Hepatic Histological Changes in Ulcerative Colitis

Operative liver biopsy was performed on 58 consecutive patients coming to radical excisional surgery for ulcerative colitis.

The histological changes seen in the liver were: increased cellularity of the portal tracts (83 per cent); fatty infiltration (83 per cent); areas of focal necrosis (47 per cent); and early cirrhosis (2 per cent).

Severe liver damage was shown to he associated with severe active colitis, and with a poor subsequent post-operative prognosis. The mechanisms responsible for liver damage in patients with colitis are discussed.     

Twenty Years' Colonoscopic Surveillance of Patients with Ulcerative Colitis Detection of Dysplastic and Malignant Transformation

Background: Endoscopic cancer surveillance in patients with ulcerative colitis has been performed for almost 3 decades. There is still no consensus on its clinical value. Methods: This study evaluates a 20-year prospective study of 143 patients with extensive ulcerative colitis and a disease duration exceeding 10 years. Colonoscopy with double biopsy specimens from nine locations of the colon was performed every 2nd year. Biopsy specimens showing dysplasia were reviewed at the end of the study. Results: Through the surveillance dysplasia/cancer was detected in 55 patients; 7 of these patients had carcinomas, and 2 were in a possibly curable stage (Dukes A). The predictive value of low-grade dysplasia for either high-grade dysplasia or cancer was 41%. Conclusions: Although impaired by limiting factors, colonoscopic surveillance of chronic extensive colitis may identify patients with dysplasia and thereby prevent malignant transformation.     

Ulcerative Colitis in Infancy

Ulcerative colitis (UC) is a chronic idiopathic inflammatory disorder of colon. Frequency of UC is gradually increasing over few years worldwide. Prevalence is 35 to 100/100 000 people in USA, 1% of them are infants. UC develops in a genetically predisposed individual with altered intestinal immune response. An eight-month-old girl presented with loose bloody stool, growth failure, and moderate pallor. The girl was diagnosed as a case of UC by colonoscopy and biopsy. Treatment was thereafter started with immunosuppressive drugs. After initial induction therapy with parenteral steroid and infliximab, the patient is now on remission with azathioprine and mesalamine. UC is rare in Bangladesh, especially in children, and it is rarer during infancy. Several conditions like infective colitis, allergic colitis, Meckel''s diverticulitis, Crohn''s disease, etc. may mimic the features of UC. So, if a child presents with recurrent bloody diarrhea, UC should be considered as differential diagnosis.     

Endoscopic Ultrasonography in Ulcerative Colitis

Abstract: Endoscopic ultrasonography (EUS) was performed in 32 patients with ulcerative colitis. The EUS findings were classified into 5 types based on our criteria. The relationship between the type of EUS finding and clinical severity, endoscopic grading, extent of disease, and therapeutic measures were examined. The type of EUS finding tended to correlate with both the clinical severity and endoscopic grading. There was also a correlation between the extent of the disease and the EUS findings. Therapeutic measures differed according to the type of EUS finding. Consequently, EUS was considered to be useful for the objective assessment and grading of the disease and for predicting prognosis. (Dig Endoc 1994; 6 : 3–6)     

Ulcerative colitis in Karachi

Experience of 189 patients with non-specific ulcerative colitis has been reviewed. The majority of patients was in the 21-30 year age group, and neither sex predominated. Seventy-two percent had mild to moderate disease. The disease was mainly confined to the left colon (60%) and 13% had total colitis.     

Appendiceal Involvement in Patients with Ulcerative Colitis

Abstract: There have been few case reports of ulcerative colitis with appendiceal involvement because the appendix has generally received little attention in ulcerative colitis patients. We encountered an inflammatory appendiceal lesion in a patient with ulcerative colitis, which piqued our interest in endoscopic findings of the appendix in these patients. Subsequently, we carefully observed the appendiceal orifice during colonoscopy in patients with ulcerative colitis. From December 1994 to December 1996, 44 patients with ulcerative colitis underwent colonoscopy in Nagaoka Red Cross Hospital. Among these 44, there were three in whom it had not been possible to observe the cecum. During this period, we encountered inflammatory appendiceal lesions in eight cases. Therefore, 20% (8/41) of patients with ulcerative colitis undergoing colonoscopy had appendiceal involvement. Five of these eight patients showed a colonoscopically normal cecum, such that appendiceal involvement thought to be a colonoscopic skip lesion was seen in five (12%: 5/41). There was only one case who had an appendiceal lesion without a microscopically diseased cecum. Appendiceal involvement may be frequent in ulcerative colitis. We thus recommend that endoscopists meticulously examine the appendiceal orifice during colonoscopy in patients with ulcerative colitis.     

Proposal of a New Clinical Index Predictive of Endoscopic Severity in Ulcerative Colitis

Assessment of disease activity by clinical parameters in ulcerative colitis is still controversial. Different clinical indexes have been proposed. Colonoscopy provides detailed information on mucosal damage. The aim of this study was to identify, among 21 clinical and laboratory parameters, which were predictive of endoscopic activity. We included 137 consecutive patients with ulcerative colitis who underwent colonoscopy, clinical examination, and blood tests within 4 weeks. Endoscopic severity was recorded using a simple score (range, 0–30). The multiple stepwise regression coefficient of each significant variable predictive of mucosal damage was used to develop a new activity index predictive of endoscopic appearance (Endoscopic–Clinical Correlation Index; ECCI). We tested the ability of our score to discriminate patients with severe endoscopic disease, calculating the area under the receiver operator characteristic curve, and we compared it to activity indexes proposed by other authors. Endoscopic severity was significantly influenced by four parameters: bloody stool, nocturnal bowel movements, body temperature >37.5°C, and serum albumin. The new scoring system was calculated as ECCI = {[serum albumin × (–26)] + (bloody stool × 17) + (nocturnal bowel movements × 16) + [fever (0 or 1) × 39]} + 107. The ECCI accurately identified patients with severe endoscopic disease in our sample (sensitivity = 81%, specificity = 95%). In conclusion, the ECCI should be useful in clinical practice because it is simple and strongly related to endoscopic activity.     

A Controlled Study of Faecal Distribution in Ulcerative Colitis and Proctitis

The object of this study was to assess faecal distribution and faecal stasis in patients with ulcerative colitis and healthy control subjects and to relate the findings to the activity and extent of the disease. Each subject ingested 10 radiopaque markers daily for 13 days and attended for a plain abdominal roentgenogram on the 14th day. Patients with active ulcerative proctocolitis retained significantly fewer markers in the whole colon (median values, 11 versus 24 markers) due to a decrease of markers in the left colon (median values, 3 versus 13 markers) compared with the control group (p <0.05). Patients with either proctitis or colitis in remission and control subjects retained similar numbers of markers. The results of this study suggest that, as a group, patients with proctocolitis do not have proximal faecal stasis.     

Colorectal Carcinomas Following Ulcerative Colitis in Japanese Patients

Abstract: Colorectal carcinomas occuring following ulcerative colitis in Japanese patients discussed in the literature were analyzed in order to review their characteristics. 1) Of the 74 cases reported from 1962 to November 1989, 29 were males and 45 were females. The sex differences in Japanese ulcerative colitis were almost 1: 1, so females with colorectal carcinomas occured more often than males. 2) Male patients had a bimodal peak in their 30's and 40's, while female patients had the peak in their 40's and 50's. More colorectal carcinomas were found among younger people than in the general population. 3) Universal colitis was the most common type of colorectal cancer occuring following ulcerative colitis. 57 patients out of 74 were classified into this type. 4) The duration of the disease prior to the diagnosis of colorectal cancer was generally 10 years or longer. 5) The rectum was the commonest site of cancer, and was seen in 44 cases out of 74. Rectosigmoid colon carcinomas occurred in 61 of 74 cases. 6) Histologically, colonic malignancy associated with ulcerative colitis was an adenocarcinoma, displaying a wide spectrum of differentiation. Poorly differentiated (4 males and 6 females) and signet ring cell carcinoma (3 males and 5 females) were also reported. 7) The so-called type 4 tumor occurred in 3 males and 6 females out of a total of 74 cases. This type of tumor is usually rare in colorectal cancer. 8) Most of the patients with early carcinomas had suffered from ulcerative colitis for more than 15 years and the characteristics of their macroscopic appearance were protruded lesions. 9) Foci of dysplasia accompanied carcinoma in as many as 80% of the Japanese cases reported. (56 out of 74 cases) Based on these, we should take consideration that: 1) Patients with pancolitis lasting more than 10 years whose forms are chronically active or intermittently active should be recognized as a high-risk group. 2) Full colonoscopy every one or two years may be sufficient to find dysplasia as well as carcinoma even if the condition of disease is stable. 3) Protruded lesions should be biopsied to detect early cancer as well as dysplasia on colonoscopy. 4) A change in the disease condition, i. e. rectal bleeding, weight loss and a change of bowel habits should not be mistaken for an exacerbation of colitis and should be investigated without fail.     

Functional Alterations of the Microflora in Patients with Ulcerative Colitis

Benno P, Leijonmarck C-E, Monsen U, Uribe A, Midtvedt T. Functional alterations of the microflora in patients with ulcerative colitis. Scand J Gastroenterol 1993;28:839-844.

The aim of the study was to examine microflora-associated characteristics in patients with inactive ulcerative colitis, receiving sulphasalazine, in relation to the spread of the disease. The conversion of cholesterol to coprostanol, the production of urobilinogen, and the degradation of tryptic activity (FTA) and β-aspartylglycine were measured in faecal samples from patients with proctitis or left-sided or total ulcerative colitis and in age- and sex-matched controls. No significant differences in the results were observed in patients with various degrees of extension of inflammatory bowel disease. However, the coprostanol ratio and the urobilinogen level were lower and the FTA was higher in patients with colitis than in the controls (p < 0.05). Beta-aspartylglycine was not found in any faecal sample. The results indicate that patients with ulcerative colitis taking sulphasalazine have a microflora with abnormal metabolic characteristics.     

Radical Surgery for Ulcerative Colitis during Pregnancy

A 21-year-old pregnant woman with fulminating ulcerative colitis in the last trimester is reported. The child was delivered with Caesarean section and weighed 1200 g. The mother was treated with colectomy, a permanent ileostomy, and a temporary rectostomy. Both made an uneventful recovery.     

Serum Transglutaminase Correlates with Endoscopic and Histopathologic Grading in Patients with Ulcerative Colitis

Factor XIIIa, a circulating form of transglutaminase, plays a key role in intestinal mucosal repair. We found that transglutaminase levels are decreased in serum of patients with inflammatory bowel diseases and demonstrated in a rat model of chronic colitis that serum transglutaminase is closely related to the severity of intestinal damage. We aimed, therefore, to correlate serum transglutaminase levels with standard endoscopic and histopathologic grading systems in patients affected by ulcerative colitis (UC). In 249 patients with UC, we assayed serum transglutaminase activity by a radioenzymatic method and measured clinical activity index (CAI) according to modified Rachmilewitz's criteria. In a subset of 82 patients undergoing colonoscopy, endoscopic and histologic indices were studied. Biopsy specimens were also taken from 28 patients to measure myeloperoxidase (MPO) as a marker of mucosa inflammation. Serum transglutaminase levels significantly correlated with the CAI scoring (r = –0.63; P < 0.01); likewise serum transglutaminase showed the best correlation with endoscopic (r = –0.71; P < 0.001) and histologic (r = –0.79; P < 0.001) scores. Myeloperoxidase activity was significantly higher in patients with active UC than those in remission (P < 0.01), showing a significant correlation with serum transglutaminase levels (r = –0.68; P < 0.01). Immunohistochemistry showed factor XIIIa localization in the extracellular matrix of damaged mucosa. In conclusion, these results suggest that transglutaminase assay can be useful in managing UC as a serological, noninvasive indicator of intestinal mucosal status.     

Has Smoking Changed the Epidemiology of Ulcerative Colitis?

The influence of smoking on the risk of developing ulcerative colitis is well documented. Compared with lifetime non-smokers, the risk is reduced in smokers and increased in ex-smokers. During the past 50 years general smoking habits have changed considerably. The proportions of smokers and ex-smokers among men and women have undergone significant changes and, consequently, probably also their risk of ulcerative colitis. A review of 56 earlier epidemiologic studies of ulcerative colitis from 1930 to 1990 showed that the sex distribution in ulcerative colitis has changed from an earlier female predominance that has now been replaced by a male predominance. In contemporary pediatric studies no such changes were seen. We propose that these changes in adults are not related to the disease per se but to an extrinsic factor affecting adults but not children—namely smoking.     

Elective Surgery for Ulcerative Colitis: Colectomy in 158 Patients

Chronic ulcerative colitis was treated by elective colectomy in 158 patients. Proctocolectomy and ileostomy was performed in 140 patients and colectomy and ileorectal anastomosis (CIRA) in 18 patients. The operative mortality was 2.5%. and postoperative complications, mostly infections, occurred in 38%. Within a 2-year postoperative period another 1.9% of the patients died, and late complications occurred in 18%. Colorectal carcinoma was present at the time of colectomy in 5.1% and developed some years later in another two patients primarily operated on with CIRA. Half of the cancer patients died of malignancy. Most extracolic complications, present in 25% of patients before colectomy, regressed or disappeared after operation. Half of the patients operated on with CIRA needed to have their rectum removed within a few years because of cancer or proctitis, and few of the rest had lasting relief of symptoms.     

Increased Protein Tyrosine Kinase Activity of the Colonic Mucosa in Ulcerative Colitis

The protein tyrosine kinase (PTK) activity was measured in the inflamed colonic mucosa of 12 patients with ulcerative colitis and in the normal colonic mucosa of 12 control patients with colon cancer. The specific PTK activity in the particulate fraction obtained from ulcerative colitis mucosa was significantly increased compared with that of normal mucosa (5.10 ± 0.60 pmol/min/mg versus 2.12 ± 0.44 pmol/ min/mg protein; p < 0.05). Inflamed ulcerative colitis mucosa also showed a significantly higher total PTK activity in the particulate fraction than normal mucosa (2.60 ± 0.42 pmol/min/g versus 0.91 ± 0.16 pmol/min/g tissue; p < 0.05). Mucosal samples from ulcerative colitis patients were divided into those with mild and those with severe inflammation on histologic examination (n - 6 each). The particulate PTK activity of severely inflamed mucosa was significantly higher than that of mildly inflamed mucosa (p < 0.05). These results suggest that colonic inflammation in ulcerative colitis is associated with alterations in cellular PTK activity.     

A Study on Atypical Endoscopic Findings of Ulcerative Colitis: Longitudinal Ulcers,Mucosal Bridges and Red Spots

Abstract: One hundred and twenty-one ulcerative colitis patients diagnosed during the period of 1984 to 1988 were examined endoscopically on repeated occasions. Forty-six patients had total colitis, 56 had left-sided colitis, 15 had proctitis, and 4 were postoperative patients. When classified according to their macroscopic findings, 28 of the patients had the polyposis type of this disease, 88 had the atrophic type, and 5 had the mixed type. Longitudinal ulcers were found in 9 patients, occuring usually in the sigmoid colon. There was no pathological evidence of ischemic changes in these 9 patients. Mucosal bridges were found in 13 of the patients with total colitis, occurring somewhere from the cecum to the rectum. The mucosal bridges tended to be present during the mildly active stage of the disease. Red spots, which sometimes looked like vascular spiders, were found in 10 patients. The spots tended to appear before the disease went into the inactive stage. Histological observation showed regenerating vessels, sometimes with intramucosal bleeding; therefore the spots seemed to be intractable changes.     

Herbal Medicine in the Treatment of Ulcerative Colitis

Ulcerative colitis (UC) is a refractory, chronic, and nonspecific disease occurred usually in the rectum and the entire colon. The etiopathology is probably related to dysregulation of the mucosal immune response toward the resident bacterial flora together with genetic and environmental factors. Several types of medications are used to control the inflammation or reduce symptoms. Herbal medicine includes a wide range of practices and therapies outside the realms of conventional Western medicine. However, there are limited controlled evidences indicating the efficacy of traditional Chinese medicines, such as aloe vera gel, wheat grass juice, Boswellia serrata, and bovine colostrum enemas in the treatment of UC. Although herbal medicines are not devoid of risk, they could still be safer than synthetic drugs. The potential benefits of herbal medicine could lie in their high acceptance by patients, efficacy, relative safety, and relatively low cost. Patients worldwide seem to have adopted herbal medicine in a major way, and the efficacy of herbal medicine has been tested in hundreds of clinical trials in the management of UC. The evidences on herbal medicine are incomplete, complex, and confusing, and certainly associated with both risks and benefits. There is a need for further controlled clinical trials of the potential efficacy of herbal medicine approaches in the treatment of UC, together with enhanced legislation to maximize their quality and safety.     

肠炎清治疗溃疡性结肠炎的临床研究

为开拓一种治疗溃疡性结肠炎的中药制剂，将78例溃疡性结肠炎（UC）分层随机分为两组，治疗组以肠炎清治疗，对照组以柳氮磺胺吡院治疗。治疗60d后结果发现，治疗组临床证候总显效率为84．61％，对照组为35．90％（P＜0．01），总有效率治疗组为89．74％，对照组58．97％（P＜0．01）；两组肠粘膜的总显效率治疗组为69．23％，对照组15．38％（P＜0．01），总有效率治疗组为87．18％，对照组56．41％（P＜0．01）。认为不论轻、中、重型的UC患者，肠炎清的疗效均优于柳氮磺胺吡啶。     

Incidence of Ulcerative Colitis and Indeterminate Colitis in Four Counties of Southeastern Norway, 1990–93 A Prospective Population-Based Study

Background: The incidence of ulcerative colitis (UC) has been difficult to interpret because prospective studies have only been performed during the past 3 decades. Geographic variations may therefore be due to differences in study design. Method: From 1 January 1990 to 31 December 1993 all new cases of UC in four counties in southeastern Norway were prospectively registered. Cases diagnosed as indeterminate colitis (IND) when endoscopy and histopathology were inconclusive or diverged with regard to diagnosis of UC or Crohn's disease (CD) were also included in the study. Results: A total of 525 cases of UC and 93 cases of IND yielded an mean annual incidence of 13.6/10⁵ and 2.4/10⁵, respectively. There were differences in incidence between counties, and a peak of 21.5/10⁵ in the annual incidence was found for the age group 25 to 34 years in UC. The distribution was about equal for each of the groups proctitis and left-sided and extensive colitis. The time interval from onset of symptoms to diagnosis was 4 months. Conclusion: In this study one of the highest incidences of UC in the world has been found. The classification ‘indeterminate colitis' seems reasonable to use in some of the cases to prevent misclassification at the initial stage of diagnosis.