Ulcerative colitis and colon cancer: the role of surveillance

Colon cancer is a well known complication of ulcerative colitis. Various methods have been discussed to reduce its risk. Since the introduction of the concept epithelial dysplasia and fiberoptic colonoscopy surveillance programmes have been launched based on these methods. The incidence of colon cancer in ulcerative colitis is moderately increased but constitutes only a fraction of all colon cancers diagnosed. Among these patients colon cancer almost exclusively affects those with extensive colitis. Duration of disease in these cases usually exceeds eight to ten years. The true benefit of a cancer surveillance programme will probably never be the subject of controlled prospective studies and is therefore difficult to evaluate. The concept of dysplasia is the major instrument for selecting patients for prophylactic colectomy. Development from normal mucosa to high grades of dysplasia shows individual variations from one to several years justifying annual colonoscopies in high risk patients. Strict criteria for dysplasia and independent evaluations from several pathologists should compensate for the subjective nature of dysplasia interpretation. The need for more objective markers such as DNA-flow cytometry is clearly needed. The role of DNA flow cytometry in surveillance, however, needs to be determined. The cost benefit aspects of such surveillance programmes have to be balanced against the total resources of a gastroenterology unit.     

Ulcerative Colitis and Colon Cancer: The Role of Surveillance

Colon cancer is a well known complication of ulcerative colitis. Various methods have been discussed to reduce its risk. Since the introduction of the concept epithelial dysplasia and fiberoptic colonoscopy surveillance programmes have been launched based on these methods. The incidence of colon cancer in ulcerative colitis is moderately increased but constitutes only a fraction of ail colon cancers diagnosed. Among these patients colon cancer almost exclusively affects those with extensive colitis. Duration of disease in these cases usually exceeds eight to ten years. The true benefit of a cancer surveillance programme will probably never be the subject of controlled prospective studies and is therefore difficult to evaluate. The concept of dysplasia is the major instrument for selecting patients for prophylactic colectomy. Development from normal mucosa to high grades of dysplasia shows individual variations from one to several years justifying annual colonoscopies in high risk patients. Strict criteria for dysplasia and independent evaluations from several pathologists should compensate for the subjective nature of dysplasia interpretation. The need for more objective markers such as DNA-flow cytometry is clearly needed. The role of DNA flow cytometry in surveillance, however, needs to be determined. The cost benefit aspects of such surveillance programmes have to be balanced against the total resources of a gastroenterology unit.     

Colitis cystica profunda: diagnosis and management

We have reported a case of colitis cystica profunda, an uncommon, benign disease of the colon presumably due to chronic inflammation, characterized by submucosal mucus-filled cysts. It may be premalignant, having been associated with ulcerative colitis and rectal adenocarcinoma. Diagnosis requires a high degree of suspicion and adequate biopsies, and treatment is by simple excision.     

Colitis, cancer, and colonoscopy.

Colonoscopy has added a new dimension to the diagnosis of colonic diseases. In the field of inflammatory bowel disease, colonscopy is indicated only when certain specific problems arise. Patients with acute colitis and those who are too sick to withstand cleansing enemas should not undergo colonoscopy. A major use of the colonoscope is in the detection of carcinoma in the colitic colon either in the form of colonic strictures or filling defects discovered by barium enema x-ray, or in the long-term surveillance of patients with universal ulcerative colitis. Criteria are listed to assist in the colonoscopic differential diagnosis between ulcerative and granulomatous colitis. By using different criteria than the radiographer, and with the help of biopsy specimens, a high degree of accuracy in proper diagnosis can be achieved.     

Crohn's disease and colorectal malignancy

There has been much debate over the past 50 years concerning the association between colorectal carcinoma and inflammatory bowel disease. Until recently, it was widely accepted there was a higher risk in those with widespread ulcerative colitis. However, evidence now suggests an almost equal incidence in those with Crohn's disease of similar extent and duration. We present a case that underlines the important clinical and pathological features of Crohn's disease associated colorectal carcinoma (CDAC). We present a literature review and debate the role of regular colonic surveillance in patients with Crohn's disease affecting the colon.     

Colorectal cancer surveillance for patients with inflammatory bowel disease

Although the cumulative prevalence of colorectal cancer among patients with ulcerative colitis is similar to that among patients with sporadic colorectal cancer, the younger age of ulcerative colitis patients with cancer accounts for the age-specific relative risk. Approximately half of ulcerative colitis patients with colorectal cancer die from metastatic disease. Pancolitis of long duration and coexistent primary sclerosing cholangitis are strong risk factors for cancer that should prompt entry into cancer surveillance programs. When done appropriately, cancer surveillance in patients with inflammatory bowel disease can be very effective, and at a reasonable cost.     

Expression of urokinase-type plasminogen activator and plasminogen activator inhibitor in colon disease

Surveillance colonoscopy and biopsy are inaccurate methods of predicting the likelihood of ulcerative colitis patients to develop colon carcinoma. We examined uPA and PAI-1 as potential markers for assessing these patients and those with familial polyposis who are at risk of developing colon cancer. For comparison, biopsies of normal colon and Crohn's disease were evaluated. We examined 77 colonic mucosa specimens taken from patients undergoing elective resection for benign and malignant colonic disease. uPA and PAI-1 were measured using a monoclonal antibody-based ELISA kit (American Diagnostica, Greenwich, CT) and expressed as ng/mg extract protein. Intra- and interassay controls of uPA gave CV = 3–4% and CV = 8–9%, respectively, while those for PAI-1 were 6–7% and 10–11%, respectively. The Mann-Whitney test showed that both uPA and PAI-1 expression were significantly higher in colon cancer, chronic ulcerative colitis, and Crohn's disease than in normal colon. uPA in familial polyposis samples was similar to that of normal colon, while PAI-1 was much lower than in normal colon. Neither patient age nor sex appeared to influence the expression of these potential markers in any tissue. The pattern of uPA and PAI-1 expression in normal, benign and malignant colon suggests these proteins deserve further consideration as markers for assessing colon carcinoma risk.     

Evolution of the concept of proctosigmoiditis: clinical observation

Proctosigmoiditis, or distal colon ulcerative colitis, has been recognized as a clinical entity for over 50 years and considerable information has emerged from the study of the clinical course of patients with distal colon ulcerative colitis who are followed for a period of years. For most patients the condition is benign, although periods of exacerbation can occur between remissions, characterized by rectal bleeding. However, extension of the disease, development of cancer, and the requirement of surgery are all relatively unusual. It has recently been recognized that there are many other causes of proctitis than the idiopathic form, and this has raised important questions in differential diagnosis, particularly in the proctitis occurring in homosexual males. Proctitis, proctosigmoiditis, and distal colon ulceratice colitis and not Crohn's disease; conversely perianal fistulae and abscesses are rare in distal colon ulcerative colitis. Treatment with various forms of topical agents has often been satisfactory.     

Colon cancer associated with ulcerative colitis and early diagnosis

Ulcerative colitis(UC) is known to be associated with colon cancer. The risk factors of cancer incidence are total colitis type and over 10 years clinical course. The macroscopic appearance of cancer with UC mainly consist of type 3, 4 and dominant histological type is mucinous adenocarcinoma or poorly differentiated adenocarcinoma. Most of cancer is considered to raise from dysplasia. The dysplasia is difficult for diagnosis macroscopically, but it has characters of DNA aneuploidy and positive p53. For early diagnosis of cancer, surveillance is very important. The surveillance program is recommended to perform colonoscopy every year to UC patients with over 10 years course and take biopsies from every 10 cm of colon. If high-grade dysplasia is discovered by surveillance colonoscopy, a resection of total colon should be performed.     

Elevated c-Src tyrosine kinase activity in premalignant epithelia of ulcerative colitis.

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon with a high incidence of colon cancer. Dysplasia is a precursor to carcinoma and a predictor of malignant potential; epithelia containing high-grade or severe dysplasia is most likely to develop cancer. The cellular oncogene c-src and its viral homologue v-src (the transforming gene of Rous sarcoma virus) encode 60-kD cytoplasmic, membrane-associated protein tyrosine kinases. For the viral protein or transforming mutants of the cellular protein (Src), a close correlation exists between elevated tyrosine kinase activity and malignant transformation of cells. Previously, we and others observed elevated Src activity in sporadic colon carcinomas and benign adenomas at greatest risk for developing cancer (those with large size, villous architecture, and/or severe dysplasia). Here we report that Src activity and protein abundance are also elevated in neoplastic UC epithelia. Activity is highest in malignant and severely dysplastic epithelia, and 6-10-fold higher in mildly dysplastic than in nondysplastic epithelia. Thus, Src activity is elevated in premalignant UC epithelia, which is at greatest risk for developing cancer. The data suggest that activation of the src proto-oncogene is an early event in the genesis of UC colon cancer.     

Cancer in chronic ulcerative colitis. Diagnostic role of segmental colonic lavage.

Saline colonic lavage in 74 patients with chronic ulcerative colitis was performed utilizing a commercially available dental irrigating unit through a polyethylene catheter in the biopsy channel of a colonoscope or through a sigmoidoscope via a lavage-aspirating double-lumen probe. Six patients were found with colonic carcinoma. Two diagnoses of malignancy were established by cytologic smears and cell block alone. Two patients had positive mucosal biopsies and cell block. One patient with a hepatic flexure carcinoma and a second patient with a malignancy proximal to the left colon stricture were missed by these techniques. Considering the established proclivity for carcinoma in these patients, it is felt that segmental lavage in areas of stricutre, grossly dostorted mucosa, or endoscopically inaccessible areas represents a valuable adjunct in the diagnosis of carcinoma in chronic ulcerative colitis.     

An investigation into the validity of the present classification of inflammatory bowel disease

To assess the validity of the present subdivision of patients with inflammatory bowel disease into those with Crohn's disease of the small bowel or of the colon and those with ulcerative colitis, 252 patients with inflammatory bowel disease have been studied by questionnaire and case note review. One hundred and seventy-two variables concerning the nature and frequency of symptoms in remission and relapse, the incidence of complications and results of investigation have been analysed by computer. As expected, there were many highly significant variables between patients with ulcerative colitis and those with Crohn's disease of the small bowel. The latter showed evidence of a more severe disease course with more complications. There were similar, although less marked, differences between patients with Crohn's disease of the colon and those with Crohn's disease of the small bowel. There were very few differences in disease course between patients with Crohn's disease of the colon and those with ulcerative colitis. The results suggest that while separate classification of patients with Crohn's disease of the small bowel is justified on clinical grounds, the present separation of patients with disease confined to the colon into groups labelled ulcerative colitis or Crohn's disease of the colon is not. Alternative methods of classification should therefore be investigated.     

Ulcerative colitis: diagnosis and treatment

Ulcerative colitis is a chronic disease with recurrent symptoms and significant morbidity. The precise etiology is still unknown. As many as 25 percent of patients with ulcerative colitis have extraintestinal manifestations. The diagnosis is made endoscopically. Tests such as perinuclear antineutrophilic cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies are promising, but not yet recommended for routine use. Treatment is based on the extent and severity of the disease. Rectal therapy with 5-aminosalicylic acid compounds is used for proctitis. More extensive disease requires treatment with oral 5-aminosalicylic acid compounds and oral corticosteroids. The side effects of steroids limit their usefulness for chronic therapy. Patients who do not respond to treatment with oral corticosteroids require hospitalization and intravenous steroids. Refractory symptoms may be treated with azathioprine or infliximab. Surgical treatment of ulcerative colitis is reserved for patients who fail medical therapy or who develop severe hemorrhage, perforation, or cancer. Longstanding ulcerative colitis is associated with an increased risk of colon cancer. Patients should receive an initial screening colonoscopy eight years after the onset of pancolitis and 12 to 15 years after the onset of left-sided disease; follow-up colonoscopy should be repeated every two to three years.     

结肠CT透明法及仿真内镜的诊断价值

目的　报告用ＣＴ特殊检查方法诊断结肠癌８ 例,溃疡性结肠炎５ 例。方法　１３ 例结肠病变同时采用了ＣＴ 透明法（Ｒａｙｓｕｍ）及仿真内镜（ＣＴＶＥ） 技术。结果　８ 例结肠癌有３ 例显示肠腔内软组织肿块,５ 例显示肠腔不同程度的狭窄,５ 例溃疡性结肠炎显示肠粘膜多个溃疡面。结论　ＣＴ 透明法及仿真内镜技术是检查结肠病变的有效方法,尤其是对早期增生型结肠癌及溃疡性结肠炎。     

Unusual form of ulcerative colitis

Segmental colitis which showed the similar findings of ulcerative colitis and right-sided colitis with back-wash ileitis has been considered as the unusual form of ulcerative colitis. Today, we have few opportunities to come across those cases, because modern diagnosis of colon disease could make differential diagnosis easily with the sense of broad spectrum of IBD. We presented three cases of segmental colitis and one case of so-called indeterminate colitis associated of carcinoma in the cecum and discussed the clinical significance for diagnosis and finding the step of studying the etiology of IBD. Especially, in the third case, thirteen years old man was showing the sign of early stage of Crohn disease with non-caseating granuloma in the biopsy specimen at first, the findings of the segmental ulcerative colitis with crypt abscess were seen after six months in the second examination. To observe the detail changes of the mucosal lesion in this kind of cases will present the new idea for studying the etiology of IBD.     

"Take your medicine": nonadherence issues in patients with ulcerative colitis.

Ulcerative colitis is a lifelong disease causing inflammation and ulceration of the colon. Symptoms of ulcerative colitis include abdominal pain, bloody diarrhea, bloating, and fecal urgency. The current standard therapy for mild to moderate ulcerative colitis is the use of 5-aminosalicylates, with patients requiring continuous treatment to maintain remission. A substantial proportion of patients, however, are nonadherent to prescribed 5-aminosalicylate treatment regimens, resulting in a greater chance of disease relapse with severe associated symptoms. There are many reasons why a patient with ulcerative colitis may be nonadherent including the patient's perception of the condition or a lack of understanding about the disease or treatment. Multiple daily dosing or rectal administration of 5-aminosalicylate medications also can adversely affect adherence rates. Because gastrointestinal nurses often are the primary points of contact for patients with ulcerative colitis, they are in a unique position to take simple steps that will improve adherence rates and thus increase the efficacy of prescribed therapy. This article highlights important aspects of education and patient care for patients with ulcerative colitis.     

Extent of inflammatory lesions in ulcerative colitis assessed by radiology,colonoscopy, and endoscopic biopsies

Radiography of the colon with double-contrast technique was performed directly after total colonoscopy with multiple biopsies in 50 patients with ulcerative colitis. In two-thirds of the series the inflammatory lesions were found to be more widespread at colonoscopy than on radiography. Signs of colitis in an even larger part of the bowel were found on examination of the biopsies in half of the cases. The distribution of characteristic inflammatory changes seen at colonoscopy was also studied. The frequency of the lesions was found to be relatively low in the rectum and highest in the descending and sigmoid parts of the colon.     

Immunological studies in ulcerative colitis. II. "Colon" antigen and human blood group A- and H-like antigens in germfree rats

Sera from patients with ulcerative colitis contain antibodies which hemagglutinate sheep red cells, sensitized with phenol-water extracts from. colon, cecum, or feces of germfree rats. Minor concentrations of such antibodies are also present in a certain fraction of normal human sera. Hemagglutination and hemagglutination inhibition experiments with human erythrocytes and with the rat extracts showed that the latter contained an antigen similar to human blood group A antigen. In contrast, a blood group B-like antigen could not be detected in these extracts. However, experiments with eel serum indicated that these extracts also contained an antigen similar to the H antigen of the human ABO system. Absorption of ulcerative colitis sera with human A₁ erythrocytes but not that with B or O erythrocytes gave, in a few cases, a slight reduction of the hemagglutinating titers against rat cecum-sensitized sheep erythrocytes. In contrast, this treatment considerably reduced such titers when found in sera from healthy persons or from patients with unrelated diseases. It could be concluded that the rat extracts also contained a "colon" antigen, detected with antibodies, present at elevated titers, in the sera of ulcerative colitis patients, but not in those of the controls. This colon antigen is immunologically distinct from the blood group antigens studied. Hemagglutination inhibition experiments indicated that A, H and colon antigen were widely distributed throughout the gastrointestinal tract of the germfree rats. The colon antigen was found to be enriched in the extracts from colon, cecum, and feces. Fluorescent antibody staining provided evidence that both the colon antigen and the A antigen were present in similar sites of the colon and cecum mucosa, particularly in goblet cells of the crypts, and in the mucus.     

Diagnosis of ulcerative colitis--barium enema examination

Barium enema is useful especially for differential diagnosis of right sided type or segmental type of ulcerative colitis from other inflammatory bowel diseases. Compared with endoscopical examination, it provides more objective informations about the range of affected colon which is necessary for the choice of treatment strategy to the reluctant case. However, as preparation procedures may cause aggravation of ulcerative colitis, an unnecessary barium study should be avoided. Even the case in remission stage, it is advisable to add 40 to 60 mg of water-soluble predonisolone to barium solution. Roentogenographic diagnosis of ulcerative colitis is not difficult, in so far as two major points are properly evaluated. The first is the presence or absence of haustration, and the second is mucosal surface of the colon, namely, multiple ulcers or erosions distributing diffusely and continuously in active stage, or granular mucosa and disarray of network pattern of colonic mucosa in remission stage.     

内镜下阑尾孔周围点状糜烂伴左半结肠弥漫性炎症在溃疡性结肠炎中的诊断意义研究

目的研究内镜下阑尾孔周围点状糜烂性改变伴左半结肠弥漫性炎症在溃疡性结肠炎中的意义。方法收集2007年1月-2012年12月内镜下出现阑尾孔周围点状糜烂性改变伴左半弥漫性结肠炎症表现共29例患者,排除阑尾孔周同充血水肿、溃疡、息肉的患者,排除升结肠、横结肠等其他部位出现炎症改变的患者,以及左半结肠为节段性炎症改变患者。结合组织病理结果分析该病变对溃疡性结肠炎诊断的关系。结果29例阑尾孔周同点状糜烂伴左半结肠炎患者中,26例诊断为溃疡性结肠炎,1例为克罗恩病,2例不能确诊。结论内镜下阑尾孔周同点状糜烂伴左半弥漫性结肠炎症改变可能对左半溃疡性结肠炎的诊断有一定的参考价值。