Clinical status of ulcerative colitis in patients who smoke

Objectives: Ulcerative colitis (UC) is largely a disease of nonsmokers. There are few patients who are current smokers, but we have identified a group and reviewed their clinical status, disease activity, and nicotine exposure to examine whether they remain well controlled while smoking.
Methods: Fifty-one patients from three centers with verified UC were reviewed.
Results: Thirty of the group were men; mean age 50 yr, with a mean age of onset of 37 yr. Twenty-two patients had proctosigmoid disease, 12 involvement of left colon, and 17 total colitis. All were current smokers; 41 were cigarette smokers averaging 17 daily. At the onset of colitis 30 were nonsmokers, 25 of them were ex-smokers and 19 developed colitis within 2 yr of stopping smoking. Twenty-eight believed smoking improved disease activity and none felt smoking had a detrimental effect on their UC. Eleven were receiving no medication for UC, 40 were receiving 5-ASA (5-aminosalicylic acid) preparations, and only two took oral steroids. All were in clinical remission, with the exception of one patient; mean St. Marks score was 1.5, out of a possible total of 22. Sigmoidoscopic grades were inactive in all patients except three. Histological assessment showed significant activity in only five. Median serum nicotine was 8 ng/ml (range, 0.4–24.4), median serum cotinine 180 ng/ml (range, 20–453), with corresponding salivary cotinine of 255 ng/ml (range, 34–683). Median rise in nicotine 2 min after a cigarette in 35 patients was 12.1 ng/ml (range, 0.4–44).
Conclusions: Because most current smokers with UC have inactive disease, smoking may contribute to the clinical remission in these patients.     

Clinical course and long-term prognosis of Japanese patients with ulcerative colitis

The course and prognosis of 308 patients with ulcerative colitis who visited Tohoku University Hospital during the period from 1954 to 1987 were investigated. Based these investigations, the following results were obtained. 1) In 27.6% of patients with proctitis, extension to the proximal colon developed during the observation period. 2) Surgical intervention was necessary in 33.9% of patients with total colitis and in 9.7% of those with left-sided colitis. 3) Of 1,566 patient-years in which the course was observed, 988 (63.1%) were active-years. When the course of ulcerative colitis was analyzed according to the duration and extent of involvement, the frequency of the attack-years in patients with proctitis or left-sided colitis steadily decreased with time. However, that of total colitis was constant, 65-85%, regardless of the follow-up period. Patients younger than age 20 at onset were prone to relapse during their course, compared with patients older than 20. 4) Ten patients died from causes related to ulcerative colitis in our hospital: 5 of them due to postoperative complications. Two patients developed colorectal cancer accompanying ulcerative colitis. 5) With respect to the cumulative survival rate, the 95% confidence limits of the observed curve was lower than the expected curve during the first 2 years and 12-16 years after the onset. The main causes of death were postoperative complications in the former and unrelated deaths of older patients in the latter.     

Clinical course and long-term prognosis of Japanese patients with ulcerative colitis

The course and prognosis of 308 patients with ulcerative colitis who visited Tohoku University Hospital during the period from 1954 to 1987 were investigated. Based these investigations, the following results were obtained. 1) In 27.6% of patients with proctitis, extension to the proximal colon developed during the observation period. 2) Surgical intervention was necessary in 33.9% of patients with total colitis and in 9.7% of those with left-sided colitis. 3) Of 1,566 patient-years in which the course was observed, 988 (63.1%) were active-years. When the course of ulcerative colitis was analyzed according to the duration and extent of involvement, the frequency of the attack-years in patients with proctitis or left-sided colitis steadily decreased with time. However, that of total colitis was constant, 65-85%, regardless of the follow-up period. Patients younger than age 20 at onset were prone to relapse during their course, compared with patients older than 20. 4) Ten patients died from causes related to ulcerative colitis in our hospital: 5 of them due to postoperative complications. Two patients developed colorectal cancer accompanying ulcerative colitis. 5) With respect to the cumulative survival rate, the 95% confidence limits of the observed curve was lower than the expected curve during the first 2 years and 12-16 years after the onset. The main causes of death were postoperative complications in the former and unrelated deaths of older patients in the latter. This work was partly supported by a grant from the Investigation and Research Committee for Intractable Inflammatory Bowel Diseases, organized by Japanese Ministry of Public Welfare.     

Clinical course of ulcerative colitis in patients with and without primary sclerosing cholangitis

BACKGROUND AND AIM: We noticed in our practice that patients with ulcerative colitis (UC) who have developed primary sclerosing cholangitis (PSC) experience a milder course of colonic disease. Our objective in this study was to define whether or not there is any difference between UC activity and its course in patients with and without PSC. METHODS: Nineteen patients with UC and PSC (eight male, mean age 25 years) were enrolled. To every patient with UC and PSC, three patients with UC alone (total of 57 patients, 28 male, mean age 24 years) matched for age at onset, duration of the disease and extension of colonic disease were selected as the control group. We used number of hospitalizations due to activity of UC and number of short corticosteroid administrations in various years of follow-up as variables indicating course and severity of the colonic disease in this period. For comparing trends of UC activity between two groups, we used repeated measures two-way analysis of variances. RESULTS: Mean duration of follow up in case and control groups was 12.2 +/- 5.7 and 11.4 +/- 4.9 years, respectively. Two groups had no significant difference in use of sulfasalzine or aminosalicylates. Number of hospitalizations and courses of steroid therapy because of UC activity decreased significantly over time (P < 0.000) in both groups, and it was significantly higher in controls than in cases (P = 0.045 and 0.032, respectively). CONCLUSIONS: Development of PSC in patients with UC might have a positive effect on colonic disease. Further investigations to evaluate the basis of this improvement are warranted.     

Long-term outcome of ulcerative colitis in patients who achieve clinical remission with a first course of corticosteroids

BackgroundAlthough the early outcomes of ulcerative colitis after a first course of corticosteroids are well known, data on long-term disease evolution in patients responding to a first corticosteroid course are scarce.AimsTo evaluate the long-term clinical evolution in ulcerative colitis patients responding to a first course of corticosteroids and to identify those factors associated with a poorer outcome.MethodsRetrospective review of 114 patients diagnosed with ulcerative colitis who responded to the first corticosteroid course, and did not start thereafter maintenance therapy with thiopurines were included.ResultsCorticosteroids were prescribed because of a moderate (78%) or a severe flare (22%). All but two patients followed maintenance treatment with mesalazine after corticosteroid discontinuation. After a median follow-up of 83 months (7–156), 72% of patients suffered new relapses leading to corticosteroid reintroduction in 65% of patients. The earlier corticosteroids were introduced in the course of ulcerative colitis, the higher the risk of relapse and corticosteroid reintroduction. Thiopurines were started in 51%, and infliximab in 19%. Eleven percent of patients underwent colectomy. No predictors of thiopurine use or colectomy were found.ConclusionsHalf of the ulcerative colitis patients responding to a first course of corticosteroids will require immunosuppressors mainly because of steroid-dependence.     

Hemophagocytic syndrome associated with fulminant ulcerative colitis and presumed acute pancreatitis

We herein report a case of hemophagocytic syndrome that developed in a 25-yr-old man with fulminant ulcerative colitis and presumed acute pancreatitis. Physical examination on admission showed a chronically ill, delirious patient with an upper abdominal mass. Peripheral blood showed progressive pancytopenia and bone marrow aspirate smears revealed hypocellular bone marrow with an increase of histiocytes showing prominent hemophagocytosis. Plain abdominal radiography revealed toxic megacolon. Both ultrasound and computed tomography showed the enlargement of the pancreas, thus indicating presumed acute pancreatitis. No apparent neoplasms or viral or bacterial infections, which are normally reported to be the cause of hemophagocytic syndrome, were detected. The patient was successfully treated with high doses of prednisolone and γ-globulin.     

Elevated serum values of procollagen Ⅲ peptide （PⅢP）in patients with ulcerative colitis who will develop pseudopolyps

AIM: To assess the impact of procollagen Ⅲ peptide as a marker of collagenesis in the development of pseudopolyps in patients with ulcerative colitis.METHODS: Development of pseudopolyps was monitored in 25 patients with ulcerative colitis classified according to Powell-Tuck index as mild (n=12) or moderate (n=13) form of disease. Patients with a mild form of disease were treated with oral mesalazine medication (2-4 g/day) and local mesalazine preparation (suppository). Patients with a moderate form of disease received oral mesalazine medication (2-4 g/day), local mesalazine preparation(suppository) and local methylprednisolone at an initial dose of 60 rag/day, followed by dose tapering. How many significant variables (previously determined by analysis of variance) were elevated in the groups with and without pseudopolyp developement was observed. ROC analysis for calculation of new index was made.RESULTS: Serum values of procollagen Ⅲ peptide (PⅢP), C-reactive protein (CRP) and C4 complement component (C4)were statistically significantly lower in the group of patients flee from pseudopolyp development bhan bhose who developed one or more pseudopolyps (0.45&#177;0.12 vs 1.42&#177;0.70,P&lt;0.0027; 7.6&#177;4.7 vs 17.8&#177;9.17, P&lt;0.035, and 0.46&#177;0.11 vs 0.34&#177;0.16, P&lt;0.068, respectively) at endoscopic conrtrols with patohistologically samples during 13 months. There were no statistically significant differences in the values of C3, ceruloplasmin and IgM between the two groups (P&gt;0.05).Discrimination function analysis yielded highest standardized cannon coefficients for PⅢP (0.876), CRP (0.104), C3 (-0.534) and C4 (0.184) (P&lt;0.036). The elevation in two of three laboratory variables (PⅢP, CRP and C4) reached sensitivity of 93 % and specificity of 90 % in the development of pseudopolyps.CONCLUSION: It is proposed that an increase in two of the three laboratory parameters (PⅢP, CRP and C4) could improve the accuracy of prediction of the development of pseudopolyps. When using PⅢP, CRP and C4 on decision making, the positive predictive value and accuracy were 90 % and 92 %, respectively.     

Elevated serum values of procollagen Ⅲ peptide (PIIIP)in patients with ulcerative colitis who will develop pseudopolyps

AIM: To assess the impact of procollagen Ⅲ peptide as a marker of collagenesis in the development of pseudopolyps in patients with ulcerative colitis.METHODS: Development of pseudopolyps was monitored in 25 patients with ulcerative colitis classified according to Powell-Tuck index as mild (n=12) or moderate (n=13) form of disease. Patients with a mild form of disease were treated with oral mesalazine medication (2-4 g/day) and local mesalazine preparation (suppository). Patients with a moderate form of disease oral mesalazine medication (2-4 g/day), local mesalazine preparation (suppository) and local methylprednisolone at an initial dose of 60 mg/day, followed by dose tapering. How many significant variables (previously determined by analysis of variance) were elevated in the groups with and without pseudopolyp developement was observed. ROC analysis for calculation of new index was made.RESULTS: Serum values of procollagen Ⅲ peptide (PⅢP), Creactive protein (CRP) and C4 complement component (C4)were statistically significantly lower in the group of patients free from pseudopolyp development than those who developed one or more pseudopolyps (0.45±0.12 vs 1.42±0.70,P＜0.0027; 7.6±4.7 vs 17.8±9.17, P＜0.035; and 0.46±0.11rs0.34±0.16, P＜0.068, respectively) at endoscopic conrtrols with patohistologically samples during 13 months. There were no statistically significant differences in the values of C3, ceruloplasmin and IgM between the two groups (P＞0.05).Discrimination function analysis yielded highest standardized cannon coefficients for PⅢP (0.876), CRP (0.104), C3 (-0.534)and C4 (0.184) (P＜0.036). The elevation in two of three laboratory variables (PⅢP, CRP and C4) reached sensitivity of 93 % and specificity of 90 % in the development of pseudopolyps.CONCLUSION: It is proposed that an increase in two of the three laboratory parameters (PⅢP, CRP and C4) could improve the accuracy of prediction of the development of pseudopolyps. When using PⅢP, CRP and C4 on decision making, the positive predictive value and accuracy were 90 %and 92 %, respectively.     

Pseudotumorous pancreatitis associated with ulcerative colitis

Pancreatitis is believed to be one of the uncommon extraintestinal manifestations of ulcerative colitis (UC). A 66-year-old woman who had been treated for UC for eight months was admitted to our hospital because of epigastralgia. Laboratory examinations revealed elevated pancreatic enzymes. Because differentiation of pseudotumorous pancreatitis from pancreatic cancer was difficult by the imaging findings, she underwent a distal pancreatectomy. Histologically, the tumorous lesion was composed of fibrosis with lymphocytic infiltration. We concluded that this case was pseudotumorous pancreatitis as an extraintestinal manifestation of UC.     

Chronic pancreatitis in patients with sclerosing cholangitis and ulcerative colitis

In the 4-year period 1980-83 sclerosing cholangitis was demonstrated in 7 out of 151 patients with ulcerative colitis hospitalized in our department. Total ulcerative colitis was demonstrated in all patients with sclerosing cholangitis, whereas abnormal pancreatograms compatible with chronic pancreatitis were seen in four of these patients. According to the criteria of Kasugai, one had minimal, two moderate, and one advanced changes of chronic pancreatitis. Although three of four patients had been treated with drugs known to induce pancreatitis (sulfasalazine and corticosteroids), it is tempting to assume that ulcerative colitis, sclerosing cholangitis, and pancreatitis, when seen in combination, are manifestations of autoimmune diseases with a genetic predisposition. A mechanical mechanism for the development of chronic pancreatitis in sclerosing cholangitis must also be considered.     

Clinical features and course of ulcerative colitis diagnosed in asymptomatic subjects

Background and AimsAlthough some ulcerative colitis (UC) patients are diagnosed when they do not have any UC-related symptoms, clinical features and prognosis of UC diagnosed in asymptomatic patients remain unclear.MethodsData for UC patients who were asymptomatic at diagnosis were retrospectively reviewed from the IBD database of the Asan Medical Center. The clinical characteristics and prognosis of those patients were analyzed and compared with matched (1:4) symptomatic UC patients.ResultsOnly nineteen asymptomatic UC patients (1.1%) were identified from 1665 UC patients. The proportion of males was 78.9% (n = 15), and their median age at diagnosis was 48 years (range, 34–71 years). At diagnosis, proctitis was noted in 11 patients (57.9%), left-sided colitis in 4 (21.1%), extensive colitis in 0 (0%), and atypical distribution in 4 (21.1%). The 5-year cumulative probability of symptom development was 68.5% (95% confidence interval [CI], 62.8%–74.2%). After UC diagnosis, oral 5-aminisalicylic acid (ASA) and topical 5-ASA were used in 14 (73.7%) and 16 (84.2%) patients, respectively. During follow-up (3.7-year median for asymptomatic patients versus 3.7-year median for symptomatic patients; P = 0.961), the 5-year cumulative probability of corticosteroids (23.7% versus 57.1%; P = 0.022) and azathioprine (0% versus 24.7%; P = 0.003) use was higher in symptomatic patients than in asymptomatic patients.ConclusionsThe frequency of asymptomatic UC patients was 1.1% in our UC patient cohort. A majority of these patients became symptomatic during follow-up. Asymptomatic UC patients at diagnosis appear to have a better prognosis than symptomatic UC patients.     

Recurrent acute pancreatitis induced by 5-ASA and azathioprine in ulcerative colitis

Drug-induced acute pancreatitis (DIAP) is an often-neglected entity where the disorder is the consequence of the toxic effects of various agents applied to treat potentially life-threatening conditions, such as inflammatory bowel disease. Here, we present the case of a male patient with ulcerative colitis with a history of two episodes of recurrent acute pancreatitis. After excluding other potential causes, we suspected DIAP since the patient received 5-aminosalycilate (5-ASA) prior to the first episode and, one year later, azathioprine (AZA) prior to the second episode. The causative effect of AZA was confirmed by performing a re-challenge with a reduced dose. While both episodes of DIAP had a mild disease course, they were associated with acute relapse of ulcerative colitis. Last seen, the patient was asymptomatic. With this case, we would like to highlight the importance and diagnostic difficulties of DIAP in the background of recurrent cases when common etiological factors of acute pancreatitis are excluded.