profile on the basis of the presence or absence of 'high-risk' features within the first 6 months of diagnosis including moderate to severe endoscopic disease, frequent need for steroids, steroid dependency, and disease involving the entire colon according to endoscopy. Treatment discordance was defined as treating 'high-risk' patients with medications other than anti-TNF therapy during the first 6 months after diagnosis or treating 'low-risk' patients with anti-TNF therapy within 6 months of diagnosis. The associations between discordance and 5-year colectomy and hospitalization rates were statistically calculated through regression analysis, as were predictors of outcomes.

RESULTS

A total of 108 patients were identified and studied. The median age was 36 years (interquartile range=27-50) and the average duration of disease was 6.6 (±3.1) years. Females comprised 62% of the cohort and 30% reported cigarette smoking. Seventy three percent of the patients were placed in the 'high-risk' category. The 5-year risk of colectomy was not statistically significantly higher in patients identified as 'high-risk' compared with those who were 'low-risk' (risk ratio=0.86, 95% confidence interval=0.24-3.1, P=0.81), nor was the 5-year risk of hospitalizations (risk ratio=1.63, 95% confidence interval=0.81-3.30, P=0.15). On the basis of stepwise model selection, colectomy was significantly predicted by discordance (P=0.039), arthritis (P=0.007), baseline stool frequency (P=0.019), Adalimumab use within the first 6 months of diagnosis (P=0.006), and pyoderma gangrenosum (P=0.049); hospitalization was predicted by discordance (P=0.018), baseline albumin concentrations (P=0.005), thromboembolism (P<0.005), thiopurine use within the first 6 months of diagnosis (P<0.005), Adalimumab use within the first 6 months of diagnosis (P=0.003), nationality (P=0.016), endoscopic severity (P=0.007), arthritis (P=0.005), and pyoderma gangrenosum (P=0.025).

CONCLUSION

Among other clinical parameters, discordance between baseline risk and treatment selection appears to be a significant predictor of outcomes in UC.

Treat to Target in Inflammatory Bowel Disease: An Updated Review of Literature

OPINION STATEMENT

Therapeutic management of patients with inflammatory bowel diseases (IBDs) has, for years, been tailored towards monitoring patient clinical presentation as a way to gauge therapeutic management. With the advent of newer biological agents, treatment and management have begun to focus on more objective rather than subjective parameters. These objective parameters include endoscopic targets and focus on the impact of mucosal healing, radiologic and histologic targets, patient reported outcomes, and use of non-invasive biomarkers. However, a recent consensus statement has identified clinical/patient-reported outcome (PRO) remission and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1) as the target for UC with histological remission being an adjunctive goal. For CD, clinical/PRO remission defined as resolution of abdominal pain and diarrhea/altered bowel habit and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, and resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy were the primary targets. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. This approach requires continuous monitoring and therapeutic adjustments with an aim to achieve the target. This article attempts to review the most updated literature regarding the treat to target approach and thus provides current recommendations and supported evidence.

Expert consensus paper on the use of Vedolizumab for the management of patients with moderate-to-severe Inflammatory Bowel Disease

Crohn's Disease (CD) and Ulcerative Colitis (UC) are chronic, relapsing conditions resulting from uncontrolled inflammation of the intestinal mucosa. Both conditions are associated with significant disability and patients with CD face higher mortality rates compared to the general population. The increasing understanding of the immunological basis of the disease led to the introduction of biologic therapies targeting key pathways of the natural and adaptive immune response such as Tumor Necrosis Factor α (TNF-α) inhibitors and, more recently, integrin-receptor antagonists. Treatment with TNF-α inhibitors improved clinical and patient-reported outcomes for many patients who did not benefit from conventional therapy. However, a sizeable share of patients still face suboptimal outcomes due to primary or secondary therapy failure. With the introduction of VDZ, a biologic treatment targeting novel IBD-relevant biologic pathways, it is crucial to understand how to integrate such innovations into current clinical practice. To this end, a panel of 14 Italian experts in the management of IBD met for a roundtable discussion. Recommendations concerning the management of moderate-to-severe IBD based on experts' opinions and literature review are discussed in the present report.

New Trends in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory disease of the gastrointestinal (GI) tract. In the past decade a shift in the treatment paradigm of IBD has ensued. The availability of drugs capable of inducing mucosal healing, combined with the recognition that IBD is not an intermittent disease, but rather a progressive one causing bowel damage and disability, led us to a more stringent strategy. Tailored therapy with more aggressive treatment in high-risk patients, treating beyond symptoms, intervening early before damage occurs, optimizing therapeutic regimens, and actively pursuing sustained remission and sustained control of inflammation are strategies that are slowly being incorporated in our clinical practice. Furthermore, new drugs targeting different immunological pathways, such as vedolizumab, have recently been approved and therefore more therapeutic resources for patients failing anti-tumour necrosis factor alpha (anti-TNFα) agents will be available. The future years look promising for IBD. Hopefully the new trends in IBD management, combined with new drugs, will make possible to change the course of disease and provide better therapy and quality of life for patients suffering from this disabling disease.

Factors associated with poor outcomes in adults with newly diagnosed ulcerative colitis

It is a challenge to accurately identify patients with early stage ulcerative colitis (UC) who are at highest risk for a poor outcome and therefore might require salvage therapy. Several epidemiologic and clinical studies have analyzed factors associated with poor prognosis and increased risk for colectomy. We review prognostic factors for adults with newly diagnosed UC and discuss which patients might benefit from rapid and progressive therapy. Patients with poor prognoses tend to be young nonsmokers with high levels of inflammatory biomarkers, low levels of hemoglobin, and extensive disease, based on colonoscopy. We examine these risk factors in 2 hypothetical patients who have been newly diagnosed with UC.

Clinical predictors of colectomy in patients with ulcerative colitis: systematic review and meta-analysis of cohort studies

INTRODUCTION

Colectomy is a major event that may significantly affect the outcome of ulcerative colitis (UC) in terms of both quality of life and mortality. This paper aims to identify clinical prognostic factors that may be significantly associated with this event.

METHODS

PubMed, ISI Web of Knowledge and Scopus were searched to identify studies investigating the association between clinical factors in adult patients with UC and studied events.The clinical factors evaluated in this meta-analysis were gender, smoking habits, disease extent,use of corticosteroids, and episodes of hospitalization.

RESULTS

Of the 3753 initially selected papers, 20 were included. The analysis showed a significantly lower risk of colectomy for female patients (odds ratio [OR] 0.78 [95% CI 0.68, 0.90]) and for smoking patients (OR 0.55 [0.33, 0.91]), and a higher risk for patients with extensive disease (OR 3.68 [2.39,5.69]), for patients who took corticosteroids at least once (OR 2.10 [1.05, 4.22]), and for patients who were hospitalized (OR 4.13 [3.23, 5.27]).

CONCLUSION

Gender, smoking habits, disease extent, need for corticosteroids, and hospitalization were all significantly associated with UC prognosis. These results may clarify the relative influences of these and other prognostic factors in the natural course of the disease and therefore help improve the management approach, thus improving the follow-up of patients.

Management of acute, severe ulcerative colitis

When a patient is hospitalized with acute, severe ulcerative colitis, the primary decision is whether or not to proceed directly to surgery. Absolute indications for an immediate colectomy include exsanguinating hemorrhage, perforation and cancer. If medical therapy is undertaken, however, the decision for urgent surgery or non-operative salvage therapy will still be required in 15-50% of the patients in which there is a failure to respond within 3-5 days to a standard regimen of i.v. steroids, antibiotics, decompressive maneuvers, fluid and electrolyte replacement and other supportive measures. The options for medical salvage therapy are usually cyclosporine or infliximab. There are theoretical and practical arguments on each side; the current GETAID and CONSTRUCT trials will probably provide support for either. The choice between colectomy or medical salvage therapy, however, must not be delayed under any circumstances. Before choosing salvage therapy, one must first be certain that there is the luxury of time, that there is a post-hospital strategy for the maintenance of remission and that the colon is worth saving. The priority is not so much saving colons as it is saving lives.

Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis

BACKGROUND & AIMS

It is uncertain whether mucosal healing after the first course of corticosteroids therapy predicts outcome in patients with ulcerative colitis (UC). We evaluated whether early clinical and endoscopic responses to this therapy are associated with late outcomes in UC.

METHODS

Patients with newly diagnosed UC who were prescribed corticosteroid therapy (n = 157) were followed up for 5 years. They were evaluated using clinical (Powel-Tuck [PT]) and endoscopic (Baron) indexes after 3 and 6 months, then every 6 months. Outcomes at month 3 (early response) were used to identify patients with complete (group A: PT, 0-1; Baron, 0), partial (group B: PT, 0-1; Baron, 1-3), or no response (group C: persistence of clinical and endoscopic activity). The association between early and late outcomes was assessed.

RESULTS

After 5 years, there were significant differences between complete and partial responders in the rates of hospitalization (25% in group A vs 48.7% in group B; P = .0152; odds ratio [OR], 2.85; 95% confidence interval [CI], 1.21-6.72), immunosuppression therapy (5% in group A vs 25.6% in group B; P = .0030; OR, 6.55; 95% CI, 1.67-25.67), colectomy (3.3% in group A vs 18.0% in group B; P = .0265; OR, 6.34; 95% CI, 1.24-32.37), and their combination (26.7% in group A vs 48.7% in group B; P = .0249; OR, 2.61; 95% CI, 1.12-6.11). After multivariate analysis, lack of mucosal healing was the only factor associated with negative outcomes at 5 years (immunosuppressors: hazard risk [HR], 10.581; 95% CI, 2.193-51.039; P = .0033; hospitalization: HR, 3.634; 95% CI, 1.556-8.485; P = .0029; colectomy: HR, 8.397; 95% CI, 1.278-55.186; P = .0268).

CONCLUSIONS

No mucosal healing after corticosteroid therapy is associated with a more aggressive disease course.

Impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis

BACKGROUND

The effect of narcotic use in the disease course of ulcerative colitis has not been studied. The aim of the study was to evaluate the impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis.

METHODS

All eligible patients with ulcerative colitis admitted to gastroenterology service for disease flare-ups between 2002 and 2008 were included. Excluded were patients with ulcerative colitis admitted to the colorectal surgery service for emergent or elective colectomy and patients with Crohn's disease. Demographic, clinical, and laboratory data were reviewed. The definition of narcotics use was oral or intravenous administration of the agents during hospital admission or at hospital transfer. Multivariable analysis was performed.

RESULTS

A total of 223 patients were included. One hundred six patients were males. The mean age was 38.7 +/- 18.1 years. Forty-four patients (19.7%) were on oral or intravenous narcotics during the hospitalization. Sixty-seven patients (30%) had colectomy during the hospitalization and the colectomy rate was similar between narcotic user and nonnarcotic users (29.5% vs 30.2%, P = .9). In multivariable analysis, only the serum albumin level remained in the model as an independent risk factor associated with colectomy (OR = 0.4; 95% CI, 0.2-0.9; P = .03). Narcotic use was not an independent risk factor for colectomy in this study (P = .5).

CONCLUSION

Narcotics were commonly prescribed to patients with ulcerative colitis who were admitted to the gastroenterology service. However, narcotic use appeared not to have a significant negative impact on the colectomy rate in inpatients with ulcerative colitis. In contrast, the low albumin level at flare was associated with an increased risk for colectomy.

The prevalence and clinical significance of perinuclear anti-neutrophil cytoplasmic antibody in Korean patients with ulcerative colitis

Perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is a serological marker associated with various immune-mediated diseases whose clinical significance and possible diagnostic roles in ulcerative colitis (UC) are still unclear. We aimed to evaluate the prevalence of pANCA expression and its association with clinical findings and disease course in Korean patients with UC. This study included 484 patients with UC who were diagnosed and treated between 1990 and 2006 at Severance Hospital, Yonsei University, Seoul, Korea, and were followed for at least 1 year. Clinical findings at diagnosis, disease extent, treatment modalities used, and cumulative relapse rates were analyzed and compared to pANCA expression. Of the 484 patients, 405 (83.7%) were evaluated for pANCA and were eligible for analysis. The overall pANCA prevalence was 22.1%, with a female preponderance (male, 21.5%; female, 31.6%; P < 0.05). Proctitis was more common in pANCA-negative patients (pANCA-negative, 37.6%; pANCA-positive, 25.2%, P < 0.05). UC activity index and cumulative relapse rates were higher in pANCA-positive patients. However, there were no significant differences in the cumulative probability of steroid and immunosuppressant use and operation rate between the two groups. The prevalence of pANCA expression in Korean patients with UC was relatively low compared to that in Western countries. Although UC patients with pANCA expression had more severe clinical findings at diagnosis and higher cumulative relapse rates in our study, further prospective studies are warranted to clarify whether pANCA positivity influences the initial clinical presentation or disease aggressiveness.

Laparoscopic surgery for inflammatory bowel disease: does weight matter?

BACKGROUND

Recent studies have shown improved outcomes after laparoscopic colorectal surgery compared with laparotomy for surgery for both benign and malignant colorectal diseases, including inflammatory bowel disease (IBD). This study was designed to evaluate the results of laparoscopic colorectal resections in normal weight patients compared with overweight and obese patients with IBD.

METHODS

A retrospective analysis of a prospectively acquired institutional review board-approved surgical database was performed. All consecutive patients with IBD who underwent laparoscopy from January 1, 2000 to April 30, 2008 were reviewed. BMI, age, gender, comorbidities, ASA classification, and surgical- and disease-related variables, including 60-day postoperative complications, were reviewed. Chi-square, Mann-Whitney U test, and Student's t test were used for statistical analysis.

RESULTS

A total of 261 patients with IBD underwent laparoscopy: 48 were excluded and 213 were analyzed. Group I comprised 127 normal-weight patients (body mass index (BMI), 18.5-24.9 kg/m(2)), and group II included 67 overweight patients (BMI, 25-29.9 kg/m(2)) and 19 obese patients (BMI >or= 30 kg/m(2)). Crohn's disease was diagnosed in 86 (67.7%) patients in group I and 52 (60.4%) in group II. Procedures performed included ileocolic resection in 56% of patients in each group. Total colectomy with or without proctectomy was undertaken in 39.4% in group I and 40.7% in group II. The conversion rate was 18% for group I and 22.09% for group II (p > 0.005; not significant). The most common reason for conversion was failure to progress due to adhesions or phlegmon. There were no differences in major postoperative complication rates (wound infection, abscess, anastomotic leakage, or small-bowel obstruction) or mean hospital stay (6.7, 6.8, respectively), and there was no mortality.

CONCLUSIONS

Patients with IBD who were overweight or obese and who underwent laparoscopic bowel resection had no significant differences in the rates of conversion, major postoperative complications, or length of stay when comparing to patients with normal BMI. Therefore, the benefits of laparoscopic bowel resection should not be denied to overweight or obese patients based strictly on their BMI.

Severity of inflammation as a predictor of colectomy in patients with chronic ulcerative colitis

PURPOSE

We evaluated a large cohort of patients with longstanding ulcerative colitis in a colonoscopic surveillance program to determine predictors of colectomy.

METHODS

We queried a retrospective database of patients who had symptoms of ulcerative colitis for seven years or more. Histologic inflammation in biopsies was graded on a validated four-point scale: absent, mild, moderate, severe. We performed a multivariate analysis of the inflammation scores and other variables to determine predictive factors for colectomy. Patients who underwent colectomy for neoplasia were censored at the time of surgery; those who did not undergo colectomy were censored at the time of last contact.

RESULTS

A total of 561 patients were evaluated, with a median follow-up of 21.4 years since disease onset. A total of 97 patients (17.3 percent) underwent surgery; 25 (4.5 percent) for reasons other than dysplasia. These 25 constitute events for this analysis. For univariate analysis, mean inflammation (P < 0.001) and steroid use (P = 0.01) were predictors of colectomy. For multivariable proportional hazards analysis, mean inflammation (P < 0.001) and steroid use (P = 0.03) were predictors of colectomy, whereas salicylate use (P = 0.007) was protective.

CONCLUSIONS

Higher median inflammation scores and corticosteroid use were predictors of colectomy in this patient population. The overall rate of colectomy during a long period of follow-up was low (<1 percent per year).

Predictive factors associated with immunosuppressive agent use in ulcerative colitis: a case-control study

BACKGROUND

Some patients with ulcerative colitis (UC) require immunosuppressants as maintenance therapy.

AIM

To assess epidemiological, clinical and disease factors at diagnosis that predict immunosuppressant use in UC.

METHODS

All UC patients diagnosed between 1992 and 2005 and currently managed in the inflammatory bowel disease (IBD) clinic were included. Forty-three patients who currently or previously received azathioprine (AZA) or mercaptopurine (MP) for UC were compared with 130 controls. Charts were reviewed and logistic regression analyses were applied to identify factors associated with AZA or MP use.

RESULTS

In univariate model, seven factors at diagnosis correlated with AZA use: male gender [odds ratio (OR) 2.2]; left-sided or extensive colitis or pancolitis (OR 8.7-14.1); systemic steroid use within the first 6 months of diagnosis (OR 5.1); more than 10 bowel movements daily (OR 6.4); persistent or mostly blood in stool (OR 2.8); endoscopic proven moderate to severe disease (OR 7.2-12.0) and requirement of hospitalization (OR 2.7) on diagnosis. In multivariate model, the first three factors were shown to be statistically significant.

CONCLUSION

Male gender, initial presentation with severe and extensive disease clinically and endoscopically, requirement of hospitalization on diagnosis or systemic steroids within 6 months of diagnosis are predictive factors for immunosuppressant use in UC.

Clinical factors that impair health-related quality of life in ulcerative colitis patients vary with the disease duration

BACKGROUND AND AIM

The health-related quality of life (HRQOL) of patients with ulcerative colitis (UC) can be impaired because of the chronic symptoms. Although UC patients suffer from such symptoms over the long term, there have been few reports on the changes of HRQOL with disease duration. The aim of this study was to clarify these changes.

METHODS

The HRQOL of 331 Japanese UC patients was examined using the validated Japanese version of the Inflammatory Bowel Disease Questionnaire (J-IBDQ). HRQOL and factors affecting HRQOL identified using multiple linear regression analysis were stratified by disease duration.

RESULTS

Of the 15 clinical factors examined, the clinical activity index score was the strongest determinant (P<0.0001) of all the scores of IBDQ regardless of disease duration. HRQOL did not differ significantly among patients with different disease durations. The factors, however, that affected HRQOL varied according to disease duration. In patients with disease duration of less than 5 years, the clinical activity index score was the predominant factor affecting HRQOL. Being 'on sick leave or hospitalized' was a significant factor impairing HRQOL in patients with disease duration of 5-9 years. Moreover, complications due to corticosteroids significantly impaired all of the IBDQ scores in patients with disease duration of 10 years or more.

CONCLUSION

Factors that affected the HRQOL of UC patients varied according to the patients' disease duration. Our findings should assist in the development of a long-term strategy for the treatment of UC patients.