Early Colectomy Research Articles

Endoscopic and chemopreventive management of familial adenomatous polyposis syndrome.

Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome predisposing affected individuals to gastrointestinal (GI) cancers through a high burden of polyposis. Colorectal cancer rates reach 100% by the age of 45, making early colectomy a mainstay of treatment. While most patients undergo colectomy at an early age, ongoing screening and surveillance of the upper gastrointestinal tract and rectal pouch must continue throughout adulthood. Endoscopic therapy of gastric, duodenal, ampullary and rectal pouch polyps is critical to reduce morbidity and cancer related mortality. Management of these lesions is not uniform, and is dependent on their location, size, histology, and risk of malignant potential. Medical therapies targeting pathways that reduce the malignant progression of pre-cancerous lesions have been studied for many years. While studies on the use of aspirin and non-steroidal anti-inflammatories (NSAIDs) in chemoprevention have shown encouraging results in Lynch syndrome and primary colorectal cancer, the potential benefits of these medications have not been duplicated in FAP cohorts. While data remains limited on chemoprevention in FAP, a number of randomized trials are currently underway examining targeted therapies with the potential to slow the progression of the disease. This review aims to provide an in-depth review of the literature on current endoscopic options and chemopreventive therapies targeting FAP. While the endoscopic management has robust data for its use, chemoprevention in FAP is still in its infancy. The complementary use of chemopreventive agents and endoscopic therapy for FAP patients is quickly becoming a growing and exciting area of research.

Outcomes of Continuous Enteral Vancomycin Infusion in Intensive Care Unit Patients: A Novel Treatment Modality for Severe Clostridium Difficile Colitis.

Background and objectiveSevere Clostridium difficile (C. difficile) infection (CDI)-related colitis is associated with high morbidity and mortality. Current guidelines recommend oral vancomycin plus intravenous metronidazole as the first-line treatment and early total colectomy in case of medication failure. In critically ill patients at high surgical risk and with multiple comorbidities, loop ileostomy creation and enteral vancomycin infusion have been employed albeit with limited success. We hypothesized that continuous enteral vancomycin (CEV) infusion via a postpyloric feeding tube would provide a less invasive, efficacious, and safer route to treat high surgical risk patients.MethodsAll adult (>18 years) non-pregnant patients admitted to the ICU for severe CDI from October 2012 to October 2016 and received CEV after the failure of conventional therapy were included. Vancomycin was prepared as a 1-2-mg/ml enteral solution and run continuously through a feeding pump at 42 ml/hour via a post-pyloric feeding tube. The primary efficacy endpoint was clinical improvement defined as (a) decrease in stool output, (b) decreased vasopressor requirement, or (c) improved leukocytosis, and the secondary endpoint was treatment failure defined as the need for total colectomy or death due to severe CDI.ResultsOur cohort comprised 11 patients in total. The median age of the participants was 64 years, and there were more females (67%) than males (36%). Clinical improvement was seen in seven patients (63%); treatment failure documented as the need for total colectomy was observed in two patients (18%), and death attributable to CDI occurred in three patients (27%).ConclusionCEV resulted in clinical improvement in most patients with severe CDI who were at high surgical risk. Sustained intestinal vancomycin delivery may increase luminal concentration and bactericidal effect. The use of a feeding tube and pump provides an effective and less invasive route of vancomycin delivery in critically ill patients.

P489 Rescue treatment with original versus biosimilar infliximab in biologic-naïve patients with moderate-severe Ulcerative Colitis and corticosteroid failure

Abstract Background Infliximab is effective as rescue therapy in moderate-severe Ulcerative Colitis (UC). Subsequently, a biosimilar of infliximab has been approved for the same indications, as its effectiveness is considered similar to the original infliximab. Our aim was to analyse the colectomy rate and the efficacy of original infliximab (Remicade®) versus biosimilar infliximab (Inflectra®) in patients with moderate-severe UC who failed to respond to intravenous corticosteroids. Methods We performed a retrospective and observational study in two hospitals in the Basque Country. All patients hospitalised between 2010–2020 with moderate-severe UC, without response to intravenous corticosteroids and rescue treatment with infliximab were consecutively included. Two cohorts were established: the first one from 2010 to 2015 in patients treated with Remicade®, and the second one from 2015 to 2020 in patients with Inflectra®. We assessed all patients that had received at least one dose of infliximab. Patients were followed for a period of one year until loss of response or colectomy. Early colectomy is the surgery performed until week 12, and late colectomy between week 12 and one year. At the moment of hospitalisation all patients were clinically and endoscopically evaluated by Mayo Score. The clinical response was assessed in week 14 and 52. Results A total of 85 patients were evaluated, 53 (64.4%) in Remicade® group and 32 (37.6%) in Inflectra® group. 21.17% (18/85) of the patients had a colectomy in one year. 77.7% of the colectomies took place in the first 12 weeks (14/18, 7 patient in each group). Rates of early (13.8% vs 21.9%, p=0.297) and late colectomy (17% vs 28.1%, p=0.223) showed a numerical but non-statistically significant difference in favour of Remicade®. Transfusion (OR=4.20, IC 95% [1.38–12.77], p=0.011) and the presence of cytomegalovirus in the colonic mucosa (OR=4.07, IC 95% [1.31–12.63], p=0.015) were univariate predictors of colectomy. A statistically significant difference was found in clinical remission at week 14 (49.1% vs 25%, p=0.040) but not at week 52 (73.7% vs 50%, p=0.074) in patients with Remicade® versus Inflectra®. Neither clinical activity nor mucosa activity showed relationship with risk of colectomy. Conclusion 1. The rescue therapy with infliximab in patients with moderate-severe Ulcerative Colitis who failed to respond to intravenous corticosteroids could show a favourable trend for Remicade® against Inflectra®. However, further research is needed to confirm it. 2. The need of transfusion and the presence of cytomegalovirus in the colonic mucosa could be predictive factors of colectomy.

Clinicopathologic Characteristics and Neoplasia Risk of Colorectal Inflammatory Polyposis in Inflammatory Bowel Disease.

Inflammatory polyps (IPs) in inflammatory bowel disease may have been associated in the past with increased neoplasia risk. Additionally, colonic mucosa in filiform polyposis and giant inflammatory polyposis may be difficult to visualize during endoscopic surveillance, perhaps contributing to early colectomy in these patients. To examine the clinicopathologic characteristics and significance of IPs and inflammatory polyposis in inflammatory bowel disease. We identified 336 resections from inflammatory bowel disease patients (212 [63.1%] male; mean age, 40.3 years; 175 [52.1%] with ulcerative colitis), including 78 with rare/few (<10) IPs, 141 with multiple (≥10) IPs, and 117 with inflammatory polyposis (including 30 with filiform polyposis/giant inflammatory polyposis) and compared them with 100 controls without IPs along various parameters, including overall and occult (unexpected) dysplasia. There was no increased neoplasia in resections with IPs compared with controls, given similar age, disease duration, degree of inflammation, anatomical extent of colitis, prevalence of primary sclerosing cholangitis, and tissue sampling. Increasing numbers of IPs and inflammatory polyposis were significantly associated in multivariate analysis with ulcerative and indeterminate colitis (P = .003) and shorter disease duration (P = .01), but also, and independently, with lower rates of dysplasia overall, including all grades (P = .001) and advanced neoplasia (P = .04). There were no instances of occult dysplasia (any grade) among inflammatory polyposis cases. These findings support the conclusion that the presence of IPs per se, and inflammatory polyposis in particular (including filiform polyposis and giant inflammatory polyposis), should not be considered an independent risk factor for the development of neoplasia in inflammatory bowel disease patients, outside the context of disease duration and inflammatory burden.

Low serum albumin at admission is a predictor of early colectomy in patients with moderate to severe ulcerative colitis

Background and AimSeveral studies have identified postinduction therapy predictors of long‐term outcomes of ulcerative colitis (UC) in patients who experienced the first attack of the disease or relapsed after therapy. We aimed to identify the preinduction therapy predictors at admission that predicted early colectomy in patients with moderate to severe UC.MethodsNinety‐five patients with moderate to severe UC who underwent induction therapy at the Kyoto Prefectural University of Medicine hospital between August 2008 and March 2020 were retrospectively included and categorized into two groups: the colectomy group (n = 27) and the noncolectomy group (n = 68). The clinical parameters (age, gender, disease extent, and disease activity on admission), induction therapies administered [including 5‐aminosalicylic acid, steroids, immunomodulators, calcineurin inhibitor, and anti‐Tumor Necrosis Factor (TNF)‐α antibodies], and laboratory data (hemoglobin, albumin, C‐reactive protein, and cytomegalovirus reactivation on admission) were evaluated and compared between the two groups. Multivariate logistic regression analyses were performed to identify significant predictors of early colectomy, and P < 0.05 was considered significant.ResultsAll clinical parameters were not significant predictors of colectomy. Among laboratory parameters, the serum albumin level on admission was a significant independent predictor of colectomy (odds ratio: 6.097, 95% confidence interval: 1.8310–20.3047). Receiver operating characteristic curves were plotted for the serum albumin levels of the 95 patients at admission. The cut‐off value of serum albumin was 2.45 g/dL.ConclusionsWhen the serum albumin level of UC patients at admission is below 2.45 g/dL, we should consider presenting the option of surgical treatment to patients.

Long-term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study.

BackgroundThe long‐term course of ulcerative colitis after a severe attack is poorly understood. Second‐line rescue therapy with cyclosporine or infliximab is effective for reducing short‐term colectomy but the impact in the long‐term is controversial.ObjectiveThe purpose of this study was to evaluate the long‐term course of acute severe ulcerative colitis patients who avoid early colectomy either because of response to steroids or rescue therapy.MethodsThis was a multicentre retrospective cohort study of adult patients with acute severe ulcerative colitis admitted to Italian inflammatory bowel disease referral centres from 2005 to 2017. All patients received intravenous steroids, and those who did not respond received either rescue therapy or colectomy. For patients who avoided early colectomy (within 3 months from the index attack), we recorded the date of colectomy, last follow‐up visit or death. The primary end‐point was long‐term colectomy rate in patients avoiding early colectomy.ResultsFrom the included 372 patients with acute severe ulcerative colitis, 337 (90.6%) avoided early colectomy. From those, 60.5% were responsive to steroids and 39.5% to the rescue therapy. Median follow‐up was 44 months (interquartile range, 21–85). Colectomy‐free survival probability was 93.5%, 81.5% and 79.4% at 1, 3 and 5 years, respectively. Colectomy risk was higher among rescue therapy users than in steroid‐responders (log‐rank test, p = 0.02). At multivariate analysis response to steroids was independently associated with a lower risk of long‐term colectomy (adjusted odds ratio = 0.5; 95% confidence interval, 0.2–0.8), while previous exposure to antitumour necrosis factor‐α agents was associated with an increased risk (adjusted odds ratio = 3.0; 95% confidence interval, 1.5–5.7). Approximately 50% of patients required additional therapy or new hospitalisation within 5 years due to a recurrent flare. Death occurred in three patients (0.9%).ConclusionsPatients with acute severe ulcerative colitis avoiding early colectomy are at risk of long‐term colectomy, especially if previously exposed to antitumour necrosis factor‐α agents or if rescue therapy during the acute attack was required because of steroid refractoriness.

Predicting Outcome in Acute Severe Colitis-Controversies in Clinical Practice in 2021.

Acute severe ulcerative colitis (ASUC) remains a common medical emergency, with 25% of patients with ulcerative colitis experiencing at least one event in their disease course. Despite advances in medical therapy, ASUC continues to be associated with considerable morbidity and mortality, with up to 30% of patients requiring colectomy during initial admission. Our aim was to review the current controversies and recent progress in risk stratification, prediction of outcome, and personalisation of care in ASUC. We re-assess the use of Truelove and Witts’ criteria, serum biomarkers and the use of composite clinical indices in current clinical practice. We explore the potential for endoscopic prediction using defined validated indices for accurate and early prognostication, and the need to define outcome. We also consider the impact of the current COVID-19 pandemic. Finally, we discuss the current research agenda including the application of new and emerging biomarkers coupled with multi-omics and the implications in management and optimisation of outcome.

Infliximab is more effective than cyclosporine as a rescue therapy for acute severe ulcerative colitis: a retrospective single-center study.

BackgroundAcute severe ulcerative colitis (ASUC) is a potentially life-threatening disease, and the best option in cases of steroid-refractory disease is still debated. We compared the early- and long-term efficacy and safety of the 2 available “rescue therapies”, infliximab (IFX) and cyclosporine (CYS), in this setting.MethodsWe retrospectively evaluated patients admitted for ASUC and treated with “rescue therapy”. The primary endpoint was early colectomy-free survival (30 days) and colectomy-free survival until the end of follow up. The secondary endpoints were predictors of colectomy and long-term maintenance of the treatment strategy over time.ResultsOf 129 patients admitted, 68 received rescue therapy (47 with IFX), whereas 7 underwent early colectomy (10.3%). At 30 days, fewer patients treated with IFX showed a need for colectomy (8.5% vs. 14.3%) compared to those in the CYS group, though the difference was non-significant (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.10-4.69; P=0.47). No severe side effects due to IFX and CYS were observed. During a mean follow up of 40 months, 23 additional patients (37.7%) underwent colectomy, and the rate was significantly lower in the IFX group (25.6%) than in the CYS group (66.7%) (hazard ratio 0.25, 95%CI 0.10-0.61; P=0.003). Colectomy-free survival was significantly higher in the IFX group than in the CYS group (P=0.018) at 12 months.ConclusionsIn our setting, the early outcomes of IFX and CYS for ASUC were comparable. IFX was associated with significantly lower colectomy rates during the observation period and had a similar safety profile to CYS.

Early Colectomy Saves Lives in Toxic Megacolon Due to Clostridium difficile Infection.

The purpose of the study was to evaluate whether early colectomy in patients who have toxic megacolon due to Clostridium difficile colitis reduces mortality. The study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016. All patients 18 to 89 years of age who underwent colectomy for toxic megacolon resulting from C. difficile colitis were included in the study. Other variables included in the study were patient demography, comorbidities, and outcomes. Patients who underwent colectomy before the presentation of septic shock (early group) were compared with patients who underwent colectomy after the onset of septic shock (late group). The main outcome of the study is 30-day all-cause mortality. Because there were some significant differences found in patient baseline characteristics in the univariate analysis, the propensity score of each patient was calculated and pair-matched analysis was performed. All P values are reported as 2-sided, and P < 0.05 was considered statistically significant. One hundred sixty-three patients met the inclusion criteria of the study. Approximately 85% of the patients underwent total abdominal colectomy. The average age of the patients was 65 years old, 51% of the patients were female, and 66% of the patients were white. The overall 30-day mortality was approximately 39%. The mortality rate of patients who underwent colectomy early compared to late was 13 (21%) vs 28 (45%), P = 0.009. The absolute risk difference was 0.24 with 95% CI: 0.07-0.42. There was a reduction of 24% in 30-day mortality when colectomies were performed before the development of septic shock.

P593 Predictors of steroid-resistance in severe colitis of inflammatory bowel disease

Abstract Background Intravenous steroids (IVS) remain the mainstay of therapy in severe colitis of inflammatory bowel disease (IBD), although 30 to 40% of patients will not respond. In such cases, rescue medical therapy with immunomodulators, or an early colectomy are considered. The aim of this study was to identify predictor factors of corticosteroid failure during severe colitis in IBD patients. Methods We conducted a 5-year retrospective study (2014–2019), including all IBD patients with severe colitis. Diagnosis was based on clinical, biochemical markers and endoscopic criteria. All patients received conventional first-line therapy with IVS. Corticosteroid failure was defined according to Travis criteria. Results A total of 40 patients with a mean age of 36 ± 13.1 years and a sex ratio H / F of 0.6 were included. Twenty-three patients (57.5%) had ulcerative colitis (UC) while 17 patients (42.5%) had Crohn’s disease (CD). The average duration of IBD in all patients was 28.8 ± 52.1 months. Severe colitis was the first flare of the disease in fifteen patients (37.5%). Twenty-seven patients (67.5%) respond to IVS. Factors associated with steroid failure on admission were type of IBD (UC) (p = 0.03), presence of fever (T≥ 38°C) (p = 0.04) and blood transfusion (p = 0.02). Biochemical predictors of steroid failure were low hematocrit rate (&amp;lt;28%) (p = 0.03) and hypokalemia (K+&amp;lt;3.5mmol/l) (p = 0.004). Upon 3 days of IVS, a reduction less than 40% in stool frequency, thrombocytosis (platelets&amp;gt; 474000/mm3) (p &amp;lt; 0.001), high-CRP level (&amp;gt; 43mg/dl) (p = 0.026) are predictors of steroid failure. Upon 5 days of IVS, high-CRP level (&amp;gt; 12,1mg/dl)(p = 0.021) was significantly associated with steroid failure. Conclusion In conclusion, stratification of risk in IBD patients with severe colitis should be considered early on admission and at the latest on day 3 of IVS in order to select patients at high risk of steroid failure and then decide to start rescue therapy.

A comparison of long-term healthcare utilization and costs in patients with acute severe ulcerative colitis receiving infliximab versus early colectomy.

Background:Early intervention for acute severe ulcerative colitis (ASUC) improves outcomes. Outcomes and healthcare costs for an infliximab-first and colectomy-first approach were compared.Methods:This single-center retrospective cohort study of inpatients with steroid-refractory ASUC who received infliximab 5 mg/kg (1–3 doses without maintenance) or initial colectomy between 2004 and 2014 assessed long-term healthcare utilization and direct costs following infliximab or colectomy, using admission coding data until 31 December 2016.Results:A total of 118 patients received either infliximab (n = 85, 72%) or colectomy (n = 33, 28%) as initial therapy, with 35(41%) patients eventually requiring colectomy post-infliximab (median 213 days, range [6, 3739]). Median follow up was 7 years [0, 14]. Following infliximab for ASUC, 44% of patients then received antitumor necrosis factor maintenance. After ASUC therapy, length of stay and number of admissions did not significantly differ between groups but higher numbers of complications prompting readmission occurred in the colectomy group (median 4 versus 1, p < 0.001). There were no differences in admissions or total length of stay for patients who had received infliximab first then colectomy versus those treated with colectomy first (median 7.0 versus 4.0, 41.5 days versus 29 days, respectively, each p > 0.05). Total costs were lower at 6 months (mean AUD17,662 versus AUD24,852, p = 0.003), yet were similar at 7 years following an infliximab compared with colectomy approach (AUD72,834 versus AUD59,557, p = 0.23). After infliximab, costs were significantly higher at 7 years with biologic rather than immunomodulator-only maintenance therapy (AUD109,365 versus AUD47,842, p < 0.01).Conclusions:In support of current practice, infliximab salvage in steroid-refractory ASUC achieved reduced short-term healthcare costs compared with initial colectomy, though long-term costs were not significantly different.

Unusual Thrombotic Complications in Severe Ulcerative Colitis

Introduction: Thromboembolic complications, both venous and arterial, are serious extra intestinal manifestations complicating the course of inflammatory bowel disease (IBD), and can lead to significant morbidity and mortality. Left ventricular thrombus formation, as well as peripheral arterial complications, are rarely reported events. We report a case with multiple arterial and venous complications in a patient with severe ulcerative colitis complicated by Clostridium difficile infection. Case description: A 38-year-old male with known severe universal ulcerative colitis, was admitted with increasing abdominal pain, bloody diarrhea, and shock. Temperature was 36.7, P 138, BP 85/57. Hemoglobin was 9.0 mg/dl, WBC 24,899 with left shift. CRP was 65.8. Clostridium difficile PCR was positive. Initial resuscitation was successful, but after 10 days of aggressive medical therapy, total colectomy was required. With initial EKG changes and borderline troponin elevations, CV work-up including transesophageal echocardiography had revealed a left ventricular thrombus, and nuclear stress testing showed a small fixed inferoapical defect, and EF of 45%. He also had developed increasing leg pain and evident arterial occlusive changes by Doppler studies/ABI. Gangrenous deterioration of the right foot developed, requiring partial amputation. Later in his course, he developed pulmonary emboli, confirmed by CTA. Thrombophilia work up was negative, including cardiolipin antibodies. He had been fully anti-coagulated early in his hospitalization. His status gradually improved after a two-month hospitalization, and he was discharged temporarily to skilled nursing facility. Discussion: This case demonstrates both arterial and venous complications of severe ulcerative colitis, including rarely previously reported left ventricular thrombus. His overall condition improved following total colectomy, and likely diminished diathesis for arterial and venous thrombotic manifestations, including distal extremity gangrenous changes requiring amputation, and potential for embolic stroke. Early colectomy may be warranted in those presenting in this fashion.

Early colectomy in steroid-refractory acute severe ulcerative colitis improves operative outcome.

Up to a third of patients with acute severe ulcerative colitis (ASUC) fail to respond to intensive steroid therapy and eventually require a salvage colectomy. We have previously reported that the mortality of emergency colectomy can be decreased by offering it within the first week of intensive medical therapy. We implemented this policy and report the results of our experience. The clinical records of all patients with ASUC who underwent emergency colectomy after failure of medical therapy between January 2005 and July 2015 were extracted from a prospectively maintained database. The data were analysed with regard to duration of intensive medical therapy, timing of surgery, in-hospital mortality and post-operative complications. Eighty-eight patients underwent emergency surgery for ASUC after failed medical therapy. Of these, 75 (85.2%) were operated within 7days of initiation of intensive medical therapy [n=51 (58%) were operated <5days]. One patient who was operated on day 8 following steroid therapy died postoperatively. The current post-operative mortality of 1.1% (1/88) was significantly lower than the mortality noted in the previously recorded retrospective case series [8/51 (15.6%); p=0.001]. In addition, the incidence of overall (9/13 vs. 23/75; p=0.012) and clinically significant (12/75 vs. 6/13; p=0.022) complications was significantly higher in patients operated after 7days as compared to those operated within 7days. The policy of early colectomy, within 7days, in patients with ASUC who fail to respond to intensive steroid-based therapy improves perioperative outcomes with significantly low in-hospital mortality and morbidity.

Clinical Predictors of the Risk of Early Colectomy in Ulcerative Colitis: A Population-based Study.

A subset of patients with ulcerative colitis (UC) will require colectomy within a few years of diagnosis. Thus, our aim was to determine the clinical predictors of early colectomy among patients with UC who are hospitalized with an acute flare. Using population-based surveillance (1996-2009), all adults (≥18 years) hospitalized for UC within 3 years of diagnosis (n = 489) were identified. The primary outcome was a colectomy within 3 years of diagnosis. All medical charts were reviewed. A logistic regression model evaluated clinical variables that predicted colectomy within 3 years of diagnosis, and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Among patients admitted to hospital with UC within 3 years of diagnosis, 57.7% underwent colectomy, with the odds of colectomy decreasing by 12% per year. Early colectomy was more likely among patients aged 35 to 64 years versus 18 to 34 years (OR 2.18 [95% CI, 1.27-3.74]), males (OR 2.03 [95% CI, 1.24-3.34]), those with pancolitis (OR 5.38 [95% CI, 3.20-9.06]), and living in rural areas (OR 2.81 [95% CI, 1.49-5.29]). Prescription of infliximab before hospitalization increased odds of surgery (OR 5.12 [95% CI, 1.36-19.30]). Patients hospitalized for UC have a high risk of early colectomy. This is particularly true in middle-aged men, those living in rural areas, and those without response to infliximab.

Inflammatory Bowel Disease Clinical

Inflammatory Bowel Disease Clinical

Segmental colectomy for bleeding diverticular disease guided by the PEEP test.

Many patients with massive lower gastrointestinal (GI) haemorrhage from diverticulosis are subjected to total colectomy when preoperative localisation is unavailable. We dissected colectomy specimens and noted that there was limited retrograde reflux in most of these cases. Therefore, we sought to assess the value of a positive endoluminal erythrocyte presence (PEEP) test (presence of fresh blood in the caecum) to direct segmental colectomies in 14 patients who required emergency operations for massive lower GI haemorrhage. Overall, 13 (93%) patients who had segmental colectomy guided by the PEEP test had successful control of bleeding. There was no mortality and a 14% postoperative morbidity after segmental resections guided by the PEEP test. One patient had persistent bleeding and required a completion colectomy on the third postoperative day. We propose that the PEEP test be added to the surgical armamentarium to guide segmental resection in the absence of localisation by conventional means. However, we advocate blind total colectomy if the PEEP test is equivocal and early completion colectomy if there is significant re-bleeding.

Long-Term Efficacy and Safety of Cyclosporine in a Cohort of Steroid-Refractory Acute Severe Ulcerative Colitis Patients from the ENEIDA Registry (1989–2013): A Nationwide Multicenter Study

To determine the efficacy and safety of cyclosporine (CyA) in a large national registry-based population of patients with steroid-refractory (SR) acute severe ulcerative colitis (ASUC) and to establish predictors of efficacy and adverse events. Multicenter study of SR-ASUC treated with CyA, based on data from the ENEIDA registry. SR-ASUC patients treated with infliximab (IFX) or sequential rescue therapy (CyA-IFX or IFX-CyA) were used as comparators. Of 740 SR-ASUC patients, 377 received CyA, 131 IFX and 63 sequential rescue therapy. The cumulative colectomy rate was higher in the CyA (24.1%) and sequential therapy (32.7%) than in the IFX group (14.5%; P=0.01) at 3 months and 5 years. There were no differences in early and late colectomy between CyA and IFX in patients treated after 2005. 62% of patients receiving CyA remained colectomy-free in the long term (median 71 months). There were no differences in mortality between CyA (2.4%), IFX (1.5%) and sequential therapy (0%; P=0.771). The proportion of patients with serious adverse events (SAEs) was lower in CyA (15.4%) than in IFX treated patients (26.5%) or sequential therapy (33.4%; P<0.001). This difference in favor of CyA was maintained when only patients treated after 2005 were analyzed. Treatment with CyA showed a lower rate of SAE and a similar efficacy to that of IFX thereby supporting the use of either CyA or IFX in SR-ASUC. In addition, the risk-benefit of sequential CyA-IFX for CyA non-responders is acceptable.

A 53-year-old man with dyspnoea, respiratory failure, consistent with infliximab-induced acute interstitial pneumonitis after an accelerated induction dosing schedule

A 53-year-old man with ulcerative colitis (UC) suffered fatal acute interstitial pneumonitis (AIP) post completing an accelerated infliximab induction course. This is the first case reported in this setting. A...

Fecal calprotectin as an alternative to ulcerative colitis endoscopic index of severity to predict the response to corticosteroids of acute severe ulcerative colitis: A prospective observational study

BackgroundFecal calprotectin (FC) might be an alternative to ulcerative colitis endoscopic index of severity (UCEIS) to predict the response to corticosteroids (CS) in acute severe colitis (ASC). MethodsOne hundred and seventeen ASC patients were prospectively enrolled. Demographic, clinical, laboratory and sigmoidoscopic data were documented. Multivariate and ROC analyses were performed to identify risk factors for non-response to CS, and the predictive accuracy of possible predictors was assessed. ResultsTotally, 39 (33.33%) patients failed intravenous CS therapy. CS responders among mild (UCEIS 3–4), moderate (UCEIS 5–6) and severe (UCEIS 7–8) groups were 40/44 (90.91%) vs. 36/55 (65.45%) vs. 2/18 (11.11%) (p<0.001). UCEIS (OR=5.08; 95% CI, 1.93–8.66; p<0.001) and FC (OR=2.56; 95% CI, 1.17–3.55; p=0.022) were found to be independent risk factors for CS non-responders. Compared with C-reactive protein, platelet, hemoglobin and albumin, baseline FC had the strongest correlation with UCEIS (r=0.701, p<0.001). ROC analysis of UCEIS and baseline FC in predicting CS non-response showed an AUC of 0.85 and 0.76 respectively. ConclusionsBaseline FC levels correlated significantly with UCEIS in ASC, and both were useful in predicting short-term outcome of CS treatment. Baseline FC levels could be used as an alternative of UCEIS to guide the decision of early salvage therapy or colectomy and reduce the adverse effects of long-term futile CS usage.

Ulcerative Colitis Endoscopic Index of Severity (UCEIS) versus Mayo Endoscopic Score (MES) in guiding the need for colectomy in patients with acute severe colitis.

BackgroundThe Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and the Mayo Endoscopic Score (MES) were developed as an objective method of the endoscopic severity in ulcerative colitis (UC); however, it was still unclear whether UCEIS vs MES could guide the need for colectomy in acute severe colitis (ASC).MethodsConsecutive ASC patients between January 2012 and May 2016 were retrospectively evaluated. Demographic data, previous therapy, clinical observations, laboratory parameters, medical therapy and endoscopic assessments were documented. The primary outcome was the need for colectomy during admission and follow-up.ResultsNinety-two patients were enrolled. 37 (40.2%) needed colectomy. UCEIS score is a predictor of requirement for colectomy in multivariate analysis (OR, 3.25; 95% CI, 1.77–5.97; P < 0.001). Receiver-operator characteristic (ROC) area of UCEIS is 0.85, with a sensitivity of 60.3% and specificity of 85.5% using cut-off value of 7, which outperforms MES with the ROC area of 0.65; When UCEIS score ≥7, 80% of patients eventually need colectomy.ConclusionUCEIS outperformed MES as a predictor for need for colectomy in ASC patients. The high probability of medical treatment failure and benefits of early colectomy should be discussed in patients with baseline UCEIS ≥ 7.Acute severe colitis; colectomy; Ulcerative Colitis Endoscopic Index of Severity; Mayo Endoscopic Score