Endoscopic Features of Inflammatory Bowel Disease in Patients with Primary Sclerosing Cholangitis

Abstract

Purpose: An increased prevalence of pancolitis, rectal sparing, and backwash ileitis has been described in inflammatory bowel disease associated with primary sclerosing cholangitis (PSC-IBD), which may represent a distinct phenotype of IBD. This study characterizes the endoscopic features of IBD in a group of patients with PSC-IBD and compares them to a matched group of patients with chronic ulcerative colitis (UC) without PSC. Methods: All patients with both PSC and IBD evaluated at St. Louis University (SLU) from 1995–2005 were identified through a retrospective review of the medical record. Cases were required to have PSC diagnosed by cholangiography (ERCP and/or MRCP) at SLU. Both cases and controls were required to have had at least one prior colonoscopy with biopsies or a colectomy at our institution. A control group of patients with chronic ulcerative colitis without PSC was matched for sex, calendar year of first visit to SLU, duration of IBD prior to first visit, and history of colectomy (2 controls per case). Results: Twenty-five patients with PSC-IBD and 50 matched controls with chronic UC were identified. Of the patients with PSC-IBD, 20 carried a diagnosis of UC, 3 Crohn's disease (CD), and 2 indeterminant colitis (IC). The endoscopic features of IBD in the PSC-IBD patients are summarized in the table below. Compared to matched controls with chronic UC, the PSC-IBD patients were no more likely to have pancolitis, rectal sparing, backwash ileitis, or fistulae. Despite being matched for duration of clinical IBD, PSC patients were more likely to have dysplasia than patients with Ulcerative colitis. (24% vs 4%, p < 0.05).Table: Endoscopic features of IBD in patients with PSC-IBD.Conclusions: The incidence of pancolitis, rectal sparing, backwash ileitis, and fistulae in our population of patients with PSC and IBD was comparable to that of matched controls with UC alone. Despite being matched for the duration of IBD, patients with PSC are more likely to develop dysplasia. This may reflect the unique natural history of dysplasia in the PSC-IBD subpopulation, longer subclinical colonic inflammation or increased use of mesalamine in patients with only UC.