Outcomes after Acute Severe Ulcerative Colitis

Abstract

Purpose: Severe ulcerative colitis (UC) requires inpatient admission and accounts for substantial resource utilization, including colectomy. Little data related to colectomy risk are available in the modern era, and whether anti-TNF and other therapies are altering disease course is unclear. We sought to describe clinical features and outcomes, including colectomy, and mortality, of UC patients requiring hospitalization for disease exacerbation. Methods: All UC patients admitted to the gastroenterology inpatient service at our institution between January 1, 1997 and December 31, 2006 for disease activity were identified. (Patients admitted for planned surgery were excluded from the analysis.) Demographics and pertinent clinical features of the index hospitalization and the post-hospitalization course were recorded. Logistic regression was used to identify factors associated with colectomy during the index hospitalization, and the Kaplan–Meier survival method was used to estimate survival free of colectomy following discharge from the index hospitalization. Results: A total of 281 UC patients were admitted for disease activity. Sixty percent were male and 86% Caucasian. Median age at hospitalization was 39.8 years, median disease duration was 18.2 months, and 25% reported a previous hospitalization elsewhere. Median length of stay at the index hospitalization was 9 days (2–38). Median follow-up in patients not undergoing a colectomy was 14.5 months. Overall, 275 patients were alive at last follow-up. No inpatient deaths occurred. One-hundred twenty-five patients (44%) underwent colectomy during the index hospitalization after a median duration of 6 days. Variables significantly associated with an index hospitalization colectomy included previous inpatient stay for UC (odds ratio [OR], 1.9; 95% CI, 1.1–3.3), previous need for intravenous corticosteroids (OR, 2.1; 1.2–3.5), Hgb less than 12 g/dL (OR, 2.1; 1.3–3.3), endoscopic Baron score 3 or 4 (OR, 2.1; 1.3–3.5) and BMI < 25 relative to BMI > 30, (OR, 2.2; 1.1–4.2). Ten patients were treated with cyclosporine, and 7 (70%) required colectomy during hospitalization. Of the 8 patients who received infliximab, 3 (37.5%) required colectomy. Survival free of colectomy post-hospitalization was 64.3% at 1 yr (56.2%-73.5%), 57.1% at 2 yr (48.3%-67.3%), and 50.0% at 5 yrs (38.3%-64.0%). Conclusion: Acute severe UC led to colectomy during the same hospitalization in 44% at our institution over the past 10 years. Factors associated with early colectomy included previous hospitalization for UC, previous IV steroids, anemia, and endoscopically moderate to severe colitis. The natural history of acute severe colitis appears largely unchanged despite advances in medical practice.