Clinical characteristics and long‐term prognosis of elderly onset ulcerative colitis

Background and Aim

The aim of this study was to investigate the clinical characteristics and prognosis of patients with elderly onset ulcerative colitis (EOUC), a new growing subgroup of UC.

Methods

This study retrospectively analyzed 3060 South Korean UC patients diagnosed between 1977 and 2014. The clinical characteristics and prognosis of EOUC, defined as UC in those aged ≥ 60 years at diagnosis, were compared with those of non‐EOUC (NEOUC).

Results

Among the 3060 patients, 226 were diagnosed with EOUC (7.4%, median age at diagnosis 65.9 years [interquartile range, 62.9–68.7 years], 58.4% male). The frequency of EOUC increased from 3.9% in the interval 1977–1999 to 9.7% in the interval 2008–2014 (P < 0.001). There were more ex‐smokers in the EOUC than in the NEOUC group (44.2% vs 19.9%, P < 0.001). In the EOUC group, extensive colitis at diagnosis, and the maximum extent thereof, was less than in the NEOUC group (13.7% vs 22.6%, P = 0.002, and 34.5% vs 42.5%, P = 0.011, respectively). The 10‐year cumulative colectomy rate was significantly higher in the EOUC than in the NEOUC group (12.6% vs 7.7%, P = 0.015). UC‐related and all‐cause mortality were higher in the EOUC than in the NEOUC group (3.5% vs 0.6%, P < 0.001, and 12.4% vs 1.8%, P < 0.001, respectively).

Conclusion

Elderly onset ulcerative colitis patients are likely to exhibit distinct features both at diagnosis and during follow‐up. It is necessary to pay more attention to, and to conduct further studies on, this particular group of patients.     

A patient who survived total colonic type ulcerative colitis complicated by toxic megacolon, disseminated intravascular coagulation, methicillin-resistant Staphylococcus aureus infection and bilateral femoral phlebothrombosis

We report a patient who survived total colonic type ulcerative colitis (UC) complicated by toxic megacolon (TM), disseminated intravascular coagulation (DIC), methicillin- resistant Staphylococcus aureus infection, and phlebothrombosis. A 69-year-old man was treated for about 4 months under the diagnosis of ischemic colitis at another hospital, and was transferred to our hospital. Based on endoscopic and pathological findings, we strongly suspected UC, and administered salazosulfapyridine and methylprednisolone, but TM and DIC developed, necessitating urgent subtotal colectomy. Despite his elderly age and the severe complications, he recovered and was discharged from our hospital about 4 months after admission. The mortality rate of UC complicated by TM and DIC in elderly patients is high, necessitating rapid initiation of high-dose steroid administration or surgical treatment. Received: May 6, 1998/Accepted: October 23, 1998     

Safety and efficacy of single‐needle leukocyte apheresis for treatment of ulcerative colitis

Leukocyte apheresis (LCAP) is a safe and effective treatment for active ulcerative colitis (UC) in Japan. Nevertheless, a limitation of LCAP is its requirement for two puncture sites (double‐needle [DN] apheresis), sometimes leading to problems with needle puncture. Single‐needle (SN) apheresis is useful in hemodialysis and reduces needle puncture pain. If SN apheresis were found to be useful in LCAP for UC, it may reduce patient burden. The aim of this study was to compare the safety and efficacy of SN apheresis with that of DN apheresis. Twenty‐four patients with active UC were retrospectively enrolled. They underwent either SN apheresis (n = 12) or conventional double‐needle (DN) apheresis (n = 12) at the Kurume University Hospital from February 2014 to March 2018. At each session, we recorded access problems defined by the time required to initiate apheresis and the frequency of puncture‐related problems, as well as blood circuit clotting, defined as clotting necessitating interruption of apheresis and changing of the circuit. Efficacy was assessed using partial Mayo scores. The number of apheresis sessions was comparable between SN and DN apheresis (9.0 ± 2.0 times vs 9.6 ± 1.4 times, mean ± SEM). SN significantly reduced the time required to start apheresis (10.0 ± 5.4 minutes vs 19.4 ± 11.9 minutes, P < .05) as well as needle puncture troubles (0.9% vs 11.5%, P < .05). SN had comparable frequency of blood clotting episodes (5.6% vs 8.7%). SN apheresis had similar clinical efficacy (P < .001 in SN and P < .01 in DN). The improvement and remission rates were comparable between groups. SN apheresis may be safe and effective and may reduce patient burden during UC treatment. Nevertheless, further comparative studies are needed.     

HLA‐DR genotypes in Chinese patients with ulcerative colitis

OBJECTIVE: To study HLA‐DR genotypes and to analyze the relationship between HLA‐DR genotypes, antineutrophil cytoplasmic antibodies (ANCA) and clinical classification of ulcerative colitis (UC) in Chinese patients. METHODS: Eighty UC patients and 123 healthy subjects were enrolled in the study. Serum ANCA was detected by using indirect immunofluorescence and HLA‐DR was genotyped by using the polymerase chain reaction with sequence‐specific primers (PCR‐SSCP). RESULTS: The positive rate of ANCA in UC patients was 55%, but 0.0% in the controls. The HLA‐DR2 and DR15 positive rates in the UC patients were 58.8 and 40%, respectively, which were significantly greater than 30.1 and 17.9% in the controls (P < 0.05). In the UC patients, the DR15‐positive rate was significantly higher, but the DR16‐positive rate was significantly lower in the ANCA‐positive group than in the ANCA‐negative group (52.3 vs 25.0%; 9.1 vs 30.6%, P < 0.05). The HLA‐DR2 and DR15‐positive rates in chronic persistent UC patients were significantly greater than those in the incipient or chronic recrudescent type of UC (84.2 vs 50.0 or 51.4%; 63.2 vs 29.2 or 35.1%, P < 0.05). CONCLUSIONS: In Chinese UC patients, the positive rates of HLA‐DR2 and ANCA were significantly higher compared with healthy controls. The increase in the DR2‐positive rate was associated with the increase in the DR15‐positive rate in ANCA‐positive UC patients, and was associated with the increase in the DR16 gene positive rate in ANCA‐negative UC patients. In general, HLA‐DR genotypes are related to the clinical classification of ulcerative colitis.     

苦参碱对溃疡性结肠炎患者T细胞亚群的影响

[目的]探讨苦参碱注射液对溃疡性结肠炎（UC）患者外周血T细胞免疫的影响.[方法]采用免疫组化（SAP）法检测30例UC患者用苦参碱注射液治疗1月前、后和10例健康志愿者外周血T细胞亚群.[结果]30例UC患者中治愈7例,好转12例,无变化11例;UC患者CD8^＋Ts细胞明显减少;用苦参碱治疗后UC患者外周血CD3^＋、CD8^＋Ts细胞较治疗前明显增高,有效组CD8^＋Ts细胞显著高于无效组（P＜0.05）.[结论]UC患者抑制性T细胞减低,免疫亢进;用苦参碱注射液治疗有较好疗效,外周血T细胞,尤其CD8^＋Ts细胞水平明显增高.     

Carcinoma of the gall‐bladder associated with primary sclerosing cholangitis and ulcerative colitis

A 64‐year‐old Japanese male was admitted to Fukuoka University Hospital to undergo further examination for an elevated γ‐glutamyltransferase (γ‐GTP) level. Endoscopic retrograde cholangiography (ERC) showed dilatation of the intrahepatic bile duct and stenosis of the proximal portion of the common bile duct. No abnormality was found in the gall‐bladder. Since the fecal occult blood test was positive, sigmoidoscopy and a barium enema were performed. Sigmoidoscopy showed a hyperemic and hemorrhagic mucosa in the rectum, but a barium enema study did not show any abnormal findings in the entire colon. We diagnosed the patient to have primary sclerosing cholangitis (PSC) and ulcerative proctitis based on these radiological and endoscopic findings. Bloody stool and fever occurred 4 months after the first admission. The patient’s colitis extended to the entire colon. Because of the failure of corticosteroid therapy, a subtotal colectomy was performed. Given that a mass was intraoperatively palpable in the gall‐bladder, a cholecystectomy was simultaneously performed. In the whole resected colon, diffuse ulcerations and mucosal islands were found. Grossly, a flat polypoid lesion, measuring 2 cm in diameter, was found in the fundus of the resected gall‐bladder. Sections of this lesion in the gall‐bladder revealed cystic atypical glands and some atypical cell clusters invading the subserosa. The present case suggests that careful observations are needed for patients with ulcerative colitis who have an elevated γ‐GTP level even if the colitis is limited to the distal colon and the serum alkaline phosphatase level is normal.     

Adenoma‐like and non‐adenoma‐like dysplasia‐associated lesion or mass in ulcerative colitis

Ulcerative colitis (UC) patients have an increased risk of colorectal cancer. UC has two general patterns of dysplasia, which are commonly classified as adenoma‐like dysplasia‐associated lesion or mass (DALM) and non‐adenoma‐like DALM. The latter has a high risk of concurrent malignancy and often requires a colectomy. Unfortunately, non‐adenoma‐like DALMs sometimes have endoscopic features similar to those of adenoma‐like DALMs. Therefore, new endoscopic techniques to distinguish between these two kinds of DALM have been proposed.     

Computer‐aided grading system for endoscopic severity in patients with ulcerative colitis

The degree of mucosal redness can be quantified as an index of hemoglobin (IHB) that changes with photographic conditions. The first aim of the present study was to stress the exclusion of γ correction as a critical procedure for reliable measurements of IHB. The second aim was to characterize Matts grade by pictorial parameters in the gray scale picture of IHB and to establish a computer‐aided grading system of endoscopic severity in ulcerative colitis. A total of 130 digital endoscopic pictures of 55 patients with ulcerative colitis (30 Matts 1, 70 Matts 2, 20 Matts 3 and 10 Matts 4) were used. The pictures without γ correction were processed for the mean IHB, SD of IHB, kurtosis of IHB and contrast feature. A computer‐aided grading system was constructed on the basis of Bayes decision theory. Significant increase in the mean IHB was seen when comparing Matts 1 to Matts 2. The SD of IHB or contrast feature significantly increased from Matts 2 to Matts 3 or from Matts 3 to Matts 4. Kurtosis of IHB was significantly larger in Matts 3 than in Matts 1 or Matts 4. Sensitivity and specificity when discriminating Matts 1 from Matts 2, Matts 2 from Matts 3 and Matts 3 from Matts 4 by the grading system were found to be 84 and 96%, 94 and 70%, and 100 and 85%, respectively. The computer‐aided grading system may permit quantitative evaluation of effects of treatments in ulcerative colitis with minimal interobserver variation.