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Kim ES, Kim KO, Jang BI, Kim EY, Lee YJ, Lee HS, Lee JS, Kim SK, Jung YJ, Kang SB, Agrawal M, Ungaro R, Colombel JF. Comparison of 1-Year Colectomy Risk Between the US and Korean Patients with Acute Severe Ulcerative Colitis: A Propensity Score Matching Analysis. Dig Dis Sci 2022; 67:2866-2875. [PMID: 34263381 PMCID: PMC8758790 DOI: 10.1007/s10620-021-07130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/21/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Colectomy risk after acute severe ulcerative colitis (ASUC) has not been compared between Eastern and Western countries. We compared the 1-year colectomy risk after ASUC between Korea and the USA. METHODS Data on patients admitted for ASUC to five tertiary referral hospitals in Korea and Mount Sinai Hospital, New York, the USA, between January 2015 and January 2019 were reviewed retrospectively. For comparability between groups, a 1:1 propensity score matching (PSM) was performed. The primary outcome was colectomy, and secondary outcomes were mortality, readmission, and venous thromboembolism (VTE) within 1-year of the index admission for ASUC. The risk of each outcome was compared using Cox proportional hazards model in pre-matched cohort and Kaplan-Meier analysis with log-rank test in post-matched cohort. RESULTS 290 ASUC patients were included in the study (121 Korea, 169 the USA). After PSM, 56 patients were selected in each group with no significant differences in baseline variables. At 1 year after ASUC, colectomy was less common in Korea than in the USA [3 (5.4%) vs. 24 (42.9%), p < 0.001]. The cumulative colectomy risk was significantly higher in the USA than in Korea in pre-matched cohort [adjusted hazard ratio 7.89, 95% confidence interval 3.23 to 19.22] and in post-matched cohort (log-rank p < 0.001), while there was no difference in cumulative risk of mortality, readmission, and VTE. CONCLUSION Colectomy risk within 1 year of ASUC is significantly higher in the USA than in Korea. We observed no differences in mortality, readmission, and VTE between the two groups.
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Affiliation(s)
- Eun Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Kyeong Ok Kim
- Division of Gastroenterology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Division of Gastroenterology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Eun Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Yoo Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Joon Seop Lee
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Sung Kook Kim
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Korea
| | - Yun Jin Jung
- Division of Gastroenterology, Department of Internal Medicine, Fatima Hospital of Daegu, Daegu, Korea
| | - Sang-Bum Kang
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Manasi Agrawal
- Department of Medicine, Icahn School of Medicine at Mount Sinai, The Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Ryan Ungaro
- Department of Medicine, Icahn School of Medicine at Mount Sinai, The Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Jean-Frederic Colombel
- Department of Medicine, Icahn School of Medicine at Mount Sinai, The Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
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Tanaka M, Takagi T, Naito Y, Uchiyama K, Hotta Y, Toyokawa Y, Kashiwagi S, Kamada K, Ishikawa T, Yasuda H, Konishi H, Itoh Y. Low serum albumin at admission is a predictor of early colectomy in patients with moderate to severe ulcerative colitis. JGH Open 2021; 5:377-381. [PMID: 33732885 PMCID: PMC7936618 DOI: 10.1002/jgh3.12506] [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] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/15/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
Background and Aim Several studies have identified postinduction therapy predictors of long‐term outcomes of ulcerative colitis (UC) in patients who experienced the first attack of the disease or relapsed after therapy. We aimed to identify the preinduction therapy predictors at admission that predicted early colectomy in patients with moderate to severe UC. Methods Ninety‐five patients with moderate to severe UC who underwent induction therapy at the Kyoto Prefectural University of Medicine hospital between August 2008 and March 2020 were retrospectively included and categorized into two groups: the colectomy group (n = 27) and the noncolectomy group (n = 68). The clinical parameters (age, gender, disease extent, and disease activity on admission), induction therapies administered [including 5‐aminosalicylic acid, steroids, immunomodulators, calcineurin inhibitor, and anti‐Tumor Necrosis Factor (TNF)‐α antibodies], and laboratory data (hemoglobin, albumin, C‐reactive protein, and cytomegalovirus reactivation on admission) were evaluated and compared between the two groups. Multivariate logistic regression analyses were performed to identify significant predictors of early colectomy, and P < 0.05 was considered significant. Results All clinical parameters were not significant predictors of colectomy. Among laboratory parameters, the serum albumin level on admission was a significant independent predictor of colectomy (odds ratio: 6.097, 95% confidence interval: 1.8310–20.3047). Receiver operating characteristic curves were plotted for the serum albumin levels of the 95 patients at admission. The cut‐off value of serum albumin was 2.45 g/dL. Conclusions When the serum albumin level of UC patients at admission is below 2.45 g/dL, we should consider presenting the option of surgical treatment to patients.
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Affiliation(s)
- Makoto Tanaka
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Tomohisa Takagi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Kazuhiko Uchiyama
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Yuma Hotta
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Yuki Toyokawa
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Saori Kashiwagi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Kazuhiro Kamada
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Takeshi Ishikawa
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
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Ghoshal UC, Rai S, Kulkarni A, Gupta A. Prediction of outcome of treatment of acute severe ulcerative colitis using principal component analysis and artificial intelligence. JGH OPEN 2020; 4:889-897. [PMID: 33102760 PMCID: PMC7578272 DOI: 10.1002/jgh3.12342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/26/2020] [Accepted: 03/13/2020] [Indexed: 12/17/2022]
Abstract
Background and Aim About 15% patients with acute severe ulcerative colitis (UC) fail to respond to medical treatment and may require colectomy. An early prediction of response may help the treating team and the patients and their family to prepare for alternative treatment options. Methods Data of 263 patients (mean age 37.0 ± 14.0-years, 176, 77% male) with acute severe UC admitted during a 12-year period were used to study predictors of response using univariate analysis, multivariate linear principal component analysis (PCA), and nonlinear artificial neural network (ANN). Results Of 263 patients, 231 (87.8%) responded to the initial medical treatment that included oral prednisolone (n = 14, 5.3%), intravenous (IV) hydrocortisone (n = 238, 90.5%), IV cyclosporine (n = 9, 3.4%), and inflixmab (n = 2, 0.7%), and 28 (10.6%) did not respond and the remaining 4 (1.5%) died, all of whom did were also nonresponders. Nonresponding patients had to stay longer in the hospital and died more often. On univariate analysis, the presence of complications, the need for use of cyclosporin, lower Hb, platelets, albumin, serum potassium, and higher C-reactive protein were predictors of nonresponse. Hb and albumin were strong predictive factors on both PCA and ANN. Though the nonlinear modeling using ANN had a good predictive accuracy for the response, its accuracy for predicting nonresponse was lower. Conclusion It is possible to predict the response to medical treatment in patients with UC using linear and nonlinear modeling technique. Serum albumin and Hb are strong predictive factors.
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Affiliation(s)
- Uday C Ghoshal
- Department of GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
| | - Sushmita Rai
- Department of GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
| | - Akshay Kulkarni
- Department of GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
| | - Ankur Gupta
- Department of GastroenterologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
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Turner D, Yerushalmi B, Kori M, Broide E, Mozer-Glassberg Y, Shaoul R, Kolho KL, Shteyer E, Shamaly H, Ledder O, Cohen S, Peleg S, On A, Levine A. Once- Versus Twice-daily Mesalazine to Induce Remission in Paediatric Ulcerative Colitis: A Randomised Controlled Trial. J Crohns Colitis 2017; 11:527-533. [PMID: 28453754 DOI: 10.1093/ecco-jcc/jjw180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/30/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Trials in adults suggested that, in ulcerative colitis [UC], once-daily [OD] dosing of 5-ASA [5-amino salicylic acid] may be as or more effective than twice-daily [BD] dosing. In this induction of remission, investigator-blinded, randomised controlled-trial, we aimed to compare effectiveness and safety of once- versus twice-daily mesalazine in paediatric UC. METHODS Children, aged 4-18 years with a PUCAI [Paediatric Ulcerative Colitis Activity Index] of 10-55 points at inclusion, were randomised in blocks of six with blinded allocation to OD or BD mesalazine, using a weight-based dosing table. The primary outcome was mean PUCAI score at Week 6. RESULTS A total of 83/86 randomised children were eligible and analysed: 43 in the OD group and 40 in the BD group (mean age 14 ± 2.7 years, 43 [52%] males, 51 [62%] extensive colitis). The groups did not differ with regard to disease activity or any other parameter at baseline. There was no difference in median PUCAI score between the OD group and BD group at Week 6: 15 ( interquartile range [IQR] 5-40) versus 10 [0-40]; p = 0.48]. Response was seen in 25 [60%] OD versus 25 [63%] BD dosing [p = 0.78]. Proportion of children in remission [PUCAI < 10] at Week 6 was 13 [30%] OD versus 16 [40%] BD; p = 0.35]. Most adverse events were related to disease aggravation; the rates of serious adverse events were similar [p > 0.2]. CONCLUSIONS In this first randomised controlled trial in children, no differences were found between OD and BD dosing for any clinical outcome. Remission was achieved in 35% of children treated with mesalazine for active UC.
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Affiliation(s)
- Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Baruch Yerushalmi
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | | | | | | | | | | | - Oren Ledder
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shlomi Cohen
- Tel Aviv Medical Center, Tel Aviv University, Israel
- Poriya Medical Center, Pediatric Gastroenterology; Bar-Ilan University, Faculty of Medicine in the Galilee, Ramat Gan, Israel
| | | | - Avi On
- Poriya Medical Center, Pediatric Gastroenterology; Bar-Ilan University, Faculty of Medicine in the Galilee, Ramat Gan, Israel
| | - Arie Levine
- Tel Aviv Univeristy and Edith Wolfson Medical Center, Paediatric Gastroenterology and Nutrition, Tel Aviv, Israel
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Abdominal X-ray in Pediatric Acute Severe Colitis and Radiographic Predictors of Response to Intravenous Steroids. J Pediatr Gastroenterol Nutr 2016. [PMID: 26196204 DOI: 10.1097/mpg.0000000000000910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abdominal x-ray (AXR) can identify complications in acute severe colitis (ASC) and may assist in selecting high-risk children for early aggressive treatment. We aimed to describe AXR findings in pediatric ASC and to explore radiological predictors of response to intravenous corticosteroid (IVCS) therapy. METHODS A total of 56 children with ASC were included in a multicenter, retrospective 1-year cohort study (41% boys, mean age 12.1 ± 4.2). Radiographs of responders to IVCS and those requiring second-line salvage therapy by discharge were analyzed independently by 2 blinded radiologists. RESULTS A total of 33 responders to IVCS were compared with 23 nonresponders. The day-3 Pediatric Ulcerative Colitis Activity Index (PUCAI) score was significantly higher in nonresponders (63 ± 16 vs 46 ± 21, P = 0.001). The mean transverse colon luminal diameter was 30 ± 16 mm in responders and 38 ± 16 mm in nonresponders (P = 0.94). The upper range of transverse colonic diameter in children <12 years was ∼40 mm, whereas in older children it was 60 mm as accepted in adults. Ulcerations and megacolon seen on AXR were associated with nonresponse to IVCS (P = 0.006 and 0.064, respectively). CONCLUSIONS The presence of mucosal ulcerations and megacolon on AXR could be considered in the risk stratification of children with ASC for early aggressive treatment, together with the previously known day-3 and day-5 Pediatric Ulcerative Colitis Activity Index scores, albumin, and C-reactive protein.
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Seah D, De Cruz P. Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther 2016; 43:482-513. [PMID: 26725569 DOI: 10.1111/apt.13491] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 09/10/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined. AIM To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management. METHODS Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings. RESULTS Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission. CONCLUSIONS Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.
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Affiliation(s)
- D Seah
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia
| | - P De Cruz
- Department of Medicine, The University of Melbourne, Melbourne, Vic., Australia.,Department of Gastroenterology, Austin Health, Melbourne, Vic., Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Vic., Australia
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Abstract
BACKGROUND No previous studies have evaluated the long-term outcomes of acute severe ulcerative colitis (ASUC) in non-Caucasian populations. The purposes of this study were to evaluate the short- and long-term outcomes of Korean patients with ASUC. METHODS We retrospectively analyzed 99 Korean patients with ASUC who satisfied the criteria given by Truelove and Witts between 1999 and 2005. The short-term outcome parameter was the colectomy rate during index hospitalization, and the long-term outcome parameters were the rates of colectomy and rehospitalization after discharge from index hospitalization. RESULTS During index hospitalization, 16 of 99 patients (16.2%) underwent colectomy: 6 of 71 responders (8.5%) to intravenous steroids on day 3 versus 10 of 28 nonresponders (35.7%), as assessed using the Oxford index (P = 0.002). Among 83 patients who avoided colectomy during index hospitalization, 13 patients (15.7%) underwent colectomy during the median follow-up period of 10.6 years. The cumulative probability of colectomy tended to be lower in complete responders on day 7 of intravenous steroid therapy (CR7) than in others: 3.7% versus 13.9% at 5 years and 7.6% versus 18.2% at 10 years (P = 0.100). The cumulative probability of rehospitalization was significantly lower in CR7 than in other patients: 20.5% versus 37.5% at 5 years and 31.4% versus 48.2% at 10 years (P = 0.043). CONCLUSIONS Assessing the degree of response to intravenous steroids helps predict the short- and long-term outcomes in patients with ASUC. Korean patients with ASUC may have better clinical courses than Caucasians, as indicated by the lower colectomy rate.
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C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2015; 110:802-19; quiz 820. [PMID: 25964225 DOI: 10.1038/ajg.2015.120] [Citation(s) in RCA: 417] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 03/01/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Persistent disease activity is associated with a poor prognosis in inflammatory bowel disease (IBD). Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a treatment concept. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity is a priority. The objective was to evaluate the diagnostic accuracy of C-reactive protein (CRP), fecal calprotectin (FC), and stool lactoferrin (SL) for assessment of endoscopically defined disease activity in IBD. METHODS Databases were searched from inception to November 6, 2014 for relevant cohort and case-control studies that evaluated the diagnostic accuracy of CRP, FC, or SL and used endoscopy as a gold standard in patients with symptoms consistent with active IBD. Sensitivities and specificities were pooled to generate operating property estimates for each test using a bivariate diagnostic meta-analysis. RESULTS Nineteen studies (n=2499 patients) were eligible. The pooled sensitivity and specificity estimates for CRP, FC, and SL were 0.49 (95% confidence interval (CI) 0.34-0.64) and 0.92 (95% CI 0.72-0.96), 0.88 (95% CI 0.84-0.90) and 0.73 (95% CI 0.66-0.79), and 0.82 (95% CI 0.73-0.88) and 0.79 (95% CI 0.62-0.89), respectively. FC was more sensitive than CRP in both diseases and was more sensitive in ulcerative colitis than Crohn's disease. CONCLUSIONS Although CRP, FC, and SL are useful biomarkers, their value in managing individual patients must be considered in specific clinical contexts.
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Bamba S, Andoh A, Imaeda H, Ban H, Kobori A, Mochizuki Y, Shioya M, Nishimura T, Inatomi O, Sasaki M, Saitoh Y, Tsujikawa T, Fujiyama Y. Prognostic factors for colectomy in refractory ulcerative colitis treated with calcineurin inhibitors. Exp Ther Med 2012; 4:99-104. [PMID: 23060930 DOI: 10.3892/etm.2012.545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 03/15/2012] [Indexed: 01/18/2023] Open
Abstract
Calcineurin inhibitors (CNIs) such as cyclosporin A (CSA) and tacrolimus (FK506) are efficacious in patients with steroid-refractory or steroid-dependent ulcerative colitis (UC). We retrospectively investigated patients with refractory UC treated with CNIs to elucidate the prognostic factors for a colectomy. Data from 59 patients (35 men and 24 women) were analyzed. CSA and FK506 were administered by intravenous infusion and peroral administration, respectively. The efficacy of the CNIs was assessed using Seo's complex integrated disease activity index. Categorical data analyses were also conducted. The results revealed that the response rates for CSA and FK506 were similar (CSA, 66.6%; FK506, 63.6%). However, oral FK506 had a slower onset of action than intravenous CSA. The risk factors for CNI non-responsiveness were: i) more than 10,000 mg of prednisolone used prior to CNI treatment; and ii) positivity for cytomegalovirus antigenemia (C7-HRP). The factors affecting the rate of colectomy were: i) CNI non-responsiveness; ii) more than 10,000 mg of prednisolone used prior to the initiation of CNI treatment; and iii) positivity for C7-HRP. The addition of azathioprine (AZA) following CNI treatment significantly reduced the incidence of colectomy. Our results revealed the prognostic factors affecting the efficacy of CNI therapy and the need for colectomy in patients with refractory UC. Importantly, some of these factors may be obtained prior to or shortly following the start of CNI treatment. Furthermore, AZA is an important agent for averting colectomy once a patient responds to CNIs.
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Mañosa M, Cabré E, Garcia-Planella E, Bernal I, Gordillo J, Esteve M, Zabana Y, Gassull MA, Domènech E. Decision tree for early introduction of rescue therapy in active ulcerative colitis treated with steroids. Inflamm Bowel Dis 2011; 17:2497-502. [PMID: 21472824 DOI: 10.1002/ibd.21634] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 12/10/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Corticosteroids are the treatment of choice for moderate-to-severe active ulcerative colitis (UC) but up to 30%-40% of patients fail to respond. It has been reported that early clinical-biological parameters may identify those patients at high risk of colectomy. The aim was to identify predictors of rapid response to systemic steroids in moderate-to-severe attacks of UC. METHODS Consecutive patients treated with prednisone 1 mg/kg/day for moderate-to-severe attacks of UC were prospectively included. Clinical and biological parameters at 3 and 7 days after starting steroids were recorded. Response was defined as mild or inactive UC activity at day 7 (as assessed by the Montreal Classification of severity) together with no need for rescue therapies (cyclosporin, infliximab, or colectomy). A logistic regression analysis was performed to identify those independent predictors of response. In addition, a decision-tree analysis was also performed. RESULTS Sixty-eight percent of patients (64 out of 94) responded to steroids. In the univariate analysis the number of bowel movements, rectal bleeding, platelet count, and C-reactive protein (CRP) levels at day 3 were associated with response at day 7, but only rectal bleeding was found to be an independent predictor in the logistic regression analysis. Conversely, the classification and regression tree (CART) model included these four variables. The decision-tree model showed a higher sensitivity in predicting a rapid response to steroids than the logistic regression one. CONCLUSIONS Rapid response to steroids in active UC attacks can be predicted after 3 days of treatment by simple clinical and biological parameters. A decision-tree model for early introduction of rescue therapies is provided.
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Affiliation(s)
- Míriam Mañosa
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain.
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Abstract
Pediatric ulcerative colitis (UC) has a more severe phenotype, reflected by more extensive disease and a higher rate of acute severe exacerbations. The pooled steroid-failure rate among 291 children from five studies is 34% (95% confidence interval [CI]: 27%-41%). It is suggested that corticosteroids should be dosed between 1-1.5 mg/kg up to 40-60 mg daily. Food restriction has a limited role in severe UC and should be generally discouraged in children who do not have a surgical abdomen. Appraisal of radiologic findings in children must recognize the variation in colonic width with age and size. Data suggest that the Pediatric UC Activity Index (PUCAI), determined at day 3, should be used to screen for patients likely to fail corticosteroids (>45 points), and at day 5 to dictate the introduction of second-line therapy (>65-70 points). Cyclosporine is successful in children with severe colitis but its use should be restricted to 3-4 months while bridging to thiopurine treatment (pooled short-term success rate 81% [95% CI: 76%-86%]; n = 94 from eight studies). Infliximab may be as effective as cyclosporine (75% pooled short-term response (95% CI: 67%-83%); n = 126, six studies) with a pooled 1-year response of 64% (95% CI: 56%-72%). In toxic megacolon, in patients refractory to one salvage medical therapy, and in chronic severe disease, colectomy may be preferred. Decision-making regarding colectomy in children must consider the toxicity of medication consumed over many future years, the quality of life and self-image associated with either choice, as well as both functional outcomes and, in females, fertility following pouch procedures.
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Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.
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Cassinotti A, Actis GC, Duca P, Massari A, Colombo E, Gai E, Annese V, D'Albasio G, Manes G, Travis S, Porro GB, Ardizzone S. Maintenance treatment with azathioprine in ulcerative colitis: outcome and predictive factors after drug withdrawal. Am J Gastroenterol 2009; 104:2760-7. [PMID: 19623172 DOI: 10.1038/ajg.2009.410] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Whether the duration of maintenance treatment with azathioprine (AZA) affects the outcome of ulcerative colitis (UC) is unclear. We investigated clinical outcomes and any predictive factors after withdrawal of AZA in UC. METHODS In this multicenter observational retrospective study, 127 Italian UC patients, who were in steroid-free remission at the time of withdrawal of AZA, were followed-up for a median of 55 months or until relapse. The frequency of clinical relapse or colectomy after AZA withdrawal was analyzed according to demographic, clinical, and endoscopic variables. RESULTS After drug withdrawal, a third of the patients relapsed within 12 months, half within 2 years and two-thirds within 5 years. After multivariable analysis, predictors of relapse after drug withdrawal were lack of sustained remission during AZA maintenance (hazard ratio, HR 2.350, confidence interval, CI 95% 1.434-3.852; P=0.001), extensive colitis (HR 1.793, CI 95% 1.064-3.023, P=0.028 vs. left-sided colitis; HR 2.024, CI 95% 1.103-3.717, P=0.023 vs. distal colitis), and treatment duration, with short treatments (3-6 months) more disadvantaged than >48-month treatments (HR 2.783, CI 95% 1.267-6.114, P=0.008). Concomitant aminosalicylates were the only predictors of sustained remission during AZA therapy (P=0.009). The overall colectomy rate was 10%. Predictors of colectomy were drug-related toxicity as the cause of AZA withdrawal (P=0.041), no post-AZA drug therapy (P=0.031), and treatment duration (P<0.0005). CONCLUSIONS Discontinuation of AZA while UC is in remission is associated with a high relapse rate. Disease extent, lack of sustained remission during AZA, and discontinuation due to toxicity could stratify relapse risk. Concomitant aminosalicylates were advantageous. Prospective randomized controlled trials are needed to confirm whether treatment duration is inversely associated with outcome.
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Affiliation(s)
- Andrea Cassinotti
- Department of Clinical Sciences, Gastroenterology Unit, Luigi Sacco University Hospital, Milano, Italy.
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13
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Moss AC, Peppercorn MA. Steroid-refractory severe ulcerative colitis: what are the available treatment options? Drugs 2008; 68:1157-67. [PMID: 18547130 DOI: 10.2165/00003495-200868090-00001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Approximately 15% of patients with ulcerative colitis will experience a severe episode requiring hospitalization. Although intravenous corticosteroids are the current first-line therapy for these patients, about 30% of patients do not respond to corticosteroids and require either an alternative anti-inflammatory agent or surgery. Ciclosporin has proven its efficacy in a number of controlled trials in this setting and is characterized by high early response rates. Patients who respond to ciclosporin and avoid colectomy are more likely to retain their colon if they bridge to immunomodulators in the medium term. Infliximab has also demonstrated efficacy in reducing early colectomy rates and longer term data are awaited. Other agents, such as tacrolimus and basiliximab, and leukocytapheresis, have been studied in small trials and may be alternative options. Key issues remain as to what should be first- and second-line therapies, when surgery should be undertaken, and the risk of switching between immunosuppressants in these critical patients.
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Affiliation(s)
- Alan C Moss
- Harvard Medical School, Center for Inflammatory Bowel Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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14
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Lau A, Chande N, Ponich T, Gregor JC. Predictive factors associated with immunosuppressive agent use in ulcerative colitis: a case-control study. Aliment Pharmacol Ther 2008; 28:606-13. [PMID: 18564323 DOI: 10.1111/j.1365-2036.2008.03772.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Some patients with ulcerative colitis (UC) require immunosuppressants as maintenance therapy. AIM To assess epidemiological, clinical and disease factors at diagnosis that predict immunosuppressant use in UC. METHODS All UC patients diagnosed between 1992 and 2005 and currently managed in the inflammatory bowel disease (IBD) clinic were included. Forty-three patients who currently or previously received azathioprine (AZA) or mercaptopurine (MP) for UC were compared with 130 controls. Charts were reviewed and logistic regression analyses were applied to identify factors associated with AZA or MP use. RESULTS In univariate model, seven factors at diagnosis correlated with AZA use: male gender [odds ratio (OR) 2.2]; left-sided or extensive colitis or pancolitis (OR 8.7-14.1); systemic steroid use within the first 6 months of diagnosis (OR 5.1); more than 10 bowel movements daily (OR 6.4); persistent or mostly blood in stool (OR 2.8); endoscopic proven moderate to severe disease (OR 7.2-12.0) and requirement of hospitalization (OR 2.7) on diagnosis. In multivariate model, the first three factors were shown to be statistically significant. CONCLUSION Male gender, initial presentation with severe and extensive disease clinically and endoscopically, requirement of hospitalization on diagnosis or systemic steroids within 6 months of diagnosis are predictive factors for immunosuppressant use in UC.
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Affiliation(s)
- A Lau
- Division of Gastroenterology, The University of Western Ontario, London, ON, Canada.
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15
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OSHITANI N, KITANO A, OBAYASHI M, TABATA A, FUKUSHIMA R, OKABE H, KASHIMA K, NAKAMURA S, OBATA A, MATSUMOTO T, OKAWA K, KOBAYASHI K. A Study on Atypical Endoscopic Findings of Ulcerative Colitis: Longitudinal Ulcers, Mucosal Bridges and Red Spots. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1991.tb00274.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Nobuhide OSHITANI
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Atsuo KITANO
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Makoto OBAYASHI
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Akihiro TABATA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Ryuji FUKUSHIMA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Hiromu OKABE
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Kazutoshi KASHIMA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Shiro NAKAMURA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Akishige OBATA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Takayuki MATSUMOTO
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Kiyotaka OKAWA
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
| | - Kenzo KOBAYASHI
- Third Department of Internal Medicine, Osaka City University Medical School, Osaka, Japan
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16
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Gisbert JP, Gomollón F. [Common errors in the management of the seriously ill patient with inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:294-314. [PMID: 17493441 DOI: 10.1157/13101982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Universidad Autónoma, Madrid, Spain.
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17
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Turner D, Walsh CM, Steinhart AH, Griffiths AM. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol 2007; 5:103-10. [PMID: 17142106 DOI: 10.1016/j.cgh.2006.09.033] [Citation(s) in RCA: 413] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colectomy is a potentially life-saving procedure for patients with severe attacks of UC who fail medical therapy. We aimed to systematically review studies that reported the short-term colectomy rate in severe UC or reported variables that could predict treatment failure. METHODS We conducted a systematic literature search for cohort studies and controlled trials published between 1974-2006. RESULTS Thirty-two studies met the inclusion criteria; 16 reported short-term outcome and predictors of therapy failure, 13 only outcome, and 3 only predictors. In the pooled analysis, 581 of 1991 patients required colectomy (weighted mean 27; 95% confidence interval [CI], 26%-28%), and 22 died (1%; 95% CI, 0.7%-1.5%). In a heterogeneity-controlled meta-regression, colectomy rate did not change during the last 30 years (R(2) = 0.07, P = .8). Cyclosporine was used in only 100 patients, with a 51% (95% CI, 41%-60%) short-term success rate. A second meta-regression failed to demonstrate a dose-colectomy response of methylprednisolone therapy beyond 60 mg daily (R(2) < 0.01, P = .98). More than 20 variables were identified in 19 studies to predict medical therapy failure, but only a few were consistently reproduced: disease extent, stool frequency, temperature, heart rate, C-reactive protein, albumin, and radiologic assessment. CONCLUSIONS The short-term colectomy rate in severe UC has remained stable during the last 30 years, despite the introduction of cyclosporine, which was not used frequently. We could not find any support for administering methylprednisolone at a higher dose than 60 mg/day. Variables that predict outcome of corticosteroid therapy could aid in the development of guidelines for introduction of rescue therapies in severe UC.
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Affiliation(s)
- Dan Turner
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
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18
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Bernal I, Mañosa M, Domènech E, Garcia-Planella E, Navarro M, Lorenzo-Zúñiga V, Cabré E, Gassull MA. Predictors of clinical response to systemic steroids in active ulcerative colitis. Dig Dis Sci 2006; 51:1434-8. [PMID: 16868820 DOI: 10.1007/s10620-006-9103-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Accepted: 10/26/2005] [Indexed: 12/09/2022]
Abstract
Although systemic steroids remain as the gold standard for the treatment of acute moderate to severe active ulcerative colitis (UC), 15-57% of patients do not achieve clinical remission. We sought to identify clinical, biological, or radiologic predictive factors of response to steroid treatment in acute UC attacks. The medical records of 39 consecutive patients admitted for an acute attack of UC and treated with systemic steroids, were reviewed. Epidemiologic, demographic, and clinical data at baseline and clinical data 3 days after starting steroid treatment were registered. Treatment failure was defined as the need of IV cyclosporine or colectomy before hospital discharge. Twenty-four patients (62%) responded to systemic steroids. Thirteen out of the 15 nonresponders, were treated with IV cyclosporine, avoiding colectomy in 7 cases (54%). More than six bowel movements per day at the third day of treatment, blood in stools in the third day of therapy, extensive UC, and the presence of malnutrition were associated with steroid treatment failure, but only blood in stools (P=.04), and more than six movements per day (P=.012) after 3 days of treatment, were found to be independent predictive factors of steroid refractoriness. In conclusion, clinical evaluation 3 days after starting systemic steroids seems to be the best tool to assess short-term prognosis.
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Affiliation(s)
- Isabel Bernal
- Gastroenterology Department Hospital Universitari Germans Trias i Pujol, 5 planta, edifici general, Ctra. del Canyet, s/n, 08916, Badalona, Spain
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19
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Kumar S, Ghoshal UC, Aggarwal R, Saraswat VA, Choudhuri G. Severe ulcerative colitis: prospective study of parameters determining outcome. J Gastroenterol Hepatol 2004; 19:1247-52. [PMID: 15482530 DOI: 10.1111/j.1440-1746.2004.03486.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND One-third of patients with exacerbations of ulcerative colitis (UC) require colectomy and 1% die. Although several studies have reported parameters associated with failure of medical treatment, studies using multivariate analysis of various predictors are scanty. METHODS Demographic, clinical and laboratory parameters within 48 h of admission of 50 consecutive patients (55 episodes) were prospectively recorded. Each episode was treated with intravenous hydrocortisone, antibiotics and fluid administration. The data of patients who failed to respond, deteriorated, developed complications requiring emergency surgery or died within 7 days of hospitalization, were compared with the data of those who responded during this period using Mann-Whitney U-test or chi-squared tests. Variables found to be significant on univariate analysis were entered into a multivariate model. RESULTS Medical treatment failed in 10 of 55 episodes; eight had surgery (one died), another died with bowel perforation and peritonitis and one left hospital in a moribund state. Younger age, pedal edema, transverse colonic diameter >5 cm on abdominal radiograph, low hemoglobin, low serum albumin, high C-reactive protein, presence of fibrin degradation product (FDP) in serum, low serum fibrinogen, prolonged prothrombin time, Truelove-Witt's fulminant disease, and high clinical activity index were associated with failure of medical treatment on univariate analysis. All the above variables were significant by multivariate analysis except age, serum albumin level and presence of FDP. CONCLUSION It may be possible to predict the failure of medical treatment in exacerbations of UC using a scoring system based on clinical parameters and simple laboratory tests.
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Affiliation(s)
- Sanjay Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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20
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Matsumoto T, Nakamura S, Shimizu M, Iida M. Significance of appendiceal involvement in patients with ulcerative colitis. Gastrointest Endosc 2002; 55:180-5. [PMID: 11818919 DOI: 10.1067/mge.2002.121335] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The appendix is occasionally involved in patients with distal ulcerative colitis. This study investigated the clinical significance of patchy involvement at the appendiceal orifice in ulcerative colitis. METHODS Colonoscopy was performed in 40 patients with active distal ulcerative colitis of mild to moderate severity. Patients were divided into 2 groups based on the presence or absence (positive or negative) of involvement at the appendiceal orifice at colonoscopy. Clinical activity, histologic grade of inflammation, and subsequent clinical course were compared between patients who were positive (appe(+)) and negative (appe(-)). RESULTS Twenty-three patients had involvement at the appendiceal orifice (reddish mucosa with mucinous exudate). The proximal-most extent of involvement by ulcerative colitis, the endoscopic grade, and clinical activity were not different between appe(+) and appe(-) groups. However, histologic grade of inflammation in the ascending colon was higher in the appe(+) group than in the appe(-) group. The endoscopic remission rate at 12 months was higher in the appe(+) group than in the appe(-) group (84% vs. 40%, p < 0.05). CONCLUSIONS In patients with distal ulcerative colitis, involvement at the appendiceal orifice may be indicative of histologically active disease, which responds reasonably well to pharmacotherapy.
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Affiliation(s)
- Takayuki Matsumoto
- Department of Endoscopic Diagnostics and Therapeutics, Kyushu University Hospital, Fukuoka, Japan
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21
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Rowe FA, Walker JH, Karp LC, Vasiliauskas EA, Plevy SE, Targan SR. Factors predictive of response to cyclosporin treatment for severe, steroid-resistant ulcerative colitis. Am J Gastroenterol 2000; 95:2000-8. [PMID: 10950049 DOI: 10.1111/j.1572-0241.2000.02186.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cyclosporin-A (CSA) has been demonstrated to be effective for treatment of severe, steroid-resistant ulcerative colitis (UC). Use of CSA has been limited, however, because of low 1-yr response rates and the potential for complications. The aim of this study is to define clinical and laboratory factors predictive of response in severe, steroid-resistant UC. METHODS A retrospective review of 36 cases of severe, steroid-resistant UC treated with CSA was performed. Intravenous (i.v.) CSA was administered at an initial dose of 2.5 mg/kg, and oral (p.o.) CSA was given as twice the i.v. dose. Clinical response was recorded and logistic regression analysis was performed on clinical and laboratory factors for prediction of response to CSA. RESULTS Of 36 patients, 25 responded to i.v. CSA and were switched to p.o. CSA. Of the 25, 13 required colectomy by 9 months. The other 12 patients had a sustained response to CSA and avoided colectomy at 9 months. Overall, 24 of 36 patients treated with CSA required colectomy by 9 months. A high percentage of band neutrophils (bands) on admission was found to be a significant predictor of response to CSA. CONCLUSIONS Bands on admission are predictive of response to CSA and ultimately, the requirement for surgery in steroid-resistant UC.
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Affiliation(s)
- F A Rowe
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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22
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Gelbmann CM. Prediction of treatment refractoriness in ulcerative colitis and Crohn's disease--do we have reliable markers? Inflamm Bowel Dis 2000; 6:123-31. [PMID: 10833072 DOI: 10.1097/00054725-200005000-00009] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Treatment refractoriness is a severe problem in the management of patients with ulcerative colitis and Crohn's disease. Despite some promising new therapeutic approaches, corticosteroids are still the preferential primary treatment for moderate to severe Crohn's disease and of severe ulcerative colitis. However, clinical response to corticosteroids varies, and many patients are resistant to such treatment. Since corticosteroids have frequent and even severe side effects, and toxicity increases with chronic steroid intake, factors predictive of response to such treatment would be very helpful for decisions on further management of these patients. At least in severe attacks of ulcerative colitis, the consensus seems to be that a high frequency of bowel movements as well as a high C-reactive protein and low serum albumin recorded after a few days of intensive medical treatment are important signs for early prediction of treatment failure in the majority of the patients. In Crohn's disease thus far, data on predictive factors are conflicting. No reliable marker with sufficient predictive value for treatment refractoriness could be identified. This might be due to the tremendous heterogeneity of Crohn's disease with many clinical phenotypes, which requires subgroup analysis with sufficient numbers of patients. Corticosteroids as well as other immunomodulating and immunosuppressive medications interfere with the immune system, which plays a central role in the mediation of intestinal inflammation. Treatment refractoriness might have its origin in specific immunological peculiarities eventually reflected in abnormal immunological, biochemical, and clinical parameters. Further exploration of those parameters to predict treatment refractoriness in patients with ulcerative colitis or Crohn's disease is of great clinical importance for safe and efficient management of patients.
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Affiliation(s)
- C M Gelbmann
- Department of Internal Medicine I, University of Regensburg, Germany
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23
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Abstract
A decrease in serum albumin concentrations is an almost inevitable finding in disease states, and is primarily mediated in the acute phase by alterations in vascular permeability and redistribution. This change is not disease specific but marked changes that persist are generally associated with a poorer prognosis. Critical appraisal of long-standing practices and the availability of alternative colloid solutions have led to a reduction in albumin replacement therapy, and a widespread tolerance of lower albumin concentrations in patients. The factors determining serum albumin concentrations, their measurement and the implications of hypoalbuminaemia are reviewed. The clinical value of serum albumin measurement is discussed.
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Affiliation(s)
- M P Margarson
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
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24
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Ricci G, D'Ambrosi A, Resca D, Masotti M, Alvisi V. Comparison of serum total sialic acid, C-reactive protein, alpha 1-acid glycoprotein and beta 2-microglobulin in patients with non-malignant bowel diseases. Biomed Pharmacother 1995; 49:259-62. [PMID: 7579005 DOI: 10.1016/0753-3322(96)82632-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Total sialic acid (TSA), C-reactive protein (CRP); alpha 1 acid glycoprotein (alpha 1-AG), and beta 2-microglobulin were determined in 84 patients affected by non-malignant intestinal diseases, Crohn's disease (CD) and ulcerative colitis (UC), active and in remission; non-ulcerative proctosigmoiditis; diverticulosis; diverticulitis (ie, inflammatory complication of diverticulosis). Only in patients with acute phase CD, TSA was statistically higher than those in remission, as well as in controls. In patients with acute CD and in those with diverticulitis, CRP was significantly higher than in the controls. alpha 1-AG was found significantly increased in acute UC and CD patients versus the respective groups in remission, as well as versus controls. Moreover, alpha 1-AG was higher in patients with diverticulitis. beta 2-microglobulin did not differ in any group of patients. In five patients with CD in acute phase, investigated before and during the pharmacological treatment (5-aminosalycilic acid and steroids), CRP values fell into the normal range after the second week of therapy, whereas TSA values reached the higher limit of the normal range after the third week, except for two CD patients with a larger location (ileocolonic) of the disease. The results are briefly discussed.
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Affiliation(s)
- G Ricci
- Institute of Internal Medicine I, Postgraduate School of Gastroenterology and Endoscopy, University of Ferrara, Italy
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Fabris C, Pirisi M, Soardo G, Falleti E, Pezzetta F, Vitulli D, Toniutto P, Bortolotti N, Gonano F, Bartoli E. Value of serum C-reactive protein measurement in the detection of hepatocellular carcinoma superimposed on liver cirrhosis. J Cancer Res Clin Oncol 1994; 120:229-32. [PMID: 7507117 DOI: 10.1007/bf01372561] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We investigated whether, in Italian patients, C-reactive protein (CRP) determination could be considered a useful adjunct, complementary to alpha 1-fetoprotein, in the detection of liver cancer. CRP was determined by particle-enhanced nephelometry in 171 subjects (102 male, 69 female). Fifty-five patients had mild chronic liver disease (CLD), 45 cirrhosis (CIR), 38 hepatocellular carcinoma (HCC); 33 subjects were healthy controls. Patients with HCC and CIR had higher CRP levels (P < 0.05) than those found in patients with CLD and controls. CRP higher than 5 mg/l was found in 30/38 (78.9%) patients with HCC, 28/45 (62.2%) patients with CIR, 16/55 (29.1%) patients with CLD (chi 2 56.0, P < 0.0001). Sensitivity, specificity and diagnostic accuracy of CRP in diagnosing HCC with respect to CLD+CIR were: 78.9%, 56.0% and 34.9%. However, when considered only in the subgroup of patients with alpha 1-fetoprotein below or equalling 30 ng/ml, they were 50.0%, 54.3% and 4.3% respectively. In conclusion, CRP concentration is frequently elevated in patients with HCC, however, it does not seem to improve the ability of alpha 1-fetoprotein to discriminate HCC from CIR.
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Affiliation(s)
- C Fabris
- Cattedra di Medicina Interna, Università degli Studi di Udine, Italy
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Kjeldsen J, Schaffalitzky de Muckadell OB. Assessment of disease severity and activity in inflammatory bowel disease. Scand J Gastroenterol 1993; 28:1-9. [PMID: 8430269 DOI: 10.3109/00365529309096037] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- J Kjeldsen
- Dept. of Medical Gastroenterology S, Odense University Hospital, Denmark
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