Flare-up Of Ulcerative Colitis Research Articles

Accuracy of ICD9 and ICD 10 Codes for Clostridium difficile Among Ulcerative Colitis Patients

Purpose: The incidence of Clostridium difficile (C. difficile) infections has increased among ulcerative colitis (UC) patients. Researchers have commonly used administrative databases to study associations between C. difficile infection and UC; however, the validity of diagnostic code for C. difficile in UC patients is unknown. The aims of this study were to: 1) evaluate the accuracy of administrative codes for C. difficile infections in UC; and 2) assess whether the frequency of testing for C. difficile and C. difficile diagnosis has changed over time. Methods: Population based surveillance was conducted in the Calgary Health Zone between January 1, 2004 and December 31, 2009 using the Discharge Abstract Database to identify adults (≥ 18 years) admitted to the hospital for UC flare-up (n=583). These patients were concurrently searched for ICD-9 (008.45) or ICD-10 (A04.7) codes for C. difficile diagnosis. In addition, the Calgary Laboratory Services (CLS) provided the results of all C. difficile toxin tests ordered for UC patients admitted to the hospital between 2004 and 2009 (n=389). Only tests performed during hospital admission and up to 7 days prior to admission to hospital were included in the analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% CIs were calculated by comparing ICD9/10 codes for C. difficile in the Discharge Abstract Database with results of CLS stool C. difficile toxin testing. Subsequently, stool toxin tests were used to define the proportion of UC patients who were tested for C. difficile who had a positive result. Joint point regression analysis was used to test for temporal trends in C. difficile testing and positive C. difficile 2004-2009. Results: Over a 6-year period, 288 (74%) UC patients admitted to hospital were tested for C. difficile and 8 (2.8%) were positive. The sensitivity, specificity, PPV and NPV of administrative data in identifying C. difficile infection in hospital was 88% [47%-100%], 100% [98%-100%], 88% [47%-100%] and 100% [98%-100%], respectively. The proportion of UC patients who were tested for C. difficile and who had a positive result remained stable between 2004 and 2009 (Figure 1). Conclusion: Laboratory proven C. difficile infection occurred in 3% of hospitalized UC patients and administrative data accurately identified this. Approximately one quarter of hospitalized UC patients were not tested for C. difficile in hospital or 7 days before hospitalization, which has important implications for clinical care and quality assurance.

Cytomegalovirus Load in Inflamed Intestinal Tissue Is Predictive of Resistance to Immunosuppressive Therapy in Ulcerative Colitis

Previous studies have suggested an association between cytomegalovirus (CMV) infection and steroid-refractory inflammatory bowel disease. In this study, the use of CMV DNA load during acute flare-ups of ulcerative colitis (UC) to predict resistance to immunosuppressive therapy was evaluated in intestinal tissue. Forty-two consecutive patients (sex ratio M/F: 0.9, mean age: 43.6 years) hospitalized for moderate to severe UC and treated with IV steroids were included prospectively. A colonoscopy was performed for each patient at inclusion; colonic biopsy samples of the pathological tissue, and if possible, of the healthy mucosa, were tested for histological analysis and determination of CMV DNA load by real-time polymerase chain reaction assay. Patients were treated as recommended by the current guidelines. Sixteen patients were found positive for CMV DNA in inflamed intestinal tissue but negative in endoscopically healthy tissue; all of these patients were positive for anti-CMV IgG, three exhibited CMV DNA in blood, and none was positive for intestinal CMV antigen by immunohistochemistry detection. In the 26 remaining patients, no stigmata of recent CMV infection were recorded by any technique. By multivariate analysis, the only factor associated with CMV DNA in inflammatory tissue was the resistance to steroids or to three lines of treatment (risk ratio: 4.7; 95% confidence interval: 1.2-22.5). A CMV DNA load above 250 copies/mg in tissue was predictive of resistance to three successive regimens (likelihood ratio+=4.33; area under the receiver-operating characteristic curve=0.85). Eight UC patients with CMV DNA in inflamed tissue and therapeutic failure received ganciclovir; a clinical remission was observed in seven cases, with a sustained response in five of them. The CMV DNA load determined in inflamed intestinal tissue predicts resistance to steroid treatment and to three drug regimens in UC. Initiation of an early antiviral treatment in these patients might delay the occurrence of resistance to current treatments.

Natural history of cytomegalovirus infection in a series of patients diagnosed with moderate-severe ulcerative colitis

To evaluate the natural history of human cytomegalovirus (HCMV) infection in a series of 28 ulcerative colitis patients in whom the search for HCMV was positive. A series of 85 patients with moderate-severe ulcerative colitis flare-up were evaluated for a HCMV search by performing a haematoxylin and eosin stain, immunohistochemical assay and nested polymerase chain reaction on rectal biopsies. Among 85 screened patients (19 of whom were steroid resistant/dependent), 28 were positive for HCMV; after remission the patients were followed up clinically and histologically. Among the 22 patients with complete follow-up, in 8 (36%) patients HCMV-DNA persisted in the intestinal specimens. Among the HCMV positive patients, 4 (50%) experienced at least one moderate-severe flare-up of colitis without evidence of peripheral HCMV. Among the 14 HCMV negative patients, 3 with pouches developed pouchitis and 5 out of 11 (45%) experienced a colitis flare-up. Our preliminary results suggest that HCMV may remain in the colon after an acute colitis flare-up despite remission; it seems that the virus is not responsible for the disease relapse.

Rapid endoscopic improvement is important for 1-year avoidance of colectomy but not for the long-term prognosis in cyclosporine A treatment for ulcerative colitis

Intravenous (IV) cyclosporine A (CSA) is one of the treatments of choice for patients with steroid-refractory severe ulcerative colitis (UC). In this study, we evaluated the overall experience with CSA treatment in UC patients, from their initial response to long-term prognosis. The medical records of 72 patients admitted to our hospital with a severe UC flare-up and treated with IV CSA between November 1996 and October 2008 were reviewed retrospectively. The initial response to CSA was assessed using a clinical activity index, and colectomy was assigned as the endpoint for the long-term prognosis. Overall, 53 of 72 (73.6%) patients responded initially to CSA. We could not determine any specific parameters that predicted an initial response. A life-table analysis for all patients revealed that 54.4% of patients required a colectomy within 11years. The long-term risk of surgery was associated with a shorter disease duration, history of adverse reactions against medications and lack of immunomodulator use. In addition, endoscopic improvement at day 14 was associated with colectomy at 1year, but not with the long-term prognosis. Although CSA can exert high initial efficacy for severe attacks of UC, >50% of patients who relapse require a colectomy. Specifically, mucosal healing evaluated by endoscopy was associated with the 1-year colectomy rate. In contrast, a history of adverse drug reactions was correlated with the long-term colectomy rate. Therefore, we propose that treatment of severe UC with CSA requires consideration of both initial remission and long-term maintenance as management goals.

Prediction of flare-ups of ulcerative colitis using quantitative immunochemical fecal occult blood test

To examine the feasibility of predicting the flare-up of ulcerative colitis (UC) before symptoms emerge using the immunochemical fecal occult blood test (I-FOBT). We prospectively measured fecal hemoglobin concentrations in 78 UC patients using the I-FOBT every 1 or 2 mo. During a 20 mo-period, 823 fecal samples from 78 patients were submitted. The median concentration of fecal hemoglobin was 41 ng/mL (range: 0-392 500 ng/mL). There were three types of patients with regard to the correlation between I-FOBT and patient symptoms; the synchronous transition type with symptoms (44 patients), the unrelated type with symptoms (19 patients), and the flare-up predictive type (15 patients). In patients with the flare-up predictive type, the values of I-FOBT were generally low during the study period with stable symptoms. Two to four weeks before the flare-up of symptoms, the I-FOBT values were high. Thus, in these patients, I-FOBT could predict the flare-up before symptoms emerged. Flare-up could be predicted by I-FOBT in approximately 20% of UC patients. These results warrant periodical I-FOBT in UC patients.

Guillain–Barré Syndrome During a Relapse of Ulcerative Colitis: A Case Report

To the Editor: A 59-year-old male patient was admitted to the hospital for bloody diarrhea and fever. He had a 5-year history of ulcerative colitis (UC) but he was in remission during the last 2 years, being treated with 5-aminosalicylate (5-ASA). Clinical examination demonstrated a well-nourished patient with a normal abdomen. He had mild iron deficiency anemia, the erythrocyte sedimentation rate (ESR) was normal, but C-reactive protein (CRP) was raised to 15.2 mg/L. His biochemical profile was within normal limits except for a slight decrease of the albumins. An abdominal ultrasound showed a slightly enlarged liver with mild steatosis and the presence of sludge in the gallbladder. Chest and abdominal x-ray were normal. Tumor markers (CEA, AFP, CA19-9, CA125, PSA) and thyroid hormones were within normal limits. Stool specimens did not reveal any ova or parasite and stool cultures including Clostridium difficile testing were negative. A colonoscopy showed a typical flare-up of UC with a moderately active chronic UC on histology. He was treated with intravenous (IV) prednisolone 25 mg twice daily and 5-ASA 1000 mg 3 times daily and as soon as clinical improvement was achieved he was discharged. Three days later he was readmitted with lower extremity weakness. On neurological examination the patient was fully consciousness. He had no deficit from cranial nerves. No speech or articulation disorders were detected. We observed neither meningial sign nor jaw reflex. There was a mild to moderate decrease in proximal muscle strength with normal tone. Superficial, vibration, and deep sensory modalities were apparently normal. Deep tendon reflexes of upper and lower extremities were reduced bilaterally. The muscle weakness of the lower extremities was more profound proximally than distally. A moderate impairment of deep sensation was observed, while superficial sensation was normal. There was a flexor plantar response. He was unable to stand or walk without aid. Therefore, he underwent neurophysiological and electromyographical studies. Electromyogram did not show any evidence of acute or chronic denervation in several muscles. However, electroneurogram (ENG) demonstrated a motor-sensory symmetrical demyelinating peripheral polyneuropathy. Cerebrospinal fluid was clear and colorless. Examination showed normal glucose up to 52 mg/dL and pathologically increased albumin up to 905 mg/L. As far as cells were concerned, 2/mm 3 lymphocytes were

Sclerosing mesenteritis, a rare mesenteric disorder, in a patient with ulcerative colitis.

A 60-year-old female who had been ill with ulcerative colitis for more than ten years presented with upper abdominal pain. A flare-up of ulcerative colitis was unlikely, because she did not report rectal bleeding, altered bowel habit, and changes of stool form. A poorly defined mass with mild tenderness was palpable in the upper abdomen, with increased levels of serum pancreatic enzymes, leading us to suspect pancreatic disease. Although CT scan revealed no abnormalities in the pancreas, a well-defined, heterogeneous soft tissue mass was found in the small bowel mesentery. Although several different diagnoses were considered, characteristic features on CT strongly supported diagnosis of sclerosing mesenteritis. The symptoms resolved quickly without specific treatment. The mesenteric lesion has never changed and no unfavorable events have yet occurred.

W1161 Prediction of Flare-Ups of Ulcerative Colitis Using Quantitative Immunochemical Fecal Occult Blood Test

W1161 Prediction of Flare-Ups of Ulcerative Colitis Using Quantitative Immunochemical Fecal Occult Blood Test

Modulation of the Th1/Th2 Balance by Infliximab Improves Hyperthyroidism Associated with a Flare-up of Ulcerative Colitis

Modulation of the Th1/Th2 Balance by Infliximab Improves Hyperthyroidism Associated with a Flare-up of Ulcerative Colitis

Flare-up of ulcerative colitis after systemic corticosteroids: A strong case for Strongyloides

Super-imposed infection with intestinal organisms can mimic a flare-up of underlying disease in patients with inflammatory bowel disease (IBD). We report a case of patient with long standing ulcerative colitis (UC), who presented with abdominal pain, diarrhea and low-grade fever after receiving systemic corticosteroids for an unrelated disorder. Despite a negative stool examination, a peripheral eosinophilia reappeared upon tapering down of a corticosteroid dose. Subsequently, duodenal biopsies showed evidence for Strongyloides, presumably acquired 20 years ago when the patient was residing in Brazil. The patient fully recovered following anti-helmintic therapy. This case underscores the importance of considering Strongyloides in the work-up of flaring-up IBD patients, even if a history of residing or traveling to endemic areas is in the distant past.

The Role of Mannan-Binding Lectin (MBL) Gene Polymorphism in Ulcerative Colitis.

Series studies suggest that enteropathogenic microorganisms play a substantial role in the clinical initiation and relapses of ulcerative colitis (UC). Mannan-binding lectin (MBL) is an important constituent of the innate immune system, and deficiency of MBL has been reported to increase the overall susceptibility of an individual to infectious disease. This study was aimed to investigate the associations between polymorphisms of the MBL gene and UC. Recruited in this study were 108 Japanese patients with UC and 144 healthy control subjects. Polymorphism at codon 54 of exon 1 of the MBL gene was investigated by polymerase chain reaction based restriction fragment length polymorphism. In general, no significant difference in MBL polymorphism was found between UC patients and health controls. However, the frequency of A carriers was significantly higher in the relapsing cases than controls (Odds ration = 2.19, 95%CI, 1.10–4.34; p = 0.023), and similar tendency was also found in A/A genotype. In conclusion, the polymorphism at codon 54 of exon 1 of the MBL gene associated with the susceptibility to the relapsing phenotype of ulcerative colitis. It suggests that codon 54 A variants of MBL gene may have an increased risk for the flare-ups of UC.

Ulcerative colitis reactivation after mercury vapor inhalation

After exposure to mercury vapor at three consecutive 10-month intervals, an electrician in an electroplating plant had flare-ups of ulcerative colitis within 24 hr, that subsided in several days, then returned upon re-exposure 10 months later. The patient and his workplace were both evaluated for mercury exposure. In addition to workplace inspection, both personal and area monitoring for environmental mercury was performed, using both multiple mercury diffusion badges and direct (instantaneous) readings, during maintenance of mercury-filled electrical blocks. Eight-hour time weighted average (TWA) mercury vapor exposure was measured at 0.41 mg/m3 (ACGIH and NIOSH recommended TWA = 0.025 mg/m3; OSHA permissible exposure limit -0.1 mg/m3) for 5 years since stopping overexposure to mercury, the patient remained symptom free in clinical remission. In a patient with chronic ulcerative colitis in remission, occupational exposure to mercury vapor led to episodes of disease reactivation.

Biologic therapies for chronic inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) make up the so-called chronic inflammatory bowel disease (IBD). Advances in the understanding of IBD pathophysiologic mechanisms in the last few years have allowed the development of novel therapies such as biologic therapies, which at least theoretically represent a more specific management of this disease with fewer side effects. Currently, the only effective and widely accepted biologic therapy for the treatment of intraluminal, fistulizing CD, both for remission induction and maintenance, is infliximab. The role of other monoclonal antibodies such as adalimumab is not clearly established. It could be deemed an alternative for patients with allergic reactions to infliximab, and for those with lost response because of anti-infliximab antibody development. However, relevant issues such as dosage and administration regimen remain to be established. Anti-integrin a4 therapies, despite encouraging results in phase-3 studies, are still unavailable, as their marketing authorization was held back in view of a number of reports regarding progressive multifocal leukoencephalopathy cases. Immunostimulating therapy may be highly relevant in the near future, as it represents a novel strategy against disease with the inclusion of granulocyte-monocyte colony-stimulating factors.Regarding ulcerative colitis, results from the ACT-1 and ACT-2 studies showed that infliximab is also useful for the management of serious UC flare-ups not responding to standard treatment, which will lead to a revision of therapeutic algorithms, where this drug should be given preference before intravenous cyclosporine. In the next few years, the role of anti-CD3 drugs (vilisilizumab), T-cell inhibiting therapies, and epithelial repair and healing stimulating factors will be established.

Analysis of the genes overexpressed in the colonic mucosa during flare-up of ulcerative colitis

Analysis of the genes overexpressed in the colonic mucosa during flare-up of ulcerative colitis

Nicotine treatment for ulcerative colitis.

Ulcerative colitis and Crohn’s disease are chronic inflammatory bowel diseases of unknown aetiology which, although similar in various aspects, exhibit some contrasting features. A typical example is their relationship with cigarette smoking. While smoking appears to exert deleterious effects in Crohn’s disease [1, 2], there is overwhelming epidemiological evidence that smoking protects against ulcerative colitis, the risk of developing the disease being significantly lower in smokers than in non-smokers or former smokers [2, 3]. The fact that patients with ulcerative colitis who resume or start smoking often experience clinical improvement [4] prompted attempts to verify the hypothesis that nicotine might be the active component of smoking responsible for the beneficial effects on the course of the disease. Preliminary, uncontrolled observations employing nicotine gum, a pharmaceutical form generally poorly tolerated, yielded encouraging but inconclusive results [5]. The introduction of transdermal nicotine in the market made it possible to assess the potential therapeutic role of nicotine in a more extensive way.

Intracolonic Release in Vivo of Interleukin-1β in Chronic Ulcerative Colitis

1. To investigate the role of interleukin-1 beta in chronic ulcerative colitis, we quantified interleukin-1 beta steady-state release into the colonic lumen. 2. We studied 26 patients with untreated chronic ulcerative colitis and seven patients with irritable bowel syndrome who served as disease controls. In seven ulcerative colitis patients, the disease was inactive and in 19 it was mild to moderately active, according to clinical and colonoscopic criteria. Seven patients with active colitis were studied before and after 4 weeks of treatment with oral 5-aminosalicylic acid. 3. Colonic perfusions were performed using a double-lumen technique. An isotonic solution was continuously infused 50 cm from the anal verge at 5 ml/min, and was recovered 30 cm distally by siphonage. Interleukin-1 beta was measured by ELISA, polymorphonuclear elastase by immunoactivation and leukotriene B4 by specific RIA. 4. All control patients and five out of seven patients with inactive colitis had undetectable interleukin-1 beta release. In active colitis, the release of interleukin-1 beta was detected in 17 out of 19 patients (median 500 pg/min, interquartiles 270-1582 pg/min, P < 0.01 compared with control subjects and patients with inactive colitis). Elastase and leukotriene B4 release were also significantly increased in active colitis compared with inactive colitis and controls. Leukotriene B4 release was similar in inactive colitis and controls, whereas elastase release was higher in inactive colitis than in controls. Five out of seven patients with colitis improved after treatment with 5-aminosalicylic acid. In all responder patients, interleukin-1 beta became undetectable or declined. 5. Our results demonstrate under conditions in vivo that active colitis is associated with enhanced interleukin-1 beta release into the colonic lumen whereas such release does not occur in remission, supporting the concept that ulcerative colitis flare-ups involve increased interleukin-1 beta production.

Efficacy of Intravenous Cyclosporine for Steroid Refractory Attacks of Ulcerative Colitis

The use of cyclosporine in refractory ulcerative colitis (UC) is still controversial. An 8-year-long retrospective review open-label treatment with intravenous cyclosporine in 21 patients with steroid-refractory UC is therefore in order. Intravenous cyclosporine, 5 mg/kg-1 day, was added to ongoing drug therapy. Those who responded were switched to oral cyclosporine for a mean 8.4-month period, and steroids were discontinued when possible. Sixteen out of 21 patients improved (76%). Mean latency time to onset of improvement was 9 days. Five did not improve: three underwent urgent surgery, one was switched to methotrexate, and the remainder died. While on oral cyclosporine, 10 out of 16 maintained remission and seven could discontinue steroids, five relapsed, and one went on continuous mild activity. One patient died of a Pneumocystis carinii pneumonia, while in remission. Five reversible episodes of hepatobiliary toxicity were recorded. Intravenous cyclosporine effectively and rapidly induces improvement of acute steroid-refractory flare-ups of UC and helps to prevent urgent surgery. However, major adverse events may limit its usefulness.

Respiratory manifestations of hemorrhagic rectocolitis

The spectrum of respiratory diseases associated with ulcerative colitis. The respiratory diseases associated with ulcerative colitis have recently been recognized, and principally affect the bronchi. Both chronic bronchitis and bronchiectasis may develop after many years, some of the patients having already undergone colectomy. Chronic bronchitis is characterized by cough and chronic mucopurulent sputum, and these symptoms may be exacerbated during acute flare-ups of ulcerative colitis. The bronchial lesions are inflammatory and can be reversed by corticosteroid therapy. Bronchiectasis produces similar symptoms, but has distinctive radiological features. Corticosteroids may sometimes reduce the symptoms, but they have no effect on the bronchial lesions. Salicylazosulfapyridine might be responsible for hypersensitivity lung diseases with eosinophilia, but the drug does not seem to be involved in the genesis of these bronchial manifestations. There have been occasional reports of other respiratory diseases associated with ulcerative colitis, including obliterative bronchiolitis, isolated and asymptomatic airflow obstruction, inflammatory tracheal stenosis, pulmonary vasculitis, pleurisy and pleuropericarditis, chronic pneumonia and interstitial fibrosis which may be diffuse or localized to the apices.

Ileorectal Anastomosis for Ulcerative Colitis: Prevention of Relapses and Neoplasia of the Rectal Stump with Topical Treatment

We studied the effect of topical treatment with sulfasalazine and corticosteroids on the fate of the rectal stump after ileorectal anastomosis (IRA) for ulcerative colitis. From 1972 to 1986, 31 patients with ulcerative colitis underwent colectomy and IRA. Macroscopically, 93.5% of them had only minor involvement of the rectal mucosa; microscopically, mild or moderate inflammation. Only 2 patients had low-grade dysplasia before surgery. Postoperatively, all patients had a continuous topical treatment with sulfasalazine and corticosteroids. They were monitored carefully for relapses, development of dysplasia and cancer in the rectal stump by endoscopy and histological examination. No proctectomy was performed 1–15 years after the operation; only 29% of the patients had flare-ups of ulcerative colitis in the rectum and 2 patients developed precancerous lesions, and the 2 patients who had preoperative dysplasia have no dysplasia at present. Therefore, we think that topical treatment with sulfasalazine and steroids is useful to improve the results of IRA for ulcerative colitis.

Ileorectal anastomosis in ulcerative colitis. Results in 27 patients.

Hr: PAST rzw DECADES have brought many changes in the surgical treatment of ulcerative colitis. At one time appendicostomy and cecostomy were performed to permit antiseptics, such as Dakin's solution, and mercurial solutions, to be flushed through the inflamed colon. Later, ileostomy, to "put the colon at rest'"by diverting the fecal stream, was preferred. When many patients continued to have active disease in the colon and acute toxic flareups of ulcerative colitis despite ileostomy, most surgeons advised that after ileostomy colectomy be performed when the patient's condition had improved. However, many patients waited for further surgery until an acute toxic flareup had occurred, and such operations had a high mortality. /leostomy alone in the patient in an acutely toxic condition was found to have a high mortality--of 2'4-66 per cenO, ~ or more. From the reports of results of ileostomy alone for ulcerative colitis it became evident that this operation did not "put the colon at rest," cure the disease, or prevent subsequent complications and acute flareups. We observed that carcinomas developed in patients with ileostomies; and in one patient, a carcinoma actually extended through the ileostomy stoma, z The next improvement in surgical therapy for ulcerative colitis was the practice of performing ileostomy and subtotal colectorny at the same time in the patient in an acutely toxic condition. Ferguson and Stevens 4 stated: "The patients are too sick not to be operated upon." Crile and Thomas -° stated: "Removal of the colon, as completely, and as quickly as possible, appears to be the safest method of treating patients with acute toxic ulcerative colitis." Crile and Thomas -° reported one death in 7 such patients subjeered to subtotal colectomy, an improvement over the mortality in patients receiving medical treatment for the condition and an improvement over the mortality in those treated surgically by ileostomy alone.