Endoscopic Diagnosis of Refractory Ulcerative Colitis

Abstract

Background & Aim: In many treatment-resistant refractory ulcerative colitis (UC) cases, repeated relapse and remission, secondary ischemic changes, inflammation, infection, and mechanical stimulation by feces can modify the original pathology, and exhibit a variety of endoscopic views. Endoscopic findings contribute greatly to the selection of the therapeutic approach, judgment of the therapeutic effects, decisions regarding the completion of therapy and dose reduction, and evaluation of the risk for exacerbation in consideration of their causes. In this study, we investigated their endoscopic characteristics and clinical views of refractory UC, and studied the frequency and location of refractory lesions, such as longitudinal ulcer, extensive mucosal abrasion, punched out ulcer. Subjects and Methods: Out of 308 UC patients who were followed at our department during the past 15 years, 68 patients with severe UC exhibiting apparent endoscopic findings that were treated with steroid(SH) were investigated. Of these, 41 patients were resistant to SH treatment (SH-resistant cases), and 27 patients responded to SH treatment (SH-responsive cases). Two groups were compared by the following item; endoscopic findings, effect of treatment, and relation to CMV infection. For between-group comparison, Mann-Whitney U test and c2 test were used. Results: In SH-refractory UC, longitudinal ulcer (65.9%) and extensive mucosal abrasion (61.0%) were found with high frequency, and there were refractory lesion significantly in the proximal colon. In case of UC with refractory lesion, there is a high possibility that treatment is ineffective (73.0%). Of 14 UC patients with refractory lesion treated with Leukocytaphrasis (LCAP® Cellsorba), 10 (71.5%) obtained remission, whereas only 12 of 30 (40%) those patients with treated by only SH-treatment achieved remission (p < 0.05). Our facility encountered 11 UC cases with complications of CMV infection, and all of these were SH-resistant and had refractory lesions: longitudinal ulcer in 5, extensive mucosal abrasion in 5, and punched out ulcer in 5. And 10 (90.9%) UC cases were refractory to SH- treatment, and only one patient with CMV infection was treated with Gancyclovir, improved and was able to taper off steroids and avoid colectomy. Conclusion: For the diagnosis and treatment of refractory UC, accurate diagnosis of the presence or absence of refractory lesions and judgment of therapeutic results by endoscopy is important for consideration of the necessity for additional treatment and therapeutic policy, and LCAP is a useful alternative therapy for patients with SH-refractory UC.