Natural History of Patients Hospitalized with Fulminant Ulcerative Colitis

Abstract

Purpose: To study the immune-status of patients with fulminant ulcerative colitis (UC) who have been hospitalized for treatment with intravenous glucocorticoids. To study the long-term clinical outcome of this patient population. Methods: A cohort of oral steroid resistant UC patients (N = 201) were evaluated for Epstein Barr Virus (EBV) and cytomegalovirus (CMV) viral load and lymphocyte subsets during and subsequent to receiving IV steroids. EBV viral load data were also obtained for a cohort of patients (N = 64) with mild to moderate UC. Retrospectively, the clinical outcome data from the Kaiser Permanente IBD Registry were analyzed for a third cohort of patients (N = 663) who had received intravenous steroids during their initial hospitalization for fulminant UC. Results: Of the first cohort evaluated, 40% had measurable copies of EBV genome in their blood as compared to 0% of less severe UC patients, and 31% had CD4 counts below 200/mcL. Furthermore, 9% had both low CD4 counts and detectable EBV. Of a subset of patients screened for CMV (N = 73), only 5% were positive for CMV genome. Of the 663 patients reviewed from the Kaiser Permanente IBD Registry, 133 underwent colectomy during the index hospitalization. 497 patients left the hospital without colectomy, 82% of which tapered off steroids within 6 months of discharge, while 18% did not. However, 41% had re-started steroids by the first anniversary of their discharge date, 21% were re-hospitalized, and 10% underwent colectomy within 12 months of the initial discharge date. Conclusions: UC Patients receiving IV steroids experience significant immunosuppression, as evidenced by increases in EBV viral load and decreased CD4 counts. This contrasts with the EBV status and CD4 counts5 of patients with mild to moderate UC, both of which are within normal range. UC patients from a community-based practice who were hospitalized for severe UC and treated with IV steroids were at significant risk for immediate colectomy before release (20%), while those who were released without colectomy were at significant risk for relapse of disease (72%) and for colectomy (10%) in the ensuing 12 months. 5 Gut 1991 32(7):779–83