Prevalence of primary sclerosing cholangitis and other liver diseases in Japanese patients with chronic ulcerative colitis

Butyrate Treatment of DSS-Induced Ulcerative Colitis Affects the Hepatic Drug Metabolism in Mice

The development of inflammatory bowel disease (IBD) is associated with alterations in the gut microbiota. There is currently no universal treatment for this disease, thus emphasizing the importance of developing innovative therapeutic approaches. Gut microbiome-derived metabolite butyrate with its well-known anti-inflammatory effect in the gut is a promising candidate. Due to increased intestinal permeability during IBD, butyrate may also reach the liver and influence liver physiology, including hepatic drug metabolism. To get an insight into this reason, the aim of this study was set to clarify not only the protective effects of the sodium butyrate (SB) administration on colonic inflammation but also the effects of SB on hepatic drug metabolism in experimental colitis induced by dextran sodium sulfate (DSS) in mice. It has been shown here that the butyrate pre-treatment can alleviate gut inflammation and reduce the leakiness of colonic epithelium by restoration of the assembly of tight-junction protein Zonula occludens-1 (ZO-1) in mice with DSS-induced colitis. In this article, butyrate along with inflammation has also been shown to affect the expression and enzyme activity of selected cytochromes P450 (CYPs) in the liver of mice. In this respect, CYP3A enzymes may be very sensitive to gut microbiome-targeted interventions, as significant changes in CYP3A expression and activity in response to DSS-induced colitis and/or butyrate treatment have also been observed. With regard to medications used in IBD and microbiota-targeted therapeutic approaches, it is important to deepen our knowledge of the effect of gut inflammation, and therapeutic interventions were followed concerning the ability of the organism to metabolize drugs. This gut–liver axis, mediated through inflammation as well as microbiome-derived metabolites, may affect the response to IBD therapy.

Prevalence of Primary Sclerosing Cholangitis in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Although the association between inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is well recognized, uncertainties remain about the magnitude of this problem. We conducted a systematic review and meta-analysis assessing prevalence of PSC in IBD to investigate whether type of IBD, how presence of PSC was defined, sex, disease extent or location, time period, or geographic location influenced prevalence.

METHODS

Medline, Embase, and Embase Classic were searched (from inception to April 10, 2021) to identify observational studies recruiting ≥50 adult patients with IBD and reporting prevalence of PSC. Data were extracted, and pooled prevalence, odds ratios (ORs), and 95% confidence intervals (CIs) calculated.

RESULTS

Of 1204 citations, 64 studies were eligible, containing 776,700 patients. Overall, pooled prevalence of PSC in IBD was 2.16%; it was highest in South America and lowest in Southeast Asia. Pooled prevalences in patients with ulcerative colitis (UC), Crohn's disease (CD), and IBD-unclassified were 2.47%, 0.96%, and 5.01%, respectively. Pooled prevalence was significantly higher in UC versus CD (OR 1.69, 95% CI 1.24-2.29). In subgroup analyses according to method used to define presence of PSC, the highest prevalence was 2.88% in studies performing both liver biochemistry and endoscopic retrograde/magnetic resonance cholangiopancreatography and the lowest was 1.79% in studies using a clinical diagnosis. Prevalence was generally higher in men, patients with more extensive, compared with left-side, UC or ileocolonic or colonic, compared with ileal, CD.

CONCLUSIONS

Our findings provide the first pooled estimates of the burden of PSC in IBD, as well as potential risk factors, which may be important in establishing a prompt diagnosis and initiating appropriate surveillance for relevant gastrointestinal malignancies.

Risk factors and clinical courses of concomitant primary sclerosing cholangitis and ulcerative colitis: a Korean multicenter study

BACKGROUND

Primary sclerosing cholangitis (PSC) is a rare progressive cholestatic liver disease of unknown causes, but is strongly associated with inflammatory bowel diseases (IBDs), particularly ulcerative colitis (UC). However, studies comparing risk factors and clinical courses of patients with concomitant UC and PSC with those of patients with PSC alone are lacking.

METHODS

We retrospectively reviewed patients with PSC diagnosed between 2005 and 2017 in four tertiary hospitals in Korea. We compared the risk factors and outcomes of concomitant UC and PSC (UC-PSC) and those of PSC alone.

RESULTS

PSC was diagnosed in 50 patients in four different tertiary hospitals in Korea. Of them, 18 patients (36.0%) had UC-PSC and 32 patients (64.0%) had PSC alone. The median age at PSC diagnosis was younger in the UC-PSC group than that in the PSC alone group (37 vs. 54 years, P = 0.002). In multivariate analysis, older age at PSC diagnosis (P = 0.007; odds ratio [OR], 0.884; 95% confidence interval [CI], 0.808-0.966) and current smoking habit (P = 0.033; OR, 0.026; 95% CI, 0.001-0.748) were determined to be independent factors for reducing the possibility of developing concomitant UC after PSC. Additionally, UC-PSC was shown to be an independent risk factor for the development of colorectal dysplasia (P = 0.044; OR, 10.829; 95% CI, 1.065-110.127).

CONCLUSIONS

Our analysis showed that UC-PSC is more likely to be negatively associated with current smoking and older age at the time of PSC diagnosis. Moreover, UC-PSC increased the risk of colorectal dysplasia.

The Natural History of Newly Diagnosed Ulcerative Colitis in Patients with Concomitant Primary Sclerosing Cholangitis

BACKGROUND AND AIMS

Primary sclerosing cholangitis (PSC) is commonly associated with ulcerative colitis (UC). Our aim was to compare the course of disease in patients with UC-PSC and UC alone in a nationwide cohort.

METHODS

We conducted a retrospective cohort study among nation-wide Veterans Affairs (VA) patients newly diagnosed with UC to determine the association between PSC status and clinical outcomes related to UC disease course. This study was divided into 2 groups of patients: (1) The incident UC-PSC group and (2) the incident UC-alone group. Follow-up began at the time of index colonoscopy that diagnosed UC and ended at the first occurrence of the respective outcome for the regression analysis of the following censoring events: (1) colectomy, (2) death, (3) end of follow-up, and (4 lost to follow-up.

RESULTS

The analysis included 836 UC patients without PSC and 74 UC-PSC patients. In univariate comparisons, PSC patients were more likely to have more extensive UC than those without PSC. In a multivariable Cox regression analysis adjusting for sex, age at UC diagnosis, race, severity of UC, and extent of UC, PSC status was not associated with the risk of colectomy for UC, increased risk of receiving ≥ 2 courses of steroids for UC, or with the risk of receiving immunomodulators for UC.

CONCLUSION

UC-PSC patients do not have a more benign disease course than UC patients without PSC. UC-PSC patients may have a modestly increased risk for multiple courses of steroids, which may be mediated by more extensive colonic involvement.

Predicting outcomes to optimize disease management in inflammatory bowel disease in Japan: their differences and similarities to Western countries

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disease of the gastrointestinal tract, with increasing prevalence worldwide. IBD Ahead is an international educational program that aims to explore questions commonly raised by clinicians about various areas of IBD care and to consolidate available published evidence and expert opinion into a consensus for the optimization of IBD management. Given differences in the epidemiology, clinical and genetic characteristics, management, and prognosis of IBD between patients in Japan and the rest of the world, this statement was formulated as the result of literature reviews and discussions among Japanese experts as part of the IBD Ahead program to consolidate statements of factors for disease prognosis in IBD. Evidence levels were assigned to summary statements in the following categories: disease progression in CD and UC; surgery, hospitalization, intestinal failure, and permanent stoma in CD; acute severe UC; colectomy in UC; and colorectal carcinoma and dysplasia in IBD. The goal is that this statement can aid in the optimization of the treatment strategy for Japanese patients with IBD and help identify high-risk patients that require early intervention, to provide a better long-term prognosis in these patients.

Risk factors for developing colorectal cancer in Japanese patients with ulcerative colitis: a retrospective observational study-CAPITAL (Cohort and Practice for IBD total management in Kyoto-Shiga Links) study I

Background and Aims

Patients with ulcerative colitis (UC) are at risk for developing colorectal cancer (CRC), despite the development of new therapeutic agents. Stratification of the individual UC-patient's risk would be helpful to validate the risk factors for CRC. The aim of this study was to evaluate the risk factors for the development of CRC in a large cohort of patients with UC.

Methods

Data were obtained from 12 hospitals in the Kyoto-Shiga region during 2003–2013. We performed a retrospective cohort study of 2137 patients with UC.

Results

In total, 60 lesions of CRC were detected in 43 (2.0%) of 2137 patients. 30 of the 43 patients were male. The median age was 53 years. The median duration of disease was 13 years, and 67.4% of these patients had a disease duration >10 years. Of the 43 patients, 34 (79.1%) had extensive colitis. Primary sclerosing cholangitis was detected in 2 patients (4.7%). The median corticosteroids (CS) dose was 6.4 g, and 4 patients were treated with a total of more than 10 g of CS. 18 of these patients underwent more than 1 year CS treatment. Of all 60 CRC lesions, 43 (71.7%) were located in the distal colon and 35 (58.3%) were of the superficial type. Moreover, the stage of CRC was stage 0 or I in 55.8% of the 43 patients with CRC. Multivariate analysis suggested that extensive colitis could be a risk factor for the development of advanced CRC in patients with UC.

Conclusions

Our findings indicated that male, extensive colitis, long-term duration of UC and family history of CRC, but not concomitant primary sclerosing cholangitis, are important factors for predicting CRC in Japanese patients with UC. Moreover, long-standing extensive colitis might contribute to the progression of CRC. Further studies are required to establish CRC surveillance in Japanese patients with UC.

Systematic review: The epidemiology of the hepatobiliary manifestations in patients with inflammatory bowel disease

BACKGROUND

Extraintestinal manifestations are frequent in inflammatory bowel diseases (IBD). Most studies published so far focused on viral hepatitis and liver toxicity of IBD-related drugs.

AIM

To conduct a systematic review of hepatobiliary manifestations associated with IBD. We excluded viral hepatitis and liver toxicity of IBD-related drugs.

METHODS

Studies were identified through the electronic database of MEDLINE, EMBASE and the annual meetings of Digestive Disease Week, the American College of Gastroenterology, the United European Gastroenterology Week and the European Crohn's and Colitis Organization.

RESULTS

One hundred and forty six articles were included in this systematic review. Cholelithiasis is more frequent in Crohn's disease (CD) than in general population. Prevalence of cholelithiasis in CD ranged from 11% to 34%, whereas it ranges from 5.5% to 15% in non-IBD patients. PSC is more frequent in UC than in CD. Prevalence of PSC ranges from 0.76% to 5.4% in UC and from 1.2% to 3.4% in CD. There is a male predominance when PSC is associated with UC, with a male/female ratio ranging from 65/35 to 70/30. No conclusion can be made on a possible increased risk of gall-bladder carcinoma. Mean prevalence of fatty liver is 23% (range, 1.5-55%). Hepatic amyloidosis occurs in less than 1% of IBD. Liver abscess is encountered mainly in CD. Portal vein thrombosis occurs in 39% to 45% of IBD patients undergoing proctocolectomy.

CONCLUSIONS

Hepatobiliary manifestations associated with inflammatory bowel diseases are frequent and probably underdiagnosed.

Hepatic early inflammation induces downregulation of hepatic cytochrome P450 expression and metabolic activity in the dextran sulfate sodium-induced murine colitis

Ulcerative colitis (UC) patients may have increased concentrations of drugs in their blood. We hypothesized that this response is mainly due to a decrease in the expression and activity of the drug-metabolizing enzyme, cytochrome P450 (CYP), in the liver. In this study, we have tried to demonstrate the hypothesis. UC was induced in mice by treatment with dextran sulfate sodium (DSS) solution. The mRNA and protein expression levels of CYP, inflammatory cytokine levels, and the metabolic activity of CYP3A in the liver were measured. The nuclear translocations of nuclear factor kappa B (NF-κB), pregnane X receptor (PXR), and constitutive androstane receptor (CAR) were analyzed. The levels of hepatic inflammatory cytokines increased in the DSS-treated group. The hepatic mRNA and protein expression of CYP (CYP1A, CYP2C, CYP2D, CYP2E, and CYP3A) and the CYP3A metabolic activity significantly decreased compared to the control group. Hepatic NF-κB nuclear translocation significantly increased in the DSS-treated group. In contrast, the nuclear translocations of PXR and CAR were decreased. Lipopolysaccharides from inflammatory sites in the colon induce hepatic inflammation in DSS-induced murine colitis. This inflammation then causes an increase in the nuclear translocation of hepatic NF-κB and a decrease in the nuclear translocation of PXR and CAR, resulting in the decreased expression and activities of CYP. The results of this study indicated that at the onset of UC, the decreased activity of hepatic CYP causes an increase in the concentrations of drugs in the blood, leading to an increase in the incidence of adverse reactions.

Role of the intestinal microbiome in liver disease

The liver integrates metabolic outcomes with nutrient intake while preventing harmful signals derived from the gut to spread throughout the body. Direct blood influx from the gastrointestinal tract through the portal vein makes the liver a critical firewall equipped with a broad array of immune cells and innate immune receptors that recognize microbial-derived products, microorganisms, toxins and food antigens that have breached the intestinal barrier. An overwhelming amount of evidence obtained in the last decade indicates that the intestinal microbiota is a key component of a wide variety of physiological processes, and alterations in the delicate balance that represents the intestinal bacterial communities are now considered important determinants of metabolic syndrome and immunopathologies. Moreover, it is now evident that the interaction between the innate immune system and the intestinal microbiota during obesity or autoimmunity promotes chronic liver disease progression and therefore it might lead to novel and individualized therapeutic approaches. In this review, we discuss a growing body of evidence that highlights the central relationship between the immune system, the microbiome, and chronic liver disease initiation and progression.

Role of gut microbiota in liver diseases

The liver constantly encounters food-derived antigens and bacterial components such as lipopolysaccharide translocated from the gut into the portal vein. Bacterial components stimulate Toll-like receptors (TLR), which are expressed on Kupffer cells, biliary epithelial cells, hepatocytes, hepatic stellate cells, endothelial cells and dendritic cells and recognize specific pathogen-associated molecular patterns. The signaling of TLR to its main ligand triggers inflammation. Usually, in order to protect against hyperactivation of the immune system and to prevent organ failure by persistent inflammation, TLR tolerance to repeated stimuli is induced. In chronic liver diseases, a breakdown in TLR tolerance occurs. Furthermore, Kupffer cells, hepatic stellate cells and natural killer T cells are key components of innate immunity. Decreased numbers and impaired ability of these cells lead to failures in immune tolerance, resulting in persistent inflammation. Recently, the activation of inflammasome was revealed to control the secretion of pro-inflammatory cytokines such as interleukin-1β in response to bacterial pathogens. Innate immunity seems to be an important contributor to the pathogenesis of fatty liver disease and autoimmune liver disease. Recently, probiotics were reported to affect various liver diseases via shifts in gut microbiota and the stability of intestinal permeability. However, many unresolved questions remain. Further analysis will be needed to gain a more comprehensive understanding of the association of innate immunity with the pathogenesis of various liver diseases.

The intestinal microbiota in chronic liver disease

Recent evidence indicates that the intestinal microflora plays a critical role in physiological and pathological processes; in particular, it is now considered a key determinant of immune pathologies and metabolic syndrome. Receiving the majority of its blood supply from the portal vein, the liver represents the first line of defense against food antigens, toxins, microbial-derived products, and microorganisms. Moreover, the liver is critically positioned to integrate metabolic outcomes with nutrient intake. To accomplish this function, the liver is equipped with a broad array of immune networks. It is now evident that, during pathological processes associated with obesity, alcohol-intake, or autoimmunity, the interaction between these immune cell populations and the intestinal microbiota promotes chronic liver disease progression and therefore they represent a novel therapeutic target. Herein, we highlight recent studies that have shed new light on the relationship between the microbiome, the innate immune system, and chronic liver disease progression.

Clinical characteristics of ulcerative colitis associated with primary sclerosing cholangitis in Korea

BACKGROUND

Primary sclerosing cholangitis (PSC) is well known as one of the extraintestinal manifestations of ulcerative colitis (UC). However, the prevalence of PSC in UC patients together with the clinical characteristics and outcomes of UC associated with PSC (UC-PSC) are not clear in Asians.

METHODS

We retrospectively reviewed the medical records of UC patients who were registered and followed up at the Asan Medical Center. The prevalence of PSC in UC and the clinical features of UC-PSC compared with matched UC without PSC were investigated.

RESULTS

A total of 1849 patients diagnosed with UC between July 1977 and September 2009 were reviewed. Among these, 21 UC-PSC patients (1.1%) were identified. The cumulative probability of PSC after diagnosis of UC was 0.71% after 1-5 years, 1.42% after 10 years, 2.59% after 15 years, and 3.35% after 20-25 years. Compared with 63 matched UC alone patients, UC-PSC showed pancolitis (95.2%), rectal sparing (38.1%), and backwash ileitis (42.9%) more frequently (P < 0.001). During follow-up, three of 21 UC-PSC patients (14.3%) were diagnosed with colorectal neoplasia and three patients (14.3%) died of PSC-associated complications. UC-PSC patients were associated with increased probability of colorectal neoplasia development (P = 0.036) and a trend toward increased mortality compared with the UC alone group.

CONCLUSIONS

The prevalence of PSC in Korean UC patients appears to be lower than that of Western patients. Similar to Caucasians, UC-PSC shows unique colonoscopic features and is associated with more frequent colorectal neoplasia development and poor prognosis in Korea.

Clinical course of ulcerative colitis in patients with and without primary sclerosing cholangitis

BACKGROUND AND AIM

We noticed in our practice that patients with ulcerative colitis (UC) who have developed primary sclerosing cholangitis (PSC) experience a milder course of colonic disease. Our objective in this study was to define whether or not there is any difference between UC activity and its course in patients with and without PSC.

METHODS

Nineteen patients with UC and PSC (eight male, mean age 25 years) were enrolled. To every patient with UC and PSC, three patients with UC alone (total of 57 patients, 28 male, mean age 24 years) matched for age at onset, duration of the disease and extension of colonic disease were selected as the control group. We used number of hospitalizations due to activity of UC and number of short corticosteroid administrations in various years of follow-up as variables indicating course and severity of the colonic disease in this period. For comparing trends of UC activity between two groups, we used repeated measures two-way analysis of variances.

RESULTS

Mean duration of follow up in case and control groups was 12.2 +/- 5.7 and 11.4 +/- 4.9 years, respectively. Two groups had no significant difference in use of sulfasalzine or aminosalicylates. Number of hospitalizations and courses of steroid therapy because of UC activity decreased significantly over time (P < 0.000) in both groups, and it was significantly higher in controls than in cases (P = 0.045 and 0.032, respectively).

CONCLUSIONS

Development of PSC in patients with UC might have a positive effect on colonic disease. Further investigations to evaluate the basis of this improvement are warranted.

Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

BACKGROUND

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA.

METHODS

Fifty-eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed.

RESULTS

The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12-91.00; P=0.001).

CONCLUSIONS

The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.

Is routine cholangiography useful in men with suspected primary biliary cirrhosis?

The aim of this study was to assess the diagnostic value of cholangiography in men with chronic cholestasis and positive antimitochondrial antibody (AMA) titers who were suspected of having primary biliary cirrhosis (PBC). The authors reviewed retrospectively the records of men who had positive AMA titers over a 16-month period to determine the results of cholangiography. They also reviewed the records of 102 patients with primary sclerosing cholangitis (PSC) from 1989 to 1995 who had undergone cholangiography and testing for AMA. Of 35 men with positive tests for serum AMA, 12 of these patients were referred for cholangiography (11 endoscopic and 1 transhepatic). All completed cholangiograms were normal. A diagnosis of PBC was made in nine patients and atypical autoimmune hepatitis in one. Conversely, only two PSC patients had positive AMA titers (1:20 and 1:80). Both of these patients had coexisting inflammatory bowel disease and cholangiograms diagnostic of PSC. Cholangiography was negative in the male patients with positive AMA titers who were suspected of having PBC. In men with cholestatic liver biochemistries and strongly positive AMA titers, especially in the absence of associated inflammatory bowel disease, routine cholangiography does not add to the diagnostic evaluation.

Hepatobiliary alterations in patients with inflammatory bowel disease: a multicenter study. Caprilli & Gruppo Italiano Studio Colon-Retto

BACKGROUND AND METHODS

Four hundred and eighty-four patients with inflammatory bowel disease underwent clinical examination, ultrasonography, and biochemical liver function tests, to estimate the prevalence of hepatobiliary alterations. The patient group included patients without a history of liver disease. Controls were recruited from patients with functional symptoms.

RESULTS

More patients with ulcerative colitis than controls had liver steatosis and increased alkaline phosphatase levels. Factors increasing the probability of liver damage were long-standing disease, the presence of moderate/severe disease activity, and treatment with steroids and mesalazine. A significant association was found between biliary disease and long-standing colitis and also therapy with steroids and mesalazine. Alkaline phosphatase and aminotransferase levels were significantly higher in Crohn's disease patients than in controls. Hepatic and biliary damage was found more commonly in the 1st year after diagnosis.

CONCLUSIONS

The monitoring of hepatobiliary function is suggested for patients with inflammatory bowel disease, even in the absence of symptoms and history.

Gastric cytoprotection by amoxycillin in the rat

Amoxycillin in combination with anti-ulcer agents has been shown to prolong duodenal ulcer remission. While this effect can be related to the eradication of Helicobacter pylori, it is not known if amoxycillin might possess cytoprotective properties. Protection against ethanol-induced gastric mucosal damage by intragastric instillation of amoxycillin suspension (prepared from capsule form) and solution (from injection form, 100% pure amoxycillin), and by intraperitoneal injection of amoxycillin solution was studied using an ex vivo gastric chamber in the rat. Intragastric and intraperitoneal administration of amoxycillin dose-dependently protected the rat gastric mucosa from damage by absolute ethanol. This protection was lost when the rats were pretreated with indomethacin. Gastric mucosal blood flow as measured by laser Doppler flowmetry and gastric acid output were unaffected by amoxycillin. Amoxycillin imparts gastric cytoprotection, and one possible mechanism is by the release of prostaglandins.