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Kim MK, Jo SI, Kim SY, Lim H, Kang HS, Moon SH, Ye BD, Soh JS, Hwang SW. PD-1-positive cells contribute to the diagnosis of inflammatory bowel disease and can aid in predicting response to vedolizumab. Sci Rep 2023; 13:21329. [PMID: 38044341 PMCID: PMC10694145 DOI: 10.1038/s41598-023-48651-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023] Open
Abstract
Differentiating inflammatory bowel disease (IBD) from other inflammatory diseases is often challenging. Programmed cell death protein-1 (PD-1) is expressed in T cells and is an indicator of their exhaustion. The role of PD-1 expression in diagnosing IBD and predicting the response of biologic agents remains inconclusive. In this study, endoscopic biopsy samples of 19 patients diagnosed with IBD, intestinal tuberculosis, and intestinal Behcet's disease were analyzed using multiplexed immunohistochemistry. Additionally, a separate "vedolizumab (VDZ) cohort" established in ulcerative colitis patients who underwent endoscopic biopsy before VDZ administration was analyzed to predict response to VDZ. In the immunohistochemistry analysis, the cell density of T cell subsets, including PD-1 + cells, was investigated and compared between IBD and other inflammatory diseases (OID). Cell densities of PD-1 + cells (p = 0.028), PD-1 + helper T cells (p = 0.008), and PD-1 + regulatory T cells (p = 0.024) were higher in IBD compared with OID. In the VDZ cohort, patients with a 14-week steroid-free clinical response had higher levels of PD-1 + cells (p = 0.026), PD-1 + helper T cells (p = 0.026), and PD-1 + regulatory T cells (p = 0.041) than the no response group. PD-1 + immune cells may contribute to the diagnosis of IBD and could be used to predict response to VDZ in ulcerative colitis patients.
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Affiliation(s)
- Min Kyu Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Su In Jo
- PrismCDX Co., Ltd., Hwaseong-Si, Republic of Korea
| | - Sang-Yeob Kim
- Convergence Medicine Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Hyun Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Ho Suk Kang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Soh
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Republic of Korea.
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
- Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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2
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Murphy ME, Bhattacharya S, Axelrad JE. Diagnosis and Monitoring of Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:421-427. [PMID: 36591402 PMCID: PMC9797286 DOI: 10.1055/s-0042-1758047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ulcerative colitis is one of the two main subtypes of inflammatory bowel disease, along with Crohn's disease. Understanding the clinical and endoscopic features of ulcerative colitis is critical in achieving a timely diagnosis. An initial evaluation includes assessing clinical symptoms, inflammatory markers, endoscopic findings, and determination of the presence or absence of extraintestinal manifestations. Initial disease management should consider disease severity at the time of diagnosis as well as prognostication, or the determination of risk factors present with a high likelihood of severe disease in the future. Once appropriate therapy has been initiated, ongoing monitoring is crucial, which may include repeated clinical assessments over time, measuring noninvasive markers of inflammation, and endoscopic and histologic reevaluation. An important aspect of disease monitoring in ulcerative colitis is dysplasia surveillance; there are many patient-specific risk factors which influence surveillance strategies. Utilizing appropriate surveillance techniques is necessary for early detection of dysplasia and colorectal neoplasia.
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Affiliation(s)
- Megan E. Murphy
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Sumona Bhattacharya
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Jordan E. Axelrad
- Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center at NYU Langone Health, NYU Grossman School of Medicine, New York, New York
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Albayrak NE, Polydorides AD. Characteristics and Outcomes of Left-sided Ulcerative Colitis With a Cecal/Periappendiceal Patch of Inflammation. Am J Surg Pathol 2022; 46:1116-1125. [PMID: 35354161 DOI: 10.1097/pas.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ulcerative colitis (UC) is characterized by continuous mucosal inflammation of the rectum, extending uninterrupted to a variable portion of the colon proximally. However, in some patients with distal colitis, a distinct pattern of skip inflammation (so-called patch) involves the cecum and/or appendiceal orifice, but data on this entity are contradictory, and its significance and prognosis are still debated. We identified 102 adult cases of left-sided UC with a cecal/periappendiceal patch and compared them to 102 controls (left-sided UC only) along clinicopathologic characteristics and disease outcomes. In multivariate analysis, patients with a patch were younger (median age: 31 vs. 41 y; P =0.004) and more likely to have rectosigmoid involvement only (58.8% vs. 28.4%; P <0.001), compared with patients without a patch. During follow-up, patients with a patch were more likely to be eventually diagnosed with Crohn disease (CD) (9.8% vs. 1.0%; P =0.022) and to show proximal extension of inflammation (35.6% vs. 10.0%; P =0.021), but showed no differences in rates of neoplasia, colectomy, or pharmacotherapy escalation. Kaplan-Meier analysis confirmed that patients with a biopsy diagnosis of cecal/periappendiceal patch were more likely to show proximal disease extension ( P <0.001) and to be diagnosed with CD ( P =0.008). In conclusion, cecal/periappendiceal skip inflammation in left-sided UC occurs more often in younger patients and in those with rectosigmoid involvement and is associated with proximal disease extension and, in a small fraction of cases, change of diagnosis to CD. However, it does not portend increased risk of neoplasia, pharmacotherapy escalation, or subsequent colectomy, compared with patients with left-sided UC only.
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Affiliation(s)
- Nazire E Albayrak
- Department of Pathology, Molecular, and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Lin YC, Liao SC, Chang CH, Chen CC, Lin WT, Chiu FW, Ko CW. Endoscopic features and clinical course of patients with asymptomatic cecal ulcers. BMC Gastroenterol 2022; 22:309. [PMID: 35751028 PMCID: PMC9229120 DOI: 10.1186/s12876-022-02383-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Cecal ulcers are
sometimes encountered in asymptomatic individuals. Their clinical outcomes and
management recommendations remain uncertain. Methods Asymptomatic patients who underwent a colonoscopic exam
for colon cancer screening were retrospectively reviewed from July 2009 to
November 2016. Patients with cecal ulcers were included. Patients who had
colorectal symptoms, such as abdominal pain, had nonsteroidal anti-inflammatory
drugs or were lost to follow-up were excluded. Results A total of 34,036 patients underwent colon cancer
screening. Cecal ulcers were found in 35 patients. After exclusion, 24 patients
(mean duration, 52 months) received follow-up colonoscopy. In 20 patients,
(83.3%), cecal ulcer resolved without intervention, but 4 patients (16.7%)
developed clinical significant diseases, including intestinal tuberculosis
(n = 2), Crohn’s disease (n = 1), and ulcerative colitis (n = 1). Patients who
developed clinically significant diseases had a higher percentage of ulcers
larger than 1 cm (75% vs. 15%, p = 0.035), terminal ileum involvement (100% vs.
15.4%, p = 0.006) and ulcers with irregular fold (75% vs. 5%, p = 0.008). Conclusions In patients with
asymptomatic cecal ulcers, the endoscopic features included larger ulcer size,
terminal ileum involvement and ulcers with irregular fold may predict
development of clinically significant diseases. If the above-mentioned features
are present, even asymptomatic patients should be closely monitored.
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Affiliation(s)
- Ying-Cheng Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan
| | - Szu-Chia Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan.,School of Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan
| | - Chia-Chang Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan
| | - Wan-Tzu Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan
| | - Fang-We Chiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, No. 1, Rongguang Rd., Puli Township, 54552, Nantou, Taiwan.
| | - Chung-Wang Ko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Section 4, Taiwan Boulevard, Xitun Dist., Taichung City, 40705, Taiwan. .,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Jangi S, Holmer AK, Dulai PS, Boland B, Valasek M, Jairath V, Feagan BG, Sandborn WJ, Singh S. Spatial Evolution of Histologic and Endoscopic Healing in the Left and Right Colon in Patients With Ulcerative Colitis. Clin Gastroenterol Hepatol 2022; 20:e750-e760. [PMID: 33556578 PMCID: PMC9550577 DOI: 10.1016/j.cgh.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite increasing interest in histologic remission as a treatment target in ulcerative colitis (UC), the accuracy of histologic findings in left colon in detecting pancolonic histologic remission is unknown. METHODS In a retrospective cohort study of patients with endoscopically active pancolitis undergoing treat-to-target interventions, we evaluated the diagnostic accuracy of left-sided (distal to splenic flexure) histologic and endoscopic findings on colonoscopy for detecting histologic and endoscopic healing elsewhere in the colon. RESULTS Of 86 patients with moderate to severely active pancolitis who underwent 2 consecutive colonoscopies during treat-to-target interventions, 38% and 51% achieved histologic and endoscopic remission, respectively. Substantial agreement (kappa, 0.67; 95% confidence interval (CI), 0.51-0.83) was observed in histologic findings between left and right colon on follow-up colonoscopy. Histologic, and endoscopic, findings in left colon showed excellent accuracy in detecting pancolonic histologic remission (area under the curve (AUC), 0.96 [95% CI, 0.93-1.0]; misclassification rate, 5.9%), histologic normalization (AUC, 1.0, 0%), endoscopic improvement (AUC, 0.95 [0.96-1.0], 3.5%) and endoscopic remission (AUC, 0.98 [0.96-1.00], 5.8%), respectively. CONCLUSIONS In patients with active pancolitis undergoing treat-to-target interventions, histologic and endoscopic findings in the left colon on colonoscopy have excellent accuracy for detecting pancolonic histologic remission, histologic normalization, endoscopic improvement, and endoscopic remission. Flexible sigmoidoscopy may suffice for monitoring histologic and endoscopic activity in patients with pancolitis.
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Affiliation(s)
- Sushrut Jangi
- Division of Gastroenterology, University of California San Diego, La Jolla, California; Division of Gastroenterology, Tufts University Medical Center, Boston, Massachusetts.
| | - Ariela K. Holmer
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Brigid Boland
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Mark Valasek
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | | | | | - William J. Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
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6
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A Study on Differences between Professional Endoscopists and Gastroenterologists in Endoscopic Detection and Standard Pathological Biopsy of Inflammatory Bowel Diseases. Gastroenterol Res Pract 2022; 2022:7333579. [PMID: 35378864 PMCID: PMC8976660 DOI: 10.1155/2022/7333579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/27/2022] [Accepted: 03/10/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To assess whether professional endoscopists need additional training on inflammatory bowel disease (IBD) diagnosis. Methods This retrospective study was conducted in patients with IBD, including Crohn's disease (CD) and ulcerative colitis (UC), which were diagnosed and treated for the first time in our hospital between January 2005 and December 2020. Doctors including gastroenterologists (group G) and professional endoscopists (group E) participated in the study. The data divided into CD or UC and group G or group E were compared. Results Patients with CD exhibited higher rates of terminal ileal lesions, reexamined colonoscopy within 6 months, and intestinal stenosis than patients with UC (P < 0.001). The positive endoscopic IBD diagnosis rate was significantly higher in group G than in group E (89.6% vs. 74.0%, P < 0.001). In the subgroup analysis for patients with CD, the positive endoscopic IBD diagnosis rate was significantly higher for group G than for group E (81.5% vs. 41.8%, P < 0.001). However, the two groups exhibited no significant difference in the subgroup analysis for patients with UC (94.1% vs. 86.5%, P = 0.060). Group G exhibited a higher rate of terminal ileal intubation (83.1% vs. 65.3%, P < 0.001) and standard pathological biopsy (72.7% vs. 26.0%, P < 0.001) than Group E. Conclusion Professional endoscopists showed lower rates of terminal ileal intubation, positive endoscopic diagnosis, and standard pathological biopsy than gastroenterologists. Hence, additional training on IBD, particularly on CD, must be provided to professional endoscopists to increase their efficiency for terminal ileal intubation and positive endoscopic diagnosis and to enhance their awareness regarding standard biopsy.
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7
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Park SB, Kim SJ, Lee J, Lee YJ, Baek DH, Seo GS, Kim ES, Kim SW, Kim SY. Efficacy of sigmoidoscopy for evaluating disease activity in patients with ulcerative colitis. BMC Gastroenterol 2022; 22:83. [PMID: 35220941 PMCID: PMC8882296 DOI: 10.1186/s12876-022-02178-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Endoscopic assessment of disease activity is a key parameter in the management of ulcerative colitis. Whether sigmoidoscopy alone is sufficient to evaluate the disease activity in ulcerative colitis lacks studies.
Methods We retrospectively analyzed the medical records and endoscopic results of patients with ulcerative colitis followed by colonoscopy in seven tertiary hospitals between January 2012 and December 2018. Endoscopic disease activity was scored using the Mayo endoscopic subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for each segment from the colonoscopy images. Concordance was evaluated by comparing the highest MES and UCEIS in the rectosigmoid and proximal regions to confirm the usefulness of sigmoidoscopy. Results A total of 500 colonoscopic examinations from 333 patients were enrolled. Only in 7.6% [k(kappa): 0.893, r(Spearman): 0.906, p < 0.001] and 8.6% [k(kappa): 0.890, r(Spearman): 0.914; p < 0.001] of cases, MES and UCEIS scored more severely in the proximal colon. Comparison of active disease (MES ≥ 2) in the rectosigmoid area and the entire colon showed a high concordance rate [k(kappa): 0.899, r(Spearman): 0.904, p < 0.001]. Endoscopic healing (MES = 0) also showed a high concordance rate [k(kappa): 0.882, r(Spearman): 0.887, p < 0.001]. In 38 cases (7.6%) of patients with a higher MES in the proximal area, it was significantly higher in patients with previous extensive colitis. Conclusions Sigmoidoscopy and colonoscopy showed a high concordance rate. Therefore, sigmoidoscopy is considered a sufficient substitute for colonoscopy. However, colonoscopy should be considered in patients with previous extensive colitis. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02178-0.
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8
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Weng MT, Shih IL, Tung CC, Leong YL, Shieh MJ, Wang CY, Wong JM, Ni YH, Wei SC. Association of young age and male sex with primary sclerosing cholangitis in Taiwanese patients with inflammatory bowel disease. Intest Res 2022; 20:224-230. [PMID: 35124955 PMCID: PMC9082000 DOI: 10.5217/ir.2021.00042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/10/2021] [Indexed: 12/04/2022] Open
Abstract
Background/Aims Primary sclerosing cholangitis (PSC) is associated with inflammatory bowel disease (IBD). We aimed to evaluate the prevalence, clinical manifestation, and outcomes of PSC in Taiwanese patients with IBD. Methods This retrospective study enrolled patients with IBD admitted from January 1, 1996, to December 31, 2018, to National Taiwan University Hospital. A case-matched analysis was performed comparing patients with IBD with and without PSC according to age, sex, and time of admission, with ratios of 1:4 and 1:2 in the adult and pediatric groups, respectively. Results In total, 763 patients with IBD were enrolled, 12 of whom were also diagnosed with PSC (1.57%). All these patients had ulcerative colitis (UC). A greater incidence of IBD with PSC was observed in younger patients than in older patients. Male sex was a risk factor for PSC in pediatric patients with IBD (P=0.015); 75% of these patients were diagnosed with PSC along with or after the diagnosis of UC. There was no significant difference in colitis extent and severity between the groups; however, a higher proportion of rectal sparing was observed in patients with PSC (P=0.001). There was no significant difference in cancer development between the groups (P=0.679). Conclusions A 1.57% prevalence of PSC was observed in Taiwanese patients with IBD. The majority of patients with IBD and PSC were men and were diagnosed at a younger age. Hence, routine evaluation of biliary enzymes and liver imaging is recommended in young male patients with IBD.
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Affiliation(s)
- Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Chien-Chih Tung
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Yew-Loong Leong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan.,Good Liver Clinic, Taipei City, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
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9
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Choi YS, Kim JK, Kim WJ. Clinical characteristics and prognosis of patients with ulcerative colitis that shows rectal sparing at initial diagnosis. World J Gastrointest Endosc 2021; 13:407-415. [PMID: 34630890 PMCID: PMC8474694 DOI: 10.4253/wjge.v13.i9.407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/23/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ulcerative colitis (UC) is characterised by mucosal inflammation from the rectum to its proximal area in a symmetric and continuous fashion. However, although uncommon, we encounter cases of UC with rectal sparing in the initial stage.
AIM To evaluate the clinical characteristics and clinical course for rectal sparing UC compared with typical UC.
METHODS We looked at records from 2004 to 2015, and selected patients who were newly diagnosed with UC, and who could be followed up for at least 5 years in our hospital. We then retrospectively analysed the medical records and endoscopic findings of those patients. To compare the clinical course and prognosis, we matched each patient with rectal sparing UC 1:3 with controls by age, sex, and disease extent.
RESULTS Of 619 UC patients, 24 (3.9%) showed rectal sparing at diagnosis. During the follow-up period (median 8 years), in two (8.3%) of the 24 patients, rectal sparing remained through follow-up inspections; but for the other 22 (91.7%) patients, obvious rectal inflammation was found at follow-up endoscopy. Of the 24 patients, 8 (33.3%) were initially misdiagnosed with infectious colitis. No diagnosis was changed to Crohn’s disease. The uses of corticosteroid or biologic agents, hospitalisation rate, and colectomy rates were not different between the rectal sparing UC group and typical UC group.
CONCLUSION Some patients with UC can reveal atypical patterns of disease distribution, such as rectal sparing in its initial stage; but despite this, the clinical course and prognosis may not differ from those of typical UC patients.
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Affiliation(s)
- Yong-Sung Choi
- Department of Internal Medicine, Daehang Hospital, Seoul 06699, South Korea
| | - Jong-Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul 06699, South Korea
| | - Wan-Jung Kim
- Department of Gastroenterology, Daehang Hospital, Seoul 06699, South Korea
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10
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Shin J, Kong SM, Kim TJ, Kim ER, Hong SN, Chang DK, Kim YH. Clinical Significance of Residual Nonrectal Inflammation in Ulcerative Colitis Patients in Clinical Remission. Gut Liver 2021; 15:401-409. [PMID: 32839361 PMCID: PMC8129662 DOI: 10.5009/gnl20078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 12/12/2022] Open
Abstract
Background/Aims The treatment goal of ulcerative colitis (UC) has been changed to achieve endoscopic remission (ER). However, there is insufficient clinical evidence to determine whether a step-up treatment should be performed to achieve ER in clinical remission (CR) without ER, and there are inadequate data on the need to consider the distribution and severity of residual inflammation. This retrospective study aimed to evaluate the prognostic significance of the distribution and severity of residual inflammation in UC patients in CR. Methods A total of 131 UC patients in CR who underwent endoscopic evaluation for more than three times between January 2000 and December 2018 were reviewed. The patients were allocated by the endoscopic healing state and the distribution of inflammation to ER (n=31, 23.7%), residual nonrectal inflammation with patchy distribution (NRI) (n=17, 13.0%) or residual rectal involvement with continuous or patchy distribution (RI) (n=83, 63.3%) groups. We reviewed clinical characteristics, endoscopic findings, and factors associated with poor outcome-free survival (PFS). Results In UC patients in CR, PFS was significantly higher in the ER and NRI groups than in the RI group (p=0.003). Patients in the ER and NRI groups had similar PFS (p=0.647). Cox proportional hazard model showed only RI (hazard ratio, 5.76; p=0.027) was associated with a higher risk of poor outcome. Conclusions We suggest that escalation of treatment modalities may be selectively performed in consideration of the residual mucosal inflammation pattern, even if ER has not been achieved, in UC patients with CR. (Gut Liver 2021;15-409)
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Affiliation(s)
- Jongbeom Shin
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Min Kong
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Jun Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Noh Hong
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Ho Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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11
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Alkhatry M, Al-Rifai A, Annese V, Georgopoulos F, Jazzar AN, Khassouan AM, Koutoubi Z, Nathwani R, Taha MS, Limdi JK. First United Arab Emirates consensus on diagnosis and management of inflammatory bowel diseases: A 2020 Delphi consensus. World J Gastroenterol 2020; 26:6710-6769. [PMID: 33268959 PMCID: PMC7684461 DOI: 10.3748/wjg.v26.i43.6710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis and Crohn’s disease are the main entities of inflammatory bowel disease characterized by chronic remittent inflammation of the gastrointestinal tract. The incidence and prevalence are on the rise worldwide, and the heterogeneity between patients and within individuals over time is striking. The progressive advance in our understanding of the etiopathogenesis coupled with an unprecedented increase in therapeutic options have changed the management towards evidence-based interventions by clinicians with patients. This guideline was stimulated and supported by the Emirates Gastroenterology and Hepatology Society following a systematic review and a Delphi consensus process that provided evidence- and expert opinion-based recommendations. Comprehensive up-to-date guidance is provided regarding diagnosis, evaluation of disease severity, appropriate and timely use of different investigations, choice of appropriate therapy for induction and remission phase according to disease severity, and management of main complications.
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Affiliation(s)
- Maryam Alkhatry
- Gastroenterology and Endoscopy Department, Ibrahim Bin Hamad Obaid Allah Hospital, Ministry of Health and Prevention, Ras Al Khaiman, United Arab Emirates
| | - Ahmad Al-Rifai
- Department of Gastroenterology, Sheikh Shakbout Medical City, Abu Dhabi, United Arab Emirates
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic, Dubai, United Arab Emirates
- Department of Gastroenterology and Endoscopy, American Hospital, Dubai, United Arab Emirates
| | | | - Ahmad N Jazzar
- Gastroenterology Division, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Ahmed M Khassouan
- Digestive Disease Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Zaher Koutoubi
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Rahul Nathwani
- Department of Gastroenterology, Mediclinic City Hospital, Dubai, United Arab Emirates
- Department of Gastroenterology, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Mazen S Taha
- Gastroenterology and Hepatology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Jimmy K Limdi
- Department of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester Academic Health Sciences, University of Manchester, Manchester M8 5RB, United Kingdom
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Appendiceal Orifice Inflammation in Ulcerative Colitis Mimicking Mucosa-Associated Lymphoid Tissue Lymphoma in the Cecum. Case Rep Gastrointest Med 2020; 2020:8893604. [PMID: 33083067 PMCID: PMC7563037 DOI: 10.1155/2020/8893604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 11/17/2022] Open
Abstract
A 55-year-old Japanese woman, who had been diagnosed with ulcerative colitis at 18 years of age, underwent screening endoscopy examinations. Esophagogastroduodenoscopy revealed an extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach. Colonoscopy showed a slightly elevated reddish lesion with dilated microvessels but no erosions or ulcers. Although MALT lymphoma in the cecum was endoscopically suspected, flow cytometry and pathological analyses led to the diagnosis of appendiceal orifice inflammation in ulcerative colitis. This case highlights the diversity of the endoscopic appearance of appendiceal orifice inflammation in ulcerative colitis.
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13
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Combining faecal calprotectin and sigmoidoscopy can predict mucosal healing in paediatric ulcerative colitis. Eur J Gastroenterol Hepatol 2020; 32:17-21. [PMID: 31651657 DOI: 10.1097/meg.0000000000001550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Mucosal healing is the endoscopic treatment target in inflammatory bowel disease. The treat-to-target strategy, emphasizing proactive assessment and optimizing treatment, is commonly applied in the clinical setting. Although colonoscopies are essential for this strategy to be successful, bowel preparation and sedative drugs are required for paediatric patients. We attempted to verify the usefulness of sigmoidoscopy, which is less invasive than colonoscopy, combined with faecal calprotectin, to assess mucosal healing. METHODS A total of 58 paediatric patients diagnosed with ulcerative colitis and followed up at Severance Children's Hospital from March 2015 to May 2018 were enrolled. Clinical data and laboratory findings (including faecal calprotectin and endoscopic data) were collected from medical records. The predictive power of mucosal healing of sigmoid colon and rectum (s-MH) combined with faecal calprotectin to predict mucosal healing throughout the colon was analysed. RESULTS Among 58 patients (mean age 16.13 ± 2.88 years), 18 (31.0%) were in mucosal healing status. The median faecal calprotectin level was 486.5 μg/g. The faecal calprotectin cutoff value for predicting mucosal healing, identified using receiver-operating characteristic analyses, was 148 μg/g (area under the curve, 0.81). Sensitivity, specificity, positive predictive value, and negative predictive value of s-MH in predicting mucosal healing were 1.0, 0.82, 0.72, and 1.0, respectively. When we combined s-MH with faecal calprotectin less than the cutoff value, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.56, 1.0, 1.0, and 0.83, respectively. CONCLUSION For patients with a low faecal calprotectin level, sigmoidoscopy might be sufficient to assess mucosal healing.
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1196] [Impact Index Per Article: 239.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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15
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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16
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Ekanayaka A, Anderson JT, Lucarotti ME, Valori RM, Shepherd NA. The isolated caecal patch lesion: a clinical, endoscopic and histopathological study. J Clin Pathol 2019; 73:121-125. [DOI: 10.1136/jclinpath-2019-206146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/11/2022]
Abstract
ObjectiveTo describe and investigate the potential causes of the isolated caecal patch lesion, a previously undescribed endoscopic phenomenon of a lesion fulfilling endoscopic and histopathological criteria for chronic inflammatory bowel disease but without evidence of similar inflammatory pathology elsewhere at colonoscopy.MethodsCases were collected prospectively by one specialist gastrointestinal pathologist over a 10-year period. Full endoscopic and histopathological analysis was undertaken and follow-up sought to understand the likely cause(s) of the lesions.ResultsSix cases are described. Two had very close links with ulcerative colitis, one predating the onset of classical distal disease and the other occurring after previous demonstration of classical distal ulcerative colitis. Two occurred in younger patients and we postulate that these lesions may predict the subsequent onset of chronic inflammatory bowel disease. Finally two can be reasonably attributed to the effects of non-steroidal inflammatory agent therapy.ConclusionsCaecal patch lesions can be demonstrated in isolation. Despite the strong association of caecal patch lesions with ulcerative colitis, solitary lesions may well have disparate causes but nevertheless possess a close relationship with chronic inflammatory bowel disease.
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Lin WC, Chang CW, Chen MJ, Hsu TC, Wang HY. Effectiveness of sigmoidoscopy for assessing ulcerative colitis disease activity and therapeutic response. Medicine (Baltimore) 2019; 98:e15748. [PMID: 31124958 PMCID: PMC6571418 DOI: 10.1097/md.0000000000015748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Ulcerative colitis (UC) typically begins in the rectum and progresses proximally in a contiguous fashion without skip lesions. Post-treatment inflammation distribution can change over time. Colonoscopy is unpleasant for the patient and clinical trials often use sigmoidoscopy for evaluation of disease severity. The aim of this study is to evaluate whether sigmoidoscopy is adequate to assess disease activity and therapeutic response as colonoscopy.We retrospectively reviewed patients who underwent colonoscopy for the initial diagnosis and follow-up by evaluating their mucosal inflammation in our hospital from January 2012 and December 2017.A total of 69 patients were analyzed. During follow up, the inflamed segment changed post-treatment in 62% (43/69). Extensive UC was common in the changed disease extent group (P < .01). Patients treated with oral mesalazine had a higher rate of changed disease extent (P < .01). The sigmoid segment was the most commonly involved segment, and the rectum was the severely inflamed segment during initial diagnosis and follow-up. According to Mayo endoscopic subscore (MES) in the most severely inflamed colonic and rectosigmoid segment, there were high degrees of correlation in the initial UC diagnosis (r = .90, P < .01) and follow-up (r = .74, P < .01).Our findings suggest that sigmoidoscopy is effective as colonoscopy for detecting disease activity and evaluating therapeutic response in UC patients during follow-up.
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Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College
| | - Ming-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College
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18
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Higashihara T, Okada A, Kishida Y, Maruno S, Matsumura M, Tamura K, Takano H. Atypical cause of intractable diarrhea in a hemodialysis patient, masked by Clostridium difficile-associated diarrhea and ischemic colitis: a case report. BMC Nephrol 2018; 19:303. [PMID: 30384836 PMCID: PMC6211476 DOI: 10.1186/s12882-018-1116-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/23/2018] [Indexed: 11/24/2022] Open
Abstract
Background Patients with end-stage kidney disease (ESKD) most commonly complain of gastrointestinal symptoms, such as diarrhea. Diarrhea negatively affects patient quality of life and has miscellaneous etiologies, such as Clostridium difficile-associated diarrhea (CDAD) and ischemic colitis. However, it is sometimes extremely difficult to determine the true etiology given the comorbidities and complications the patients have. A rare cause of diarrhea is ulcerative colitis (UC), which commonly affects the rectum and proximal colon in a continuous fashion. UC with rectal sparing or segmental distribution, although atypical, sometimes leads to misdiagnosis. Herein, we present a case of UC in a patient on hemodialysis with intractable diarrhea; we initially considered that the diarrhea was caused by CDAD and ischemic colitis. Case presentation A 69-year-old man with a history of hypertension, bilateral thalamic hemorrhage, and decreased kidney function was admitted to our hospital because of congestive heart failure. Volume control was impossible due to renal dysfunction and he was started on hemodialysis. Thereafter, he received various antibiotics for bacterial infections. Simultaneously, he experienced continuous watery, and sometimes bloody, diarrhea, which was diagnosed as CDAD owing to a positive stool test for Clostridium difficile toxins. Antibiotic treatment for CDAD did not result in symptom relief. Subsequently, we performed colon biopsy via colonoscopy, and the pathology showed virtually no inflammation with rectal sparing and segmental distributions. These findings favored the presence of ischemic colitis due to arteriosclerosis and ESKD rather than infections. He died of cardiac arrest before the diarrhea was alleviated. Finally, UC was revealed on autopsy as the main cause of the uncontrollable diarrhea. Conclusions Patients with ESKD have a greater risk of developing CDAD and ischemic colitis, which have clinical features that sometimes overlap with those of UC, as in the present case. This case emphasizes the importance of correctly diagnosing the etiology of intractable diarrhea and the fact that other diarrhea etiologies can obscure the existence of inflammatory bowel disease, which should be considered and treated properly when patients on hemodialysis present with intractable diarrhea.
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Affiliation(s)
- Takaaki Higashihara
- Department of Nephrology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan.,Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Akira Okada
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yukiko Kishida
- Department of Pathology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan
| | - Sayako Maruno
- Department of Nephrology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan
| | - Mimiko Matsumura
- Department of Nephrology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan
| | - Koichi Tamura
- Department of Pathology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan
| | - Hideki Takano
- Department of Nephrology, Tokyo Teishin Hospital 2-14-23, Fujimi, Chiyoda-ku, Tokyo, 102-8798, Japan
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Urushikubo J, Yanai S, Nakamura S, Kawasaki K, Akasaka R, Sato K, Toya Y, Asakura K, Gonai T, Sugai T, Matsumoto T. Practical fecal calprotectin cut-off value for Japanese patients with ulcerative colitis. World J Gastroenterol 2018; 24:4384-4392. [PMID: 30344422 PMCID: PMC6189847 DOI: 10.3748/wjg.v24.i38.4384] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/10/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To determine appropriate fecal calprotectin cut-off values for the prediction of endoscopic and histologic remission in Japanese patients with ulcerative colitis (UC).
METHODS We performed a cross-sectional observational study of 131 Japanese patients with UC and measured fecal calprotectin levels by fluorescence enzyme immunoassay. The clinical activity of UC was assessed with the partial Mayo score (PMS). Relapse was defined as increase of PMS by 2 points or more in stool frequency or rectal bleeding subscore. The endoscopic and histologic activities of UC were evaluated in 50 patients within a 2-mo period from fecal sampling. Endoscopic activity was determined by Mayo endoscopic subscore, Rachmilewitz endoscopic index, and ulcerative colitis endoscopic index of severity. The histologic grade of inflammation was evaluated with biopsy specimens obtained from the endoscopically most severely inflamed site, according to the scheme by Matts grade and Riley’s score.
RESULTS Fecal calprotectin levels varied from 1-20783 μg/g. There was a significant correlation between the partial Mayo score and fecal calprotectin levels (r = 0.548, P < 0.001). In 50 patients who underwent colonoscopy with biopsy, levels were significantly correlated with the Mayo endoscopic subscore (r = 0.574, P < 0.001), Rachmilewitz endoscopic index (r = 0.628, P < 0.001), ulcerative colitis endoscopic index of severity (r = 0.613, P < 0.001), Riley’s histologic score (r = 0.400, P = 0.006), and Matts grade (r = 0.586, P < 0.001). Receiver-operating characteristic analyses identified the best cut-off value for the prediction of endoscopic remission as 288 μg/g, with an area under the curve of 0.777 or 0.823, while that for histologic remission was 123 or 125 μg/g, with an AUC of 0.881 or 0918, respectively. Of the 131 study patients, 88 patients in clinical remission were followed up 6 mo. During the follow-up period, 19 patients relapsed. The best fecal calprotectin cut-off value for predicting relapse was 175 μg/g.
CONCLUSION Fecal calprotectin is a predictive biomarker for endoscopic and histologic remission in Japanese patients with UC.
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Affiliation(s)
- Jun Urushikubo
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Keisuke Kawasaki
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Risaburo Akasaka
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Kunihiko Sato
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Kensuke Asakura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Tamotsu Sugai
- Division of Molecular Diagnostic Pathology, Department of Pathology, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan
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20
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Choi YS, Kim WJ, Kim JK, Kim DS, Lee DH. Efficacy of topical 5-aminosalicylate monotherapy in patients with ulcerative proctitis with skip inflammation. J Gastroenterol Hepatol 2018; 33:1200-1206. [PMID: 29205498 DOI: 10.1111/jgh.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM In some patients with ulcerative proctitis (UP), skip inflammation is noted in the right side of the colon, but little is known about its clinical course. The aim of this study was to evaluate the clinical course of UP with skip inflammation and the efficacy of topical 5-aminosalicylate (5-ASA) monotherapy. METHODS This study reviewed the data of 388 patients with an initial diagnosis of UP from January 2005 to October 2015. This study matched each UP patient with skip inflammation 1:2 with controls who had UP without skip inflammation; to reduce bias, this study matched the controls with the cases by age, gender, and initial disease activity. RESULTS During the follow-up period (median: 69.5 months), the overall progression rates for the control group (n = 192) and the skip inflammation group (n = 96) were 24.0% and 32.9% at 10 years, respectively (log-rank P = 0.71). In the skip inflammation group, the progression rates were not significantly different between the 5-ASA combination group and the topical group, 33.4% and 26.6% at 10 years, respectively (log-rank P = 0.96). The overall acute exacerbation rates for the control and skip inflammation groups were 17.2% and 26.8% at 10 years, respectively (log-rank P = 0.68). In the skip inflammation group, the exacerbation rates were also not significantly different between the combination and topical treatment groups, 26.6% and 23.6% at 10 years, respectively (log-rank P = 0.88). CONCLUSION The clinical course of UP with skip inflammation was not different from that of typical UP, and topical 5-ASA monotherapy for maintaining remission was as effective as 5-ASA combination therapy irrespective of the presence of skip lesions.
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Affiliation(s)
- Yong Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Wan Jung Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Jong Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Do Sun Kim
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Doo Han Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
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21
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Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, Burisch J, Gecse KB, Hart AL, Hindryckx P, Langner C, Limdi JK, Pellino G, Zagórowicz E, Raine T, Harbord M, Rieder F. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders. J Crohns Colitis 2017; 11:649-670. [PMID: 28158501 DOI: 10.1093/ecco-jcc/jjx008] [Citation(s) in RCA: 1111] [Impact Index Per Article: 158.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 02/01/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Fernando Magro
- Department of Pharmacology and Therapeutics, University of Porto; MedInUP, Centre for Drug Discovery and Innovative Medicines; Centro Hospitalar São João, Porto, Portugal
| | | | - Rami Eliakim
- Department of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Sandro Ardizzone
- Gastrointestinal Unit ASST Fatebenefratelli Sacco-University of Milan-Milan, Italy
| | - Alessandro Armuzzi
- IBD Unit Complesso Integrato Columbus, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Barreiro-de Acosta
- Department of Gastroenterology, IBD Unit, University Hospital Santiago De Compostela (CHUS), A Coruña, Spain
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark
| | - Krisztina B Gecse
- First Department of Medicine, Semmelweis University, Budapest,Hungary
| | | | - Pieter Hindryckx
- Department of Gastroenterology, University Hospital of Ghent, Ghent, Belgium
| | - Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust; Institute of Inflammation and Repair, University of Manchester, Manchester, UK
| | - Gianluca Pellino
- Unit of General Surgery, Second University of Naples,Napoli, Italy
| | - Edyta Zagórowicz
- Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Department of Oncological Gastroenterology Warsaw; Medical Centre for Postgraduate Education, Department of Gastroenterology, Hepatology and Clinical Oncology, Warsaw, Poland
| | - Tim Raine
- Department of Medicine, University of Cambridge, Cambridge,UK
| | - Marcus Harbord
- Imperial College London; Chelsea and Westminster Hospital, London,UK
| | - Florian Rieder
- Department of Pathobiology /NC22, Lerner Research Institute; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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22
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Horio Y, Uchino M, Bando T, Chohno T, Sasaki H, Hirata A, Takesue Y, Ikeuchi H. Rectal-sparing type of ulcerative colitis predicts lack of response to pharmacotherapies. BMC Surg 2017; 17:59. [PMID: 28526076 PMCID: PMC5437574 DOI: 10.1186/s12893-017-0255-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/10/2017] [Indexed: 12/29/2022] Open
Abstract
Background Ulcerative colitis (UC) is known as an immune disorder of the colon that generally involves the rectum, but an atypical distribution of inflamed mucosa has previously been noted in certain subtypes of UC, such as the rectal-sparing type (RST). As noted in a previous report, patients with the RST may be at elevated risk for disease refractoriness, but the clinical significance of RST remains unknown. Methods UC patients who underwent surgery between January 2010 and April 2015 were included. Patients were classified as having the RST or a non-RST based on colectomy specimens or a pre-operative endoscopy. Possible risk factors for urgent/emergent surgery were analyzed. We specifically determined whether the RST is a significant predictor for urgent/emergent surgery. Results In total, 46/482 patients were classified as having the RST. Disease severity was significantly worse in patients with the RST than in other patients (p = 0.02). Urgent/emergent surgery was required for 24/46 patients with the RST, compared with 107/436 non-RST patients (p < 0.01). The overall incidence of urgent/emergent surgery was 131/482. Disease duration < 70.2 months [odds ratio (OR) 2.45], severe disease (OR 87.1), total administered steroid dose < 5000 mg (OR 3.02), daily pre-operative steroid dose ≥ 9 mg (OR 2.59), and the RST (OR 5.59) were identified as independent risk factors for urgent/emergent surgery. Conclusion The RST was an independent risk factor for urgent/emergent surgery in our analysis of surgically treated patients with UC.
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Affiliation(s)
- Yuki Horio
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Teruhiro Chohno
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hirofumi Sasaki
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akihiro Hirata
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshio Takesue
- Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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Abstract
In a patient presenting with suspected inflammatory bowel disease, the initial endoscopic evaluation is a valuable tool for determining the correct disease diagnosis and the extent and severity of disease. A full colonoscopy and ileoscopy should be performed when possible, with systematic biopsies from each segment. When a diagnosis of inflammatory bowel disease is established, it is possible to distinguish between Crohn disease and ulcerative colitis, and specific endoscopic features may assist in this categorization. Because patchy healing can occur with treatment, it is important to obtain a thorough and accurate assessment of disease characteristics and distribution before initiating therapy.
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Anzai H, Hata K, Kishikawa J, Ishii H, Yasuda K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Kawai K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Watanabe T. Appendiceal orifice inflammation is associated with proximal extension of disease in patients with ulcerative colitis. Colorectal Dis 2016; 18:O278-82. [PMID: 27354363 DOI: 10.1111/codi.13435] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 04/28/2016] [Indexed: 12/24/2022]
Abstract
AIM Ulcerative colitis (UC) is considered to be a disease of continuous mucosal inflammation extending proximally from the rectum. However, appendiceal orifice inflammation (AOI) is a skip lesion with segments of continuous involvement from the rectum. The aim of this study was to examine the clinical characteristics and clinical course, particularly focused on proximal extension, of UC in patients with AOI. METHOD A retrospective evaluation of patients with UC who underwent total colonoscopy at the Department of Surgical Oncology, The University of Tokyo, from 2004 to 2014. The degree of AOI was graded endoscopically as follows: 0 (no inflammation); 1 (slight oedema); 2 (moderate inflammation); and 3 (marked inflammation). A total of 189 patient records were reviewed retrospectively. The presence of AOI was analysed with regard to the clinical information of each patient, and its association with proximal extension of proctitis or left-sided colitis was evaluated. RESULTS Of 189 patients with UC who underwent total colonoscopy at our institution, 92 were diagnosed with pancolitis, 50 with left-sided colitis and 47 with proctitis. Endoscopic findings of AOI were observed in 26 patients, including 11 (12.0%) with pancolitis, six (12.0%) with left-sided colitis and nine (19.1%) with proctitis. During follow up, proximal extension of the disease occurred in all nine patients with proctitis AOI. CONCLUSION AOI is more frequently observed in patients with proctitis. Our results showed correlations between AOI and subsequent proximal extension of mucosal inflammation in patients with proctitis.
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Affiliation(s)
- H Anzai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - J Kishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Ishii
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Yasuda
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Otani
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Tanaka
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Kiyomatsu
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Kawai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Nozawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Kazama
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Yamaguchi
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - E Sunami
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Watanabe
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Lee JM, Lee KM. Endoscopic Diagnosis and Differentiation of Inflammatory Bowel Disease. Clin Endosc 2016; 49:370-5. [PMID: 27484813 PMCID: PMC4977735 DOI: 10.5946/ce.2016.090] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 12/15/2022] Open
Abstract
Patients with inflammatory bowel disease have significantly increased in recent decades in Korea. Intestinal tuberculosis (ITB) and intestinal Behcet’s disease (BD), which should be differentiated from Crohn’s disease (CD), are more frequent in Korea than in the West. Thus, the accurate diagnosis of these inflammatory diseases is problematic in Korea and clinicians should fully understand their clinical and endoscopic characteristics. Ulcerative colitis mostly presents with rectal inflammation and continuous lesions, while CD presents with discontinuous inflammatory lesions and frequently involves the ileocecal area. Involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps are more frequently seen in ITB than in CD. A few ulcers with discrete margins are a typical endoscopic finding of intestinal BD. However, the differential diagnosis is difficult in many clinical situations because typical endoscopic findings are not always observed. Therefore, clinicians should also consider symptoms and laboratory, pathological, and radiological findings, in addition to endoscopic findings.
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Affiliation(s)
- Ji Min Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Kang-Moon Lee
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Pillet S, Williet N, Pouvaret A, Del Tedesco E, Saint-Sardos P, Pozzetto B, Roblin X. Distribution of Cytomegalovirus DNA Load in the Inflamed Colon of Ulcerative Colitis Patients. Am J Gastroenterol 2016; 111:439-41. [PMID: 27018121 DOI: 10.1038/ajg.2016.27] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sylvie Pillet
- EA-3064, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Faculty of Medicine of Saint-Etienne, University of Lyon, Lyon, France
- Laboratory of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Nicolas Williet
- Department of Gastroenterology, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Anne Pouvaret
- Laboratory of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Emilie Del Tedesco
- Department of Gastroenterology, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Pierre Saint-Sardos
- EA-3064, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Faculty of Medicine of Saint-Etienne, University of Lyon, Lyon, France
- Laboratory of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Bruno Pozzetto
- EA-3064, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Faculty of Medicine of Saint-Etienne, University of Lyon, Lyon, France
- Laboratory of Infectious Agents and Hygiene, University-Hospital of Saint-Etienne, Saint Etienne, France
| | - Xavier Roblin
- EA-3064, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Faculty of Medicine of Saint-Etienne, University of Lyon, Lyon, France
- Department of Gastroenterology, University-Hospital of Saint-Etienne, Saint Etienne, France
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