Case Report: Chronic Prostatitis as an Extraintestinal Manifestation of Ulcerative Colitis

Aims: To define the number/frequency of organ systems affected by extraintestinal manifestations (EIMs), to identify factors affecting the clinical course of inflammatory bowel disease (IBD) and EIM development, and to determine the impact of smoking, disease duration and location on the diagnosis of EIMs in Crohn's disease (CD) and ulcerative colitis (UC). Methods: IBD patients were derived from a single university colorectal surgery practice. Smoking data were obtained through a modified Behavioral Risk Factor Surveillance System survey. The frequencies of arthritis/arthralgia, primary sclerosing cholangitis (PSC), ocular and cutaneous EIMs were determined. Results: Of the 757 patients evaluated (CD 488, UC 269), 50% had ≥1 EIM. Arthritis/arthralgia, cutaneous and ocular EIMs were significantly higher in frequency in CD compared to UC patients. Prolonged disease duration was associated with increased prevalence of arthritis/arthralgia in IBD (p ≤ 0.001) as well as PSC (p = 0.049), ocular (p = 0.030) and cutaneous (p = 0.009) EIMs in CD. Disease location affected the occurrence of EIMs in CD. Smoking appeared to increase the prevalence of ocular EIMs in UC (p = 0.026). Conclusion: Arthritis/arthralgia, cutaneous and ocular EIMs occurred in a significantly higher proportion of CD patients. CD patients with longer disease duration had a significantly higher prevalence of PSC, ocular and cutaneous EIMs. Smoking was found to increase ocular EIMs in UC.

Recurrent pericarditis due to mesalamine hypersensitivity: a pediatric case report and review of the literature.

Excerpt INTRODUCTION Considerable disagreement exists as to the nature of the changes in the liver associated with intestinal amebiasis. The clinical syndrome of diffuse amebic hepatitis is widely ...

Inflammatory Bowel Diseases (IBD) lead to chronic intestinal inflammation along with extra-intestinal manifestations which could present prior to, subsequent with or after the diagnosis of IBD. We present a unique case of Ulcerative Colitis (UC), Autoimmune Hemolytic Anemia (AIHA) and Primary Sclerosing Cholangitis (PSC) diagnosed simultaneously in a patient. The unique triad of these diseases gives important clues to the immunological factors involved in the pathogenesis of these diseases. An 18-year-old male presented with 1 week of bloody diarrhea, abdominal cramps and nausea. Vitals were stable. Initial labs showed Hb 9.5 g/dL, MCV 102 fL, WBC 22.4 x 103/μL, total bilirubin 2.4 mg/dL, direct bilirubin 0.7 mg/dL, alkaline phosphatase 436 units/L, ALT 133 units/L and AST 83 units/L. Hepatitis panel and Clostridium difficile toxin assay were negative. Further work-up revealed reticulocyte count > 17%, LDH 529 units/L, haptoglobin < 10 mg/dl and positive direct Coomb's test. Peripheral smear showed hemolysis by a warm antibody. Hydrocortisone was started for AIHA. CT abdomen showed mild colonic wall thickening. Colonoscopy showed moderate pancolitis and biopsies showed findings consistent with UC. Mesalamine was started. MRCP showed irregular beaded appearance of intra and extrahepatic bile ducts. ERCP was performed and biopsies taken from the ducts showed chronic inflammation but no evidence of malignancy. ASMA and ANCA were positive. Liver biopsy ruled out overlap syndrome with autoimmune hepatitis. The patient clinically improved and was discharged to follow-up with a gastroenterologist. In patients with UC, extra-intestinal manifestations involving cutaneous, hepatobiliary and ocular systems are common. The concomitant presence of PSC is 2-7% and AIHA is 0.2 -1.7% in patients with UC. The extra-intestinal manifestations of UC could be due to associated autoimmune diseases or they could be immune-mediated due to damaged mucosal wall. The exact pathogenesis of PSC and AIHA is unknown. The absorption of toxins and antigenic substances from the mucosa in the circulation mediates inflammation in the biliary system leading to PSC. This also leads to warm anti-E antibody production which cross-react with intestinal microbiome and the E antigen at the surface of RBCs. In UC patients, a vigorous workup for early detection of other autoimmune diseases is important to improve the quality of life and to prevent mortality associated with them.Figure: Peripheral smear showing polychromatic RBCs and microspherocytes.Figure: Axial CT demonstrating mild wall thickening and featureless appearance of the rectosigmoid colon compatible with chronic ulcerative colitis (left). Descending colon at 4X magnification showing crypt distortion, cryptitis and crypt abscess (right).Figure: Left: Coronal thin section T2 weighted image showing a beaded appearance of the left hepatic and intrahepatic bile ducts with alternating strictures (arrows) and dilatation (arrowheads). Right: A) Fluoroscopic image from an ERCP depicting beading of the bilateral intrahepatic bile ducts due to segmental strictures (thin arrows). Guidewire in the left intrahepatic bile duct (thick arrow). B) ERCP image after biliary stent placement (arrowhead) with decompression of the biliary tree.

Background Inflammatory bowel diseases (IBD) are often characterized by associated conditions with extraintestinal manifestations that can make diagnosis and treatment difficult. It is known that chronic inflammation, nutritional deficiencies and corticosteroid treatment in IBD are the main risk factors for developing metabolic bone diseases. This study aims to evaluate ulcerative colitis (UC) patients with osteoporosis and osteopenia as extraintestinal manifestation. Methods We analyzed 79 patients (mean age 42 years) with UC and we measured bone mineral density by dual energy X-ray absorptiometry (DXA). Patients who received treatment with corticosteroids were not included in the study. 25(OH)D levels were also measured in all patients enrolled in the study. The patients did not follow vitamin D supplementation treatment. Disease remission was defined with partial Mayo score ≤2. Among the patients included in the study, 52 were under biologic therapy. Results Among the patients included in the study 55 patients (69%) were in remission and 49 patients (62%) with low vitamin D levels &amp;lt;20 ng/ml. Osteoporosis (T score &amp;lt;-2.5) was found in 24% of patients at the lumbar-sacral spine and in 13.9% of patients at the femoral neck; osteopenia (T score between -1.0 and -2.5) was also found in 40.5% of patients at the lumbar-sacral spine and in 35.5% of patients at the femoral neck. All patients with osteoporosis had vitamin D deficiency (p=0.01) and osteopenia was present in 61% of patients with vitamin D deficiency (p=0.05). Regarding disease activity, 23.6% patients in remission and 29.1% patients with active ulcerative colitis were diagnosed with osteoporosis (p=0.69), meanwhile in the osteopenia group, 38.1% patients were in remission and 41.6% patients were with active disease (p=0.84). From the patients included in the study, 65.8% were following biological therapy of which only 3.8% were diagnosed with osteoporosis (p=0.007) and 11.5% were diagnosed with osteopenia (p=0.006). Conclusion Our data confirm that osteoporosis and osteopenia are common extraintestinal manifestations in ulcerative colitis. Patients with vitamin D deficiency were more likely to develop metabolic bone diseases without statistically significant differences between ulcerative colitis patients with active disease or those in remission. Patients who follow biological therapy have a lower risk of developing metabolic bone disease. Screening for osteoporosis and osteopenia is indicated in UC patients and vitamin D supplements are mandatory.

Immune thrombocytopenic purpura (ITP) is characterized by immune-mediated platelet destruction of platelets. The condition involves the presence of autoantibodies targeting platelet membrane antigens. ITP has been documented in the literature as a rare extra-intestinal manifestation of inflammatory bowel disease (IBD). This case report aims to describe the rare association of ITP as an extra-intestinal manifestation of ulcerative colitis (UC), accompanied by a literature review. We report the case of a 21-year-old male presenting with acute bloody diarrhea refractory to broad-spectrum antibiotic therapy. Given the patient’s significant history of intermittent persistent diarrhea, hematochezia, hematuria, and thrombocytopenia, an evaluation for relapsing IBD was undertaken. Colonoscopic biopsy findings were consistent, with UC showing mild activity, while bone marrow aspiration revealed features indicative of chronic ITP. The patient was managed with oral corticosteroids for the IBD flare and oral mesalamine, resulting in a significant improvement in platelet count. Upon follow-up, with remission of UC, it was accompanied by a complete normalization of the patient’s platelet count. ITP has been reported as a rare extra-intestinal manifestation of IBD (UC). This report emphasizes the importance of suspecting IBD in cases of unexplained thrombocytopenia, particularly in compatible clinical settings, to enable timely diagnosis and management of both conditions, ultimately improving patient outcomes.

Studies of inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn's disease, is highly relevant due to their growing incidence and prevalence, and a wide range of extraintestinal manifestations. The paper deals with the discussion of renal damage types in IBD. Renal damage in IBD refers to rare cases of extra-intestinal manifestations and could both originate by the immunological mechanism common with IBD and directly related to inflammatory activity in the intestine, as well as be unrelated to the immunological activity of the bowel disease and be associated with metabolic disorders that develop in IBD. Finally, kidney damage in IBD can be caused by side effects of treatments. As an example, we present a case of mesangioproliferative glomerulonephritis as an extra-intestinal manifestation of ulcerative colitis and discuss the challenges of therapy and the effectiveness of genetically engineered biological agent golimumab. An algorithm for the differential diagnosis of the renal damage in patients with ulcerative colitis and Crohn's disease is proposed to be used in real clinical practice, with recommendations for monitoring of patients with IBD as those at risk for the development of chronic kidney disease.

Excerpt INTRODUCTION The effects of corticotropin (ACTH) and cortisone in ulcerative colitis have been characterized as beneficial,1-5indifferent6-8and unfavorable.9-14Numerous studies also have em...

Inflammatory bowel disease in children and adolescents: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Inflammatory bowel disease (IBD) had been uncommon in China until about 1990, but since then, it has been seen in the clinical setting more and more. The prevalence and phenotype of IBD in the Chinese population is not well known. The present study investigates the trend of prevalence in ulcerative colitis (UC) and Crohn's disease (CD) in Wuhan City, central China, and evaluates clinical features, extraintestinal manifestations, and the treatment of IBD in the last 14 years. Three hundred and eighty-nine patients with UC and 63 patients with CD were retrospectively collected from 5 central hospitals in Wuhan City, in which high-quality endoscopic and histological diagnoses were available from 1990 to 2003. UC and CD were diagnosed based on clinical, experimental, radiological, endoscopic, and histological examinations according to the internationally accepted Lennard-Jones criteria. The trend toward prevalence of UC and CD increased between 1990 and 2003 in Wuhan City. There was no change in the sex and age distribution comparing 1990 to 1996 with 1997 to 2003 both in UC and CD. However, the number of individuals with higher education and a professional occupation during 1997 to 2003 was significantly higher than that during the period 1990 to 1996 in patients with UC (OR 2.1, 95% CI 1.27-3.35, P = 0.004; OR 2.2, 95% CI 1.31-3.61, P = 0.003). The mean age of patients with CD was significantly younger than that of UC at the time of diagnosis (32.6 +/- 12.5 vs. 42 +/- 14.5, P < 0.0001). The ratio of male to female patients was 1.53:1 in UC and 2.32:1 in CD, respectively. The mean duration of onset of the disease to diagnosis was 1.4 years in UC and 1.1 years in CD. The extra intestinal manifestations of UC and CD were 5.7% and 19%, respectively, and complications of UC and CD were 6.4% and 50.8%, respectively. Only 3% of UC patients required surgery, whereas 27% of CD patients underwent surgical procedures (P < 0.001). The prevalence of IBD has increased in Wuhan City, central China, but is not as high as in Western countries. The disease in Wuhan City has often been associated with young adult professional males with a high level of education. The clinical presentation of UC was often mild and had few extra intestinal manifestations.

Background and AimsExtraintestinal manifestations are reported to occur in up to 45% of inflammatory bowel disease (IBD) patients during the course of disease. It is unknown whether colectomy reduces the rate of de novo extraintestinal manifestations (EIMs) or impacts on severity of EIMs following a parallel versus independent disease course from underlying IBD.MethodsUsing data from the Swiss Inflammatory Bowel Disease Cohort Study we aimed to analyse the course of EIMs in ulcerative colitis (UC) and Crohn’s disease (CD) patients undergoing colectomy during the cohort’s prospective follow‐up.ResultsOne hundred and twenty‐one IBD patients (33 CD, 81 UC and seven unclassified) underwent colectomy during prospective follow‐up in the Swiss Inflammatory Bowel Disease Cohort Study. Within the 114 patients with UC or CD any EIM was reported in 40 (nine CD and 31 UC) patients. Activity of EIMs ceased entirely after colectomy in 21 patients (52.5%). Complete cessation of EIM after colectomy was higher in patients with UC versus CD with 58.1% versus 33.3%. After colectomy, 29 out of the 114 patients (25.4%) experienced any EIM. Two thirds of these (19 patients) represented persisting EIMs, while in one third (10 patients) EIM represented a de‐novo event after colectomy. Overall, 13.5% of IBD patients developed a de‐novo EIM after colectomy.ConclusionsIn IBD patients undergoing colectomy, EIMs present prior to surgery will persist in about half of patients. Complete cessation of EIM after colectomy may be less common in CD than in UC. In patients who never experienced EIMs prior to colectomy de‐novo manifestations thereafter should be expected in up to one in seven patients.

Ulcerative colitis (UC) is an idiopathic, chronic inflammatory bowel disease (IBD) most often located in the rectum, but may involve the entire colon. Extra intestinal manifestations (EIMs) occur with varying frequency depending on the affected organ. The most common ones are musculoskeletal EIMs, affecting up to 33%-40% of IBD patients. These include, among others, inflammatory back pain, tendinitis, plantar fasciitis and arthritis. Only a few case reports in literature discuss Achilles tendinitis. This report describes a patient with UC and Achilles tendinitis in whom after many unsuccessful attempts of treatment with sulfasalazine, mesalazine, glucocorticosteroids, infliximab and tofacitinib, a complete UC remission and resolution of Achilles tendinitis were achieved with the use of dual biologic therapy (DBT)-ustekinumab and adalimumab (ADA). This case mentions rare EIMs of UC and suggests that DBT may be an alternative for patient with ulcerative colitis and EIMs.

The data on prevalence of extraintestinal manifestations (EIM) in ulcerative colitis (UC) are scanty and highly variable. Consecutive patients with UC were prospectively evaluated from November 2016 to August 2017. A detailed history was obtainedand physicalexamination wasdone. Presence of EIM was confirmed bya consultant rheumatologist, ophthalmologist and dermatologist. Tests performed were hemogram, liver function test, abdominal ultrasound, slit lamp examination, X-ray and magnetic resonance imaging when deemed necessary. A total of 227 patients with UC were enrolled in this study. The prevalence of EIM was 7.92%. Mucocutaneous (4.84%) manifestations were the commonest, followed by musculoskeletal (1.32%) and ocular (0.88%). Hepatobiliary (0.44%) and vascular (0.44) manifestations were present in equal frequency. History of appendicectomy was associated with EIM. The prevalence of EIM in UC was low in our study. History of appendicectomy was a risk factor for EIM.

Purpose: Primary endpoint is to determine risk factors that predict chronic pouchitis in those patients having ileal pouch anal anastamosis (IPAA.) Methods: 237 patients with ulcerative colitis (UC) and undergoing IPAA by one surgeon at Oregon Health & Science University from 1993–2003 were evaluated. Data were gathered via retrospective chart reviews and by a questionnaire administered by telephone in 2004. Patients were excluded if there was less than one year follow-up documented in the chart or they could not be contacted by telephone (n = 63), post-operative diagnosis of Crohn's disease (n = 3), failed ileoanal procedure (n = 1), and 1-stage IPAA (n = 3.) Patients were defined as having chronic pouchitis (CP = >3 episodes of pouchitis) or having no pouchitis (≤3 episodes of pouchitis.) Potential risk factors included number of operations used to perform IPAA, fulminant UC with 2-stage operation, duration of diverting ileostomy following pouch formation, primary sclerosing cholangitis (PSC), other extra-intestinal manifestations (EIMs) of UC, pre-operative liver function tests, duration of UC, and the occurrence of post-operative complications. Initial univariate analysis was performed on all risk factors. Multivariate analysis was performed on all univariate risk factors with p values < 0.2. Results: The prevalence of CP in our population was 46%. The following variables were identified during univariate analysis and entered into a multivariate model: pre-operative serum albumin (p = .07), PSC (p = 0.126), duration of diverting ileostomy (p = 0.111), fulminant UC with 2-stage operation, (p = .051), and occurrence of post-operative complications (p = .007). Patients who did not undergo diverting ileostomy at the time of their IPAA trended towards a lower likelihood of developing CP (p = 0.06.) Multivariate analysis showed that patients with post-operative complications (53%) were more likely to develop CP (p = .009.) 8% of patients had PSC and 11% of patients had at least one EIM of UC. Patients with PSC and EIMs were not more likely to develop CP (p = 0.273, p = 0.126.) Conclusions: Chronic pouchitis (CP) is a frequent complication following IPAA. In this study patients with PSC or other EIMs of UC were not more likely to develop CP. Patients with post-operative complications following IPAA were more likely to develop CP and may benefit from early strategies to prevent pouchitis.

Inflammatory Bowel Disease Extending Its Reach