Definitive Diagnosis Of Ulcerative Colitis Research Articles

Evaluation of adalimumab effects on left ventricle performance by echocardiography indexes among patients with immunosuppressant refractory ulcerative colitis.

Inflammatory bases lead to a simultaneous flourishing of cardiovascular complications with inflammatory bowel disease (IBD). As a released cytokine, tumor necrosis factor-α (TNF-α) can either disrupt or preserve cardiovascular performance. Due to this controversy, this study aimed to appraise the short-term anti-TNF (adalimumab [ADA]) relics on cardiac function by gauging the echocardiography indexes in patients with immunosuppressant refractory ulcerative colitis (UC). All cases with a definite diagnosis of UC were included based on providing written informed consent and owning the severe form of active disease (Mayo score ≥7), which did not dampen with immunosuppressant. Patients were excluded in the case of previous cardiac ailments/risk factors and prior related surgical or pharmaceutical intervention. Transthoracic echocardiography (TTE) was carried out before and 3 months after biological regimen allocation and changes in indexes [ejection fraction (EF), left ventricular end-diastolic volume (LVEDV)/left ventricular end-systolic volume (LVESV), and global longitudinal strain (GLS) in standard parasternal short axis from mid-ventricular level, two-, three-, and four-chamber apical long axes] were compared via statistical analyses. The study consisted of 13 (65%) men and 7 (35%) women, with a mean age of 36.54 ± 11.3 years. Participants mainly possessed Montreal class I (45%) and an average of 3.25 years of disease duration. The intervention significantly controlled inflammation [endoscopic Mayo score (P = 0.001), partial Mayo score (P = 0.001), and C-reactive protein (P = 0.001)]. Endoscopic and clinical remission was obtained in 7 (35%) and 9 (45%) patients, respectively; however, no significant discrepancy related to the LVEDV (P = 0.86), LVESV (P-value = 0.25), EF (P-value = 0.06), and GLS in standard parasternal short axis (P = 0.73), long axis [apical 2-chamber (P-value = 0.61), apical 3-chamber (P-value = 0.15), and apical 4-chamber (P-value = 0.19) views] was observed before and after the intervention. Furthermore, no statistically significant correlation between disease activity and cardiac function was found, neither before nor after ADA administration. The present perusal found no deterioration in left ventricular function indexes with ADA intervention among patients with IBD without cardiac ailment. Thus, prescribing the anti-TNF to alleviate the inflammation can be carried out with less concern about cardiac consequences and considering other adverse traces in the target group.

Pankolitis Akibat Kolitis Ulseratif

Introduction: Ulcerative colitis is a chronic disease affecting large intestine, characterized by rectal bleeding, diarrhea, abdominal pain, and could be accompanied by extraintestinal manifestation such as fever, anemia, and weight loss. Ulcerative colitis is causing an inflammation even ulceration of the rectum which can extend to proximal colon. The incidence of this disease is increasing worldwide and its frequency is variable depend on age, race and geographic area. Thorough history and examination are needed in diagnosing ulcerative colitis, since its symptoms are similar to many other gastrointestinal diseases. Definitive diagnosis of ulcerative colitis can be obtained by colonoscopy and histopathology. Case Report: We reported a case of 53 years old man who suffered from diarrhea and weight loss for one month before admission. There were also blood and mucus in his stool. The result of colonoscopy was hyperemia and ulcers along the rectum to the caecum. Histopathology examination showed pieces of intestinal mucosal tissue covered by columnar epithelium, with goblet cell and round-oval core. The lamina propria is densely packed with lymphocyte cells, plasma cells and PMN leukocytes. This result represents chronic colitis with acute exacerbation. Conclusion: Patient was treated with mesalazine 3x1000 mg per oral, methyl prednisolone 3x16 mg per oral, and low fiber diet to achieve remission.

Tasas de colectomía en colitis ulcerosa 15 años después del diagnóstico. Datos de la cohorte Navarra 2001-2003

IntroductionKnowing the natural history of ulcerative colitis (UC) is essential to understand the course of the disease, assess the impact of different treatment strategies and identify poor prognostic factors. One of the most significant matters in this regard is the need for surgery. ObjectivesTo analyse the Colectomy Incidence Rate (CIR) from diagnosis to end of follow-up (31/12/2017) and identify predictive factors for colectomy. Material and methodsA retrospective study enrolling patients with a definitive diagnosis (DD) of UC or Unclassified Colitis (UnC) in the 2001-03 Navarra cohort. ResultsWe enrolled 174 patients with a DD of UC (E2 42.8%; E3 26.6%) and 5 patients with a DD of UnC: 44.1% women, median age 39.2 years (range 7-88) and median follow-up 15.7 years. A total of 8 patients underwent surgery (CIR 3 colectomies/103 patient-years: 3 at initial diagnosis (<1 month), 2 in the first 2 years, 2 at 5 years from diagnosis and 1 at 12 years from diagnosis. All had previously received steroids; 5 had received immunomodulators and 2 had received biologics. In 7 patients (87%), surgery was performed on an emergency basis. The indication was megacolon in 3 (37.5%), severe flare-up in 3 (37.5%) and medical treatment failure in 2 (25%). In 5 cases (62.5%), an ileoanal pouch was made, and in 3 cases, a definitive ileostomy was performed. In the univariate analysis, patients with loss of more than 5 kg at diagnosis and admission at diagnosis had a lower rate of colectomy-free survival. ConclusionsIn our series, colectomy rates are lower than usually reported. Most colectomies were performed in the first 5 years following diagnosis and had an emergency indication.

Evaluation of Calprotectin Levels in First-Degree Relatives of Patients with Ulcerative Colitis

Recent studies have shown the diagnostic value of fecal as well as serum calprotectin in predicting the severity and activity of inflammatory bowel disease. Given the strong familial and inherited predisposition to inflammatory bowel disease, it is assumed that changes in calprotectin levels are also influenced by familial predispositions. Therefore, the present study aimed to evaluate the level of fecal calprotectin in patients and their first-degree relatives in order to determine the relationship between changes in this marker and its possible familial orientation. The study participants were the first-degree relatives (n = 100) of the patients (n = 33) with the definitive diagnosis of ulcerative colitis who referred to Rasoul-e-Akram hospital in 2018 and 2019. The fecal value of calprotectin was assessed using the ELISA method in both patients and the relatives. Fecal calprotectin level in patients was estimated to be 232.09±44.16μg/g. Fecal calprotectin level in the parents was 86.06±12.66μg/g, in siblings was 58.02±7.24μg/g and in the patient's children was 47.40±4.77μg/g. Fecal calprotectin levels were not affected by baseline indices such as gender, age, or BMI (either in patients or their relatives) and therefore these baseline factors had no effect on fecal calprotectin levels. Although fecal calprotectin levels are significantly longer in patients with ulcerative colitis than in healthy controls, the higher level of this marker among first-degree relatives of patients than healthy individuals also indicates the inherited tendency of changes in this marker in terms of high risk of disease in first-degree relatives of patients. These changes in fecal calprotectin levels will be independent of gender, age, and BMI

Epidemiology and Clinical Characteristics of Ulcerative Colitis in Chaharmahal and Bakhtiari Province, Iran

Background & Aims of the Study Ulcerative colitis (UC) is an inflammatory bowel disease, which is spreading continuously. This study aimed to determine the epidemiologic profile of the patients with UC in Chaharmahal and Bakhtiari province, Iran, as a database for other researches.Materials and MethodsThis descriptive cross-sectional study was performed on the profiles of the patients with a definitive diagnosis of UC during 2012-2016 in Chaharmahal and Bakhtiari in 2019. All the samples were selected through the census method. The data consisted of demographic characteristics, clinical features, as well as colonoscopy and histopathology results, and other symptoms which were collected based on the checklists. The data were analyzed in SPSS software (version 22); moreover, the qualitative and quantitative variables were reported using frequency and percentage as well as mean and standard deviation, respectively.ResultsThis study analyzed 177 UC patients with a mean age of 38.31±11.69 years. According to the findings, the 31-40-year-old group was the most vulnerable age group. Regarding gender, 59.3% of the patients were male. The mean duration between the onset of the symptoms and diagnosis was reported as 7±11.51 years. The most common symptoms were bleeding (72%) and abdominal pain (53%). Moreover, erythema (63.27%) and erosion (54.8%) were the most prevalent complications based on the pathologic findings. Extra-intestinal manifestations were reported among 18.36% of the cases. Considering the involved locations, pancolitis (36.72%) and the inflammation of rectosigmoid (35.6%) were the most common types.ConclusionThe results of this study were similar to the findings of other investigations in terms of demographic characteristics. On the other hand, the clinical symptoms and complications of the disease were different from those in some previous studies.

P286 Rate of colectomy in ulcerative colitis: Results from a Spanish cohort with 15 years of follow-up

Abstract Background Knowing the natural history of ulcerative colitis (UC) is essential to understand the evolution of the disease, assess the impact of different therapeutic strategies, identify poor prognostic factors and provide patients with understandable information who help them in decision making. It has been suggested that biological drugs could modify natural history of UC and therefore decrease the rates of colectomy. In Spain, infliximab is approved for CU since 2005. Methods We performed a retrospective study that includes all patients with a definitive diagnosis (DD) of UC or Unclassifiable Colitis (UC) in the Navarra Incident Cohort (which includes all patients diagnosed between 2001 and 2003 in Navarra, Spain). Our objectives were to analyse the Colectomy Incidence Rate (CIR) from diagnosis to the end of follow-up (12-31-2017) and identify predictive factors of colectomy. Results We included 174 patients with DD of UC (42.5% E2 - 26.8% E3) and 5 of IC: 44.1 women, median age 39.2 years (7–88), median follow-up of 15.7 years. At the end of the follow-up, 8 patients underwent colectomy (CIR 3 surgeries per 100000patients-year). Timing of colectomy was: 3 at the initial diagnosis (&amp;lt;1 month), 2 in the first 2 years, 2 at 5 years and 1 at 12 years from diagnosis. All had previously received steroids, 5 immunomodulators and 2 biological agents. In 7 (87%) the surgery was urgent and the indication, megacolon in 3 (37.5%), severe outbreak in 3 (37.5%) and failure to medical treatment in 2 (25%). In 5 cases (62.5%), an ileoanal reservoir was made and in 3 definitive ileostomy. Conclusion In our cohort, global colectomy rates are lower than those reported in other series and occur mostly in the first 5 years of evolution.

Cinematic rendering: a new imaging approach for ulcerative colitis.

Cinematic rendering (CR) is a new technique for visualizing volumetric three-dimensional data. The purpose of this study was to investigate the added value of CR to conventional computed tomography (CT) in the diagnosis and evaluation of ulcerative colitis (UC). We retrospectively evaluated the CT data of 48 patients (33 men, 15 women; mean age, 44.35years) with a definitive diagnosis of UC. All patients underwent conventional CT and CR, and had colonoscopy results. Two radiologists independently reviewed the conventional CT images first without and then with CR. Then, the imaging value of CR was evaluated by both radiologists together. The readers were blinded to the disease extent. The diagnostic performance of CR for both readers was assessed by receiver-operating characteristic (ROC) curve analysis. There were 23 cases of mild to moderate UC and 25 cases of severe UC, which were divided into two groups. Both readers showed improved diagnostic performance with the addition of CR (the area under the ROC curve improved from 0.676 to 0.804, P = 0.0255, and from 0.679 to 0.826, P = 0.0049, for readers 1 and 2, respectively). Full view of the lesion and contrast enhancement was not significantly different between the two groups (P > 0.05). Increased mesenteric vascularity and the comb sign on CR were more clearly observed in the severe group (P < 0.05). Adding CR to conventional CT improved the diagnostic performance of evaluating the extent of UC.

Ulcerative Colitis as a Novel Cause of Increased Need for Levothyroxine.

Background: Thyroxine absorption takes place at the small intestine level and several disorders affecting this intestinal tract lead to thyroxine malabsorption. An increased need for thyroxine has also been observed in gastric disorders due to variations in drug dissolution and/or in its ionization status. Ulcerative colitis (UC) is an inflammatory bowel disease that has been postulated as a potential cause of the increased need for thyroxine, but there is a lack of evidence on this topic. This study is aimed at measuring the thyroxine requirement in hypothyroid patients with UC.Patients and Methods: Among 8,573 patients with thyroid disorders consecutively seen in our referral center from 2010 to 2017, we identified 34 patients with a definite diagnosis of UC. Thirteen of them were hypothyroid (12 F/1 M; median age = 53 years), bearing UC during the remission phase and in need for thyroxine treatment, thus representing the study group. The dose of T4 required by UC patients has been compared to the one observed in 51 similarly treated age- and weight-matched patients, compliant with treatment and clearly devoid of any gastrointestinal and /or pharmacological interference.Results: To reach the target serum TSH, the dose of thyroxine had to be increased in twelve out of thirteen (92%) hypothyroid patients with ulcerative colitis. The median thyroxine dose required by UC patients was 1.54 μg/kg weight/day, that is 26% higher than the control patients, to reach a similar TSH (1.23 μg/kg weight/day; p = 0.0002). Since half of our study group consisted of patients aged over 60 years old, we analyzed the effect of age on the subdivision in two classes. Six out of seven (86%) adult patients (<60 years) required more T4 than those in the respective control group (1.61 vs. 1.27 μg/kg weight/day; +27%; p < 0.0001). An increased dose (+17%; p = 0.0026) but to a lesser extent, was also observed in all patients over 60 years, as compared to the control group.Conclusions: In almost all hypothyroid patients with UC, the therapeutic dose of thyroxine is increased. Therefore, ulcerative colitis, even during clinical remission, should be included among the gastrointestinal causes of an increased need for oral thyroxine.

Backwash ileitis in ulcerative colitis: Are there MR enterographic features that distinguish it from Crohn disease?

ObjectiveTo reveal the MR enterography (MRE) findings that distinguish backwash ileitis (BWI) from terminal ileitis due to Crohn's disease (CD) and to determine the usability of barium studies manifestations (ileocecal valve (ICV) gaping, terminal ileum dilatation) in MRE for the diagnosis of BWI in ulcerative colitis (UC) patients by pointing at the diagnostic performance of these imaging findings. Subjects-methodsThe study population consisted of patients who were diagnosed as ulcerative colitis (UC), and underwent 1.5 T MRI between August 2011 and November 2017 to rule out small bowel involvement. The matched controls were comprised of Crohn’s patients examined at the same period. Ileocolonoscopic/ histopathologic findings were accepted as reference standard. Mural/extramural changes in bowel segments, ileocecal valve (ICV) gaping, terminal ileum dilatation, restricted diffusion and anatomical extent of involvement were evaluated. In UC patients, the association between ICV gaping and terminal ileum dilatation and BWI was assessed by χ2 test. The diagnostic accuracy of these two findings in BWI was determined. ResultsSixty patients were included in the study (30 UC; 30 CD; mean age, 43 years in both groups). Ileocecal valve gaping and terminal ileum dilatation were significantly more frequent among BWI patients (p < 0.001) in UC. Patients with BWI showed a higher rate of pancolitis (88.9%). Median terminal ileum wall thickness was found to be significantly greater in patients with CD (p < 0.001). ConclusionIn patients with definite diagnosis of UC, ileocecal valve gaping and terminal ileum dilatation suggest the development of BWI. However, these findings cannot be use to differentiate cause of terminal ileitis in patients with unconfirmed diagnosis and do not give reliable information about the causative factor of ileitis.

Clinical and Sociodemographic Characteristics of Inflammatory Bowel Disease in Mexico: A Multi-center and Nationwide Study (EPIMEX-IBD)

BACKGROUND: The global incidence of Inflammatory Bowel Disease (IBD), Ulcerative Colitis (UC) and Crohn's Disease (CD), is increasing. However, there are no epidemiological or descriptive data from a nationwide study in Mexico. The aim of this study is to describe the clinical and socio-demographical characteristics of Mexican patients with IBD from whole country. METHODS: This is a multi-center study where gastroenterologists and colorectal surgeons were involved from 14 states in Mexico who collected clinical and socio-demographic data of all patients with definitive diagnosis of UC, CD and Indeterminate Colitis (IC) during the period between March and June 2017. Data were analyzed using the statistics program SPSS v.24. A p value <0.05 was considered significant. RESULTS: A total of 1,101 patients was studied, 908 (82.5%) with UC, 174 (15.8%) with CD and 17 (1.5%) with IC from 14 states in Mexico. Female represented 47.2% and male 52.8%. The median age at the time of inclusion in the study was 46 years. The median age at diagnosis was 37 years. Extra-intestinal manifestations were present in 39.1% of patients with UC and 32.8% with CD. The most frequent extra-intestinal manifestations were: arthralgia (28.3%), arthritis (10.8%), osteopenia (5.8%), osteoporosis (3.9%), sacroiliitis (2.8%), primary sclerosing cholangitis (1.8%) and uveitis (1.5%). Most of the patients were born in the most industrialized States of the country, 21.9% being born in Mexico City; 20.2% in Jalisco; 8.8% in State of Mexico and 4.2% in Nuevo Leon. Patients that received attention at public institutions represented 79.7% of the total sample and those which were treated at private centers only 20.3%. In the case of UC: 52.6% of patients had extensive colitis (E3), 17.4% left-sided colitis (E2), 20% distal colitis and 10% no specified extension. In the case of CD: 34.5% of patients reported the following location: colonic (L2), 29.3% ileo-colonic (L3), 17.2% ileal (L1), 2.9% upper tract involvement (L4) and 16.1% no specified location. Most of the patients were under treatment with 5-aminosalicylates (66.3% and 65.5% respectively), followed by steroids (28.7% and 46% respectively), thiopurines (24.9% and 42% respectively) and anti-TNF therapy (16.2% and 37.4% respectively). In the case of UC, 1.9% required surgical treatment and in the case of CD, 17.8%. Patients with CD required surgical treatment more often compared with those with UC (OR=11.36, IC 95%=6.13-21.06, P=0.000). Employee state was associated with higher risk to have diagnosis of UC compared to CD (OR=1.96, IC 95%=1.40-2.75, P=0.000). CONCLUSION(S): In this first multicenter study at national level, UC was 6 times more frequent than CD. The most frequent extent of UC was pancolitis, while in CD was colonic location. Socio-demographic and clinical variables were associated with different clinical outcomes in Mexican patients with IBD.

Management of acute severe ulcerative colitis in children

The incidence of pediatric-onset ulcerative colitis (UC) is rising. Children often present with a more severe disease phenotype as compared to adults with over a third requiring hospitalization for the management of acute severe ulcerative colitis (ASUC). Further, in pediatric patients presenting with inflammatory bowel disease (IBD) limited to the colon, a definitive diagnosis of UC vs. Crohn’s disease is often unclear. Here, we review the unique aspects of pediatric ASUC including the epidemiology, diagnosis, medical, and surgical management of this disease.

Epidemiological and clinical aspects of ulcerative colitis in west of Iran: a cross sectional study.

Introduction One of the forms of inflammatory bowel disease (IBD) that causes inflammation and ulcers in colon is ulcerative colitis (UC). This study was aimed to determine the epidemiological and clinical aspects of patients with ulcerative colitis in the west of Iran.MethodsIn this cross sectional study, we evaluated 150 patients with definite diagnosis of UC who referred to a subspecialty gastroenterology clinic in Khorramabad, Iran. The study was performed from May 2014 to August 2015 by using census method. Demographic characteristics as well as patients’ clinical profiles were extracted using a checklist. Disease severity was determined by the Truelove and Witt’s classification of ulcerative colitis (UC). Data were analyzed using SPSS software, version 17 for windows (IBM Inc., NY, US).ResultsA total of 150 patients with definite diagnosis of UC were analyzed, including 84 (56 %) women and 66 (44 %) men (male/female ratio = 1.27). The mean age of patients was 33.7 ± 12.5 years with an age range of 17–98 years. The age of the majority of patients was 20–29 and most of them (56 %) were women and living in urban areas (70.7 %). The most common site of the involvement in colon was rectosigmoid (66 patients, 44 %). Severity of the disease was mild in 36 patients (24.1 %), moderate and severe in 74 and 40 patients (49.3 and 26.6 %), respectively. The most common clinical manifestation of the patients was dysentery (68 %) and then rectorrhagia (60 %). Only 12 of all patients (7.8 %) mentioned a positive family history of IBD in their first degree kinfolks. Ten patients (6.7 %) had a history of regular smoking and four of them (2.6 %) mentioned a history of appendectomy. Four patients (5.3 %) had a positive history of smoking by their mothers during their pregnancy.ConclusionThe results of this study demonstrate differences and similarities in demographic and clinical characteristics of UC in this part of Iran in comparison to other parts of the country.

Atypical pANCA as a marker of indeterminate colitis for the prediction of ulcerative colitis and crohn’s disease

The aim of this study was to demonstrate that the presence of atypical perinuclear antineutrophil cytoplasmic antibodies (pANCA) in indeterminate colitis (IC) patients and the potential role of pANCA for predicting the patients either with ulcerative colitis (UC) or Crohn's disease (CD) for UC and CD. Outpatients and inpatients from the hospital were retrospectively enrolled between April 2008 and December 2010. A total of 25 IC patients enrolled in the present study. Subsequently, 25 randomly selected serum samples were tested for pANCA in our laboratory. Determination of pANCA was performed by enzyme linked immunosorbent assay. Minimum follow-up was 12 months. The mean duration of disease was 20.52 months. The diagnosis was changed to UC in 13, to CD in 5 patients. The remaining 7 patients are still classified with IC, with mean disease duration of 21.29 months. Duration of disease differs statistically when comparing pANCA positive versus pANCA negative. A positive correlation was found between IC and disease location in our study. Patients with an initial diagnosis of IC who have positive serology are given a definitive diagnosis of UC or CD, respectively, more often than patients with negative serology.

IBD and related diagnostically difficult entities of the colon

This lecture (review) summarises current diagnostic problems and advances with regard to patterns of inflammation and dysplasia in inflammatory bowel disease (IBD), particularly ulcerative colitis and Crohn’s disease. In a small percentage of cases, a definite diagnosis of ulcerative colitis or Crohn’s disease cannot be established in which the term ‘indeterminate colitis’ has been used. Most cases of indeterminate colitis are related to fulminant colitis, a condition in which the classic features of ulcerative colitis or Crohn’s disease may be obscured by severe ulceration with early fissuring ulceration, transmural inflammation, and relative rectal sparing. Several studies suggest that ileal/anal pouch anastomosis procedure is safe and effective in patients with indeterminate (fulminant) colitis. In biopsy studies, there are a number of exceptions to the classic principles in IBD pathology that may lead to diagnostic confusion and simulate Crohn’s-like tissue reactions in patients with ulcerative colitis. For instance, skip lesions may occur in patients with ulcerative colitis in the follow settings: long-term oral or topical therapy, and on initial presentation in paediatric patients. Patients with IBD are at increased risk for the development of dysplasia and carcinoma. Dysplasia in IBD is classified as flat or elevated, and then microscopically as negative, indefinite, low or high grade. In addition to the conventional (intestinal) type of dysplasia, other less common and more diagnostically difficult types of dysplasia, such as serrated dysplasia and mucinous hypervillous epithelium, may occur in some patients with IBD. There is recent evidence to suggest that patients with flat low grade dysplasia should also be considered strongly for colectomy. Elevated lesions in IBD (DALM) are subdivided into adenoma-like and non-adenoma-like based on their endoscopic appearance. Regardless of the grade of dysplasia, adenoma-like lesions may be treated adequately by polypectomy if there are no other areas of flat dysplasia in the patient. The surveillance and treatment options for patients with flat and elevated dysplasia in IBD will be reviewed in detail.

Intestinal Protozoa Infections among Patients with Ulcerative Colitis: Prevalence and Impact on Clinical Disease Course

Background: Epidemiological and microbiologic studies suggest that enteropathogenic microorganisms play a substantial role in the clinical initiation and relapses of inflammatory bowel disease. Aim: To explore the prevalence of intestinal protozoa in patients with ulcerative colitis (UC) and its impact on clinical disease course. Methods: A total of 215 patients with definitive diagnosis of UC were studied. Fresh feces samples taken from all UC patients were examined immediately using trichrome-staining methods. Results: A total of 103 female and 112 male UC patients were analyzed. The mean age at diagnosis was 30.5 ± 10.8 years. The prevalence of overall parasitic infections was 24% and distributed as follows: Blastocystis hominis in 22 patients (10%), Endolimax nana in 19 cases (9%), and Entamoebahistolytica in 11 cases (5%). A significantly increased frequency of protozoa infection was found in those patients with persistent activity and intermittent activity as compared to active than inactive group (p = 1 × 10^–7, OR 13.05, 95% CI 4.28–42.56, and p = 0.003, OR 1.42–14.47, respectively). Interestingly, this association remained significant when we compared the persistent activity group versus intermittent activity group (p = 0.003, OR 2.97, 95% CI 1.35–6.59). Subgroup analysis showed no association between protozoa infection (E. histolytica, B. hominis, and E. nana) and other clinical variables such as gender, extent of disease, extraintestinal complications, medical treatment and grade of disease activity. Conclusion: The prevalence of intestinal protozoa infections in Mexican UC patients was 24% and these microorganisms could be a contributing cause of persistent activity despite medical treatment in our population.

Incidence and prevalence of inflammatory bowel disease in children in south-western Sweden.

The incidence and prevalence of inflammatory bowel disease were estimated in all children less than 16 years of age living in the city of Göteborg and in three countries in South-Western Sweden, from 1983 to 1987. One hundred and thirty-two patients were classified according to set criteria into one of four diagnostic categories: ulcerative colitis, Crohn's disease, probable Crohn's disease and indeterminate colitis. The crude incidence of inflammatory bowel disease was 5.3 per 100,000 children per year and the prevalence 21.5 per 100,000 children. This study lends support to the hypothesis that Crohn's disease has increased among Swedish children. Crohn's disease now appears to be at least as common as ulcerative colitis. Thirty-five of 55 patients first classified as indeterminate colitis or probable Crohn's disease later fulfilled the criteria of ulcerative colitis or Crohn's disease during a mean follow-up period of 4.6 years. This study emphasizes the importance, in epidemiological studies of inflammatory bowel disease, of including those cases where a definite diagnosis of ulcerative colitis or Crohn's disease cannot be established initially and of re-evaluating the initial diagnosis regularly.

Pathology of indeterminate colitis.

The term indeterminate colitis (IC) is an interim, or preliminary, descriptive term used by pathologists for cases of inflammatory bowel disease (IBD) in which a definite diagnosis of ulcerative colitis (UC) or Crohn's disease (CD) cannot be established based on the information available at the time of surgical sign-out. Most cases are due to fulminant ulcerative colitis, a condition in which the classic pathologic features of UC are often obscured and may overlap with CD. For instance, fulminant UC may show early superficial fissuring ulceration, transmural lymphoid aggregates and relative rectal sparing, simulating CD. Other common causes for establishing a diagnosis of IC include confusion of backwash ileitis in UC for terminal ileal involvement in CD, failure to accept hard criteria, such as granulomas, or segmental disease, as representative of CD, and failure to recognize unusual variants of UC that can cause CD-like patchiness of disease. Also, a diagnosis of IC should be avoided on biopsy studies and should not be established until all available clinical, endoscopic, radiologic and pathologic information are available for review. Some cases of IC may represent other forms of colitis as well, such as chronic ischemic or infectious colitis. The natural history of IC more closely resembles that of UC than CD. In fact, most cases of IC represent UC upon long-term clinical follow-up. Although, in some instances, serologic testing for ANCA or ASCA may be helpful in separating UC from CD in patients with IC, there is much overlap in the results of these assays for cases in which CD involves the colon in a UC-like pattern. Approximately 20% of IC patients develop severe pouch complications, which is intermediate in frequency between that seen in UC or CD. The risk of pouch complications, such as perianal fistulas or abscesses, and the risk of pouch breakdown is, overall, quite similar between IC and UC patients, supporting the notion that most patients with IC probably have UC and can safely undergo an ileal pouch-anal anastomosis procedure and have a reasonably good chance of having a good outcome.

Diagnostic Problems and Advances in Inflammatory Bowel Disease

This review summarizes current diagnostic problems and advances with regard to patterns of inflammation and dysplasia in ulcerative colitis and Crohn's disease. Ulcerative colitis and Crohn's disease have a variety of characteristic but non-specific pathologic features. In approximately 5% of inflammatory bowel disease cases, a definite diagnosis of ulcerative colitis or Crohn's disease cannot be established, in which case the term “indeterminate” colitis is used. Most cases of indeterminate colitis are related to fulminant colitis, a condition in which the classic features of ulcerative colitis or Crohn's disease may be obscured by severe ulceration with early superficial fissuring ulceration, transmural lymphoid aggregates, and relative rectal sparing. Approximately 20% of patients with indeterminate colitis develop severe pouch complications, which is intermediate in frequency between ulcerative colitis (8–10%) and Crohn's disease (30–40%). In order to establish a diagnosis of ulcerative colitis or Crohn's disease, it is important to evaluate pathologic material in conjunction with clinical, laboratory, radiologic, and endoscopic features and to recognize the variety of changes that may be seen in fulminant ulcerative colitis. There are a number of exceptions to the classic principles of inflammatory bowel disease pathology that may lead to diagnostic confusion. For instance, apparent skip lesions on biopsy analysis may occur in patients with ulcerative colitis in the following settings; long term oral or topical therapy, focal ascending colon, cecum and/or appendiceal involvement in patients with left sided ulcerative colitis, upper gastrointestinal involvement in patients with ulcerative colitis, and at initial presentation of ulcerative colitis in pediatric patients. In all of these circumstances, the finding of patchy disease and/or rectal sparing should not be misinterpreted as either evidence against a diagnosis of ulcerative colitis, or as representing skip areas characteristic of Crohn's disease. Patients with ulcerative colitis and Crohn's disease are at increased risk for the development of dysplasia and carcinoma. Recent studies suggest that given a similar duration and extent of disease, patients with Crohn's disease have a similar risk of dysplasia and cancer as patients with ulcerative colitis. Dysplasia in ulcerative colitis may be classified as flat or elevated (dysplasia associated lesion or mass [DALM]). Patients with flat high grade dysplasia are generally treated with colectomy. However, there is recent evidence to suggest that patients with flat low grade dysplasia, particularly if detected at the time of initial endoscopic exam, or if its multifocal or synchronous, should also be treated with colectomy. Elevated lesions in ulcerative colitis (DALM) are subdivided into “adenoma-like” and “non-adenoma-like” lesions based on their endoscopic appearance. Recent data suggests that adenoma-like lesions, regardless of the grade of dysplasia, or the location of the lesion (i.e., inside or outside areas of established colitis) may be treated adequately by polypectomy if there are no other areas of flat dysplasia in the patient. Although there are some histologic and molecular features that can help differentiate sporadic adenomas from adenoma-like polypoid dysplastic lesions related to ulcerative colitis, none of these adjunctive techniques can help distinguish these lesions definitively in any single patient. Patients with a non-adenoma-like DALM, (irregular, broad based, or strictured lesion) should be treated with colectomy because of the high probability of adenocarcinoma. The surveillance and treatment options for patients with flat and elevated dysplasia in ulcerative colitis are reviewed in detail.

Inflammatory bowel disease in children and adolescents in Sweden, 1984-1995.

A prospective study of inflammatory bowel disease (IBD) in Sweden was performed to investigate whether the incidence and morbidity have changed from 1984 through 1995. Children 15 years of age or less with IBD were included--i.e., those with a definite diagnosis of ulcerative colitis (UC) and Crohn's disease (CD) and those classified as having indeterminate colitis (IC) and probable Crohn's disease (PCD). The study covered 56.5% of the pediatric population of Sweden. The diagnosis of IBD was made in 639 children, which corresponds to a mean annual incidence of 5.8 per 100,000. The incidence increased from 4.6 per 100,000 per year from 1984 through 1986 to 7.0 from 1993 through 1995. It reflected an increase in UC from 1.4 to 3.2 per 100,000 per year, which is a significant yearly percentage of increase (8%; confidence interval, 2-14%; P < 0.05). In contrast, no change occurred in the incidence of CD (1.2-1.3 per 100,000). The incidence of IC and PCD also remained fairly stable. The percentages of children who underwent surgery decreased from 17.3% in the first 6 years to 4.6% in the last 6 years (P < 0.001). Surgery was performed in 27.7% of CD and 5.3% of UC cases. The median age at diagnosis was 12.2 years for UC, 13.0 years for CD, 11.2 for IC, and 11.2 for PCD. At diagnosis, 48 children (7.5%) were 5 years of age or less, whereas most of the patients were 11 years of age or more (398 children, 62.3%). In Sweden, the incidence of UC has increased, whereas that of CD remains the same. A significant number of children were classified with IC and PCD. In most children, IBD was diagnosed when they were 11 years old or more, but some cases were detected even in those below 6 years of age. A decrease in the frequency of surgery occurred during the study.

Epidemiology of ulcerative colitis in Israel: a survey of Israeli Kibbutz settlements

OBJECTIVE: The incidence of ulcerative colitis ranges from 3 to 15 cases per 100,000 persons per year with a prevalence of 50–80 cases per 100,000, and the disease is 3–5 times more common among Jews. In Israel, Ashkenazi Jews have a higher incidence than Sephardi Jews, but a lower incidence than Ashkenazi Jews in the United States or Northern Europe. The aim of this study was to examine the prevalence, mean annual incidence, and clinical patterns of ulcerative colitis in a stable population of communal settlements (kibbutz). METHODS: We repeated a community-based survey in 124,400 kibbutz residents, 10 yr after our first study. This population represents 2.5% of the Jewish population of Israel. All ulcerative colitis patients were located by contacting the kibbutz clinics of the 269 kibbutz settlements (100% compliance). Data were updated to December 31st, 1997, which was designated the point prevalence date, and included information on gender, age, origin, education, profession, extent of the inflammatory process, clinical spectrum of the disease, therapy, complications of the disease, and treatment. The mean annual incidence for the 10 yr was calculated from the prevalence data. Only cases with a definite diagnosis of ulcerative colitis made in a recognized gastroenterology unit were accepted into the study. RESULTS: There were 208 confirmed cases of ulcerative colitis disease, 113 women and 95 men (female:male ratio = 1.19). The prevalence rate rose from 121.0/100,000 in 1987 to 167.2/100,000 in 1997 ( p < 0.001). The prevalence rates were higher in women than men. Prevalence was highest in Israeli-born members in 1987 but in European/American-born members in 1997. The average annual incidence rate for the 10-yr period was 5.04/100,000/yr. In 1987, 146 cases of ulcerative colitis were collected. During 10 yr of surveillance 17 patients left the kibbutz, 12 died, and 62 new cases were added. The mean age at presentation of the disease was lower in 1987 than in 1997, 46.14 ± 11.10 and 51.43 ± 16.67 yr, respectively. Prevalence was highest in men with >16 yr and in women with 9–10 yr of education, 259.3 and 242.9/100,000, respectively. CONCLUSIONS: The prevalence of ulcerative colitis in this Israeli population increased and has reached the upper range for European and American populations. The mean annual incidence rate of ulcerative colitis is in the lower range of that reported for the Western countries.