Association of Anti-TNF Therapy With Increased Risk of Acute Cholangitis in Patients With Primary Sclerosing Cholangitis

2020 ◽  
Author(s):  
Chiraag Kulkarni ◽  
Soumya Murag ◽  
George Cholankeril ◽  
Touran Fardeen ◽  
Ajitha Mannalithara ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Confidence Interval ◽  
Bowel Disease ◽  
Odds Ratio ◽  
Sclerosing Cholangitis ◽  
Medical Center ◽  
Acute Cholangitis ◽  
Immunosuppressive Medications ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background Patients with primary sclerosing cholangitis (PSC) are at increased risk of developing acute cholangitis. The majority of patients with PSC have comorbid inflammatory bowel disease, and many take immunosuppressive medications. The epidemiological risks for the development of acute cholangitis in patients with PSC, including the impact of immunosuppressive therapy, are unknown. Methods We conducted a 2-center, retrospective cohort study using data from 228 patients at Stanford University Medical Center and Santa Clara Valley Medical Center (CA), a county health care system. Patient demographics, medications, PSC disease severity, and inflammatory bowel disease status were extracted. Using stepwise variable selection, we included demographic and covariate predictors in the multiple logistic regression model assessing risk factors for cholangitis. Time-to-event analysis was performed to evaluate specific immunosuppressive medications and development of cholangitis. Results Thirty-one percent of patients had at least 1 episode of acute cholangitis (n = 72). Anti-tumor necrosis factor (TNF) therapy was associated with increased odds of acute cholangitis (odds ratio, 7.29; 95% confidence interval, 2.63-12.43), but immunomodulator use was protective against acute cholangitis (odds ratio, 0.23; 95% confidence interval, 0.05-0.76). Anti-TNF therapy was associated with decreased time-to-cholangitis, with a median time of 28.4 months; in contrast, only 11.1% of patients who were prescribed immunomodulators developed cholangitis over the same time period (P < 0.001). Conclusions Our observations suggest that classes of immunosuppressive medications differentially modify the odds of acute cholangitis. Biologic therapy, ie, anti-TNF therapy, was shown to have significantly higher odds for patients developing acute cholangitis whereas immunomodulator therapy was shown to have a potential protective effect. These findings may help guide physicians in decision-making for determining appropriate immunosuppressive therapy.

scholarly journals Sclerosing cholangitis and inflammatory bowel disease: which comes first?

2021 ◽  
Vol 66 (1) ◽  
pp. 39-46
Author(s):  
A. V. Nikitin ◽  
G. V. Volynets
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Sclerosing Cholangitis ◽  
Clinical Symptoms ◽  
Cross Reactivity ◽  
Formation Mechanisms ◽  
Malignant Neoplasms ◽  
Increased Risk ◽  
Bowel Diseases ◽  
Inflammatory Bowel

Sclerosing cholangitis is one of the most common hepatologic extraintestinal manifestations of inflammatory bowel disease. The article discusses the phenotype of the combination of sclerosing cholangitis and inflammatory bowel disease. The authors present their theories of the etiopathogenesis of sclerosing cholangitis in patients with inflammatory bowel disease, as well as some features of the phenotype of both mixed and monogenic forms of diseases.Sclerosing cholangitis in combination with inflammatory bowel disease is commonly associated with pancolitis, but the endoscopically visualized activity of inflammatory bowel diseases is significantly lower and clinical symptoms are less pronounced. The authors have established that the patients with the combination of sclerosing cholangitis and inflammatory bowel disease are at the increased risk of developing malignant neoplasms. The formation mechanisms of a combination of inflammatory bowel disease and sclerosing cholangitis remain poorly understood, although this pathology is influenced by lymphocytic cross-reactivity, aberrant recognition of microbiotic epitopes and intestinal microbiota imbalance. New biological agents aimed at correcting the interaction between the immune system and target organs may provide new ways of treatment for sclerosing cholangitis associated with inflammatory bowel disease.

scholarly journals Predictive value of fibrinogen in identifying inflammatory bowel disease in active stage

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiao-Fu Chen ◽  
Yuan Zhao ◽  
Yu Guo ◽  
Zhi-Ming Huang ◽  
Xie-Lin Huang
Keyword(s):  
Inflammatory Bowel Disease ◽  
Confidence Interval ◽  
Disease Activity ◽  
Bowel Disease ◽  
Odds Ratio ◽  
Activity Index ◽  
Characteristic Curve ◽  
Disease Activity Index ◽  
Mayo Score ◽  
Inflammatory Bowel

Abstract Background We aimed to externally validate for the first time the diagnostic ability of fibrinogen to identify active inflammatory bowel disease (IBD). Methods The research totally involved 788 patients with IBD, consisted of 245 ulcerative colitis (UC) and 543 Crohn’ s disease (CD). The Mayo score and Crohn disease activity index (CDAI) assessed disease activity of UC and CD respectively. The independent association between fibrinogen and disease activity of patients with UC or CD was investigated by multivariate logistic regression analyses. Area under the receiver operating characteristic curve (AUROC) assessed the performance of various biomarkers in discriminating disease states. Results The fibrinogen levels in active patients with IBD significantly increased compared with those in remission stage (P < 0.001). Fibrinogen was an independent predictor to distinguish disease activity of UC (odds ratio: 2.247, 95% confidence interval: 1.428–3.537, P < 0.001) and CD (odds ratio: 2.124, 95% confidence interval: 1.433–3.148, P < 0.001). Fibrinogen was positively correlated with the Mayo score (r = 0.529, P < 0.001) and CDAI (r = 0.625, P < 0.001). Fibrinogen had a high discriminative capacity for both active UC (AUROC: 0.806, 95% confidence interval: 0.751–0.861) and CD (AUROC: 0.869, 95% confidence interval: 0.839–0.899). The optimum cut-off values of fibrinogen 3.22 was 70% sensitive and 77% specific for active UC, and 3.87 was 77% sensitive and 81% specific for active CD respectively. Conclusions Fibrinogen is a convenient and practical biomarker to identify active IBD.

Effectiveness of Conjugate and Polysaccharide Pneumococcal Vaccines for Prevention of Severe Pneumococcal Disease Among Inflammatory Bowel Disease Patients

2021 ◽  
Author(s):  
Bryan L Love ◽  
Christopher J Finney ◽  
Jill K J Gaidos
Keyword(s):  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Pneumococcal Disease ◽  
Pneumococcal Vaccination ◽  
Cox Proportional Hazards Model ◽  
Health Administration ◽  
Immunosuppressive Medications ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
The Impact

Abstract Background Streptococcus pneumoniae is an important pathogen responsible for severe pneumococcal diseases, including pneumonia, bacteremia/sepsis, and meningitis. Inflammatory bowel disease (IBD) patients have an increased risk for infections due to an altered immune system and treatment with immunosuppressive medications. The aim of this study was to assess the prevalence of severe pneumococcal disease (SPD) and evaluate the impact of pneumococcal vaccination on the risk of SPD in Veterans with IBD. Methods Subjects with IBD and SPD were identified from the VA Health Administration database using ICD9/10 codes. Pneumococcal vaccination and use of immunosuppressant medications were collected. Risk of SPD was evaluated using an adjusted Cox proportional hazards model controlling for demographics, medications, vaccination, and comorbidities. Results A total of 1798 cases of SPD were identified (283 pneumonia, 1,513 bacteremia, and 2 meningitis). SPD patients were older (60.9 years vs 59.4 years; p&lt;0.001), had more comorbidities (Charlson Comorbidity Index of 2.11 vs. 0.96; p&lt;0.001) and had increased mortality (4.6% vs. 1.5%, p&lt;0.001). The risk of SPD was increased in Crohn’s disease (HR 1.15; 95% CI 1.05-1.27) and with more comorbidities (HR 1.45; 95% CI 1.42-1.48). Use of immunosuppressive medications increased the risk of SPD. Receipt of PCV13 either alone or in combination with PPSV23 predicted a five-fold decreased risk of SPD compared with no vaccination. Conclusion Vaccination with PCV13 alone or in combination with PPSV23 and revaccination with PPSV23, was protective against SPD. All IBD patients should be evaluated for pneumococcal vaccination, particularly those receiving or expected to receive immunosuppressive therapies.

scholarly journals Predictors of mortality in inflammatory bowel disease patients treated for pneumonia

2020 ◽  
Vol 13 ◽  
pp. 175628482093945
Author(s):  
Offir Ukashi ◽  
Yifatch Barash ◽  
Michael J. Segel ◽  
Bella Ungar ◽  
Shelly Soffer ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Confidence Interval ◽  
Bowel Disease ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Predictors Of Mortality ◽  
Inflammatory Bowel

Background: Community-acquired pneumonia is among the most common infections affecting ulcerative colitis and Crohn’s disease patients. Data regarding epidemiology and outcomes of pneumonia in inflammatory bowel disease patients is lacking. We aimed to identify predictors of adverse outcomes among inflammatory bowel disease patients treated for pneumonia. Methods: This was a retrospective cohort study that included adult patients admitted to Sheba Medical Center for pneumonia between 2012 and 2018. Data was collected from an electronic repository of all emergency department admissions and included tabular demographic and clinical variables and free-text physician records. Pneumonia cases were extracted using the International Classification of Diseases (ICD-10) coding. Results: Of 16,732 admissions with pneumonia, 97 were inflammatory bowel disease patients (45 Crohn’s disease; 52 ulcerative colitis). We found a similar rate of 30-day mortality among inflammatory bowel disease and non-inflammatory bowel disease patients (12.1% versus 11.3%, p = 0.824) and between Crohn’s disease and ulcerative colitis patients (11.1% versus 11.5%, p = 0.947). There was an increased hospitalization rate among inflammatory bowel disease patients (92.8% versus 85.6%, p = 0.045), but similar hospitalization duration (4 versus 4 days, p = 0.384). Crohn’s disease patients had a shorter hospitalization duration compared with ulcerative colitis patients (3 versus 5.5 days, p = 0.029). Bronchiectasis (adjusted odds ratio 60.95, 95% confidence interval 2.72–1364.39, p = 0.01) and opioids use (adjusted odds ratio 13.21, 95% confidence interval 1.29–135.18, p = 0.03) were associated with an increased 30-day mortality rate in inflammatory bowel disease patients. Conclusion: This is the first study to identify predictors of mortality in inflammatory bowel disease patients with pneumonia. The rate of mortality and hospitalization duration of stay were similar among inflammatory bowel disease and non-inflammatory bowel disease patients. Use of opioids and presence of bronchiectasis were associated with a higher risk of mortality in inflammatory bowel disease patients with pneumonia.

Clinical Characteristics, Associated Malignancies and Management of Primary Sclerosing Cholangitis in Inflammatory Bowel Disease Patients: A Multicentre Retrospective Cohort Study

2019 ◽  
Vol 13 (12) ◽  
pp. 1492-1500 ◽  
Author(s):  
Ivan Guerra ◽  
Luis Bujanda ◽  
Jesús Castro ◽  
Olga Merino ◽  
Joan Tosca ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Incidence Rate ◽  
Primary Sclerosing Cholangitis ◽  
Bowel Disease ◽  
Sclerosing Cholangitis ◽  
Clinical Characteristics ◽  
Additional Data ◽  
Poor Survival ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background and Aims Primary sclerosing cholangitis [PSC] is usually associated with inflammatory bowel disease [IBD]. An increased risk of malignancies, mainly colorectal cancer [CRC] and cholangiocarcinoma [CCA], has been reported in PSC-IBD patients. Our aim was to determine the clinical characteristics and management of PSC in IBD patients, and the factors associated with malignancies. Methods PSC-IBD patients were identified from the Spanish ENEIDA registry of GETECCU. Additional data were collected using the AEG-REDCap electronic data capture tool. Results In total, 277 PSC-IBD patients were included, with an incidence rate of 61 PSC cases per 100 000 IBD patient-years, 69.7% men, 67.5% ulcerative colitis and mean age at PSC diagnosis of 40 ± 16 years. Most patients [85.2%] were treated with ursodeoxycholic acid. Liver transplantation was required in 35 patients [12.6%] after 79 months (interquartile range [IQR] 50–139). It was more common in intra- and extrahepatic PSC compared with small-duct PSC (16.3% vs 3.3%; odds ratio [OR] 5.7: 95% confidence interval [CI] = 1.7–19.3). The incidence rate of CRC since PSC diagnosis was 3.3 cases per 1000 patient-years [95% CI = 1.9–5.6]. Having symptoms of PSC at PSC diagnosis was the only factor related to an increased risk of CRC after IBD diagnosis [hazard ratio= 3.3: 95% CI = 1.1–9.9]. CCA was detected in seven patients [2.5%] with intra- and extrahepatic PSC, with median age of 42 years [IQR 39–53], and presented a lower life expectancy compared with patients without CCA and patients with or without CRC. Conclusions PSC-IBD patients with symptoms of PSC at PSC diagnosis have an increased risk of CRC. CCA was only diagnosed in patients with intra- and extrahepatic PSC and was associated with poor survival.

scholarly journals A164 PATTERNS IN MEDICAL THERAPY AND CLINICAL OUTCOMES IN PATIENTS WITH CONCOMITANT INFLAMMATORY BOWEL DISEASE AND PRIMARY SCLEROSING CHOLANGITIS: A SINGLE CENTRE RETROSPECTIVE ANALYSIS

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 173-174
Author(s):  
K Donaldson ◽  
R A Mitchell ◽  
R A Enns ◽  
B Bressler ◽  
G Rosenfeld ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Primary Sclerosing Cholangitis ◽  
Medical Therapy ◽  
Bowel Disease ◽  
Sclerosing Cholangitis ◽  
Adverse Outcomes ◽  
Low Grade ◽  
Strict Adherence ◽  
Increased Risk ◽  
Inflammatory Bowel

Abstract Background Inflammatory bowel disease (IBD) in patients with primary sclerosing cholangitis (PSC) is characterized by pancolitis with rectal sparing and is associated with an increased risk of colorectal and biliary malignancies. Currently, pharmacologic management of IBD in the setting of PSC is the same as in IBD alone. Aims To assess patterns in medical therapy, and incidence of adverse outcomes in patients with concomitant IBD and PSC. Methods A retrospective review was conducted on all PSC-IBD patients followed between January 2010 and June 2018. The Endoscopic Mayo Score was used to grade IBD severity in PSC-ulcerative colitis (UC). Results 69 patients were identified, 44 (63.8%) were male. The mean ages of IBD and PSC diagnosis were 28.6 (SD 14.9) and 37.0 (SD 18.9) years, respectively. The median length of follow up was 12 (range 2–49) years. 52 (75.4%) patients had UC, and 17 (24.6%) had Crohn’s disease (CD). 28 (87.5%) PSC-UC patients had pancolitis, and 4 (12.5 %) had proctitis. Among those with pancolitis, 8 (28.6%) had relative rectal sparing. 4 (14.3%) patients had more severe inflammation proximally, whereas only 1 (3.6%) had more severe distal inflammation. 23 (82.1%) patients had the same degree of inflammation throughout. 14 (93.3%) PSC-CD patients had colitis/ileocolitis and 1 (6.7%) had ileitis. Among those with PSC-UC, 16 (50.0%), 12 (37.5%), and 4 (12.5%) patients had grade 1, 2, and 3 disease, respectively. 62 (89.9%) PSC-IBD patients were treated with aminosalicylates, and 26 (37.7%) with biologics at some point in their IBD course. 26 (37.7%) were treated with aminosalicylates alone. 4 (5.8%) did not require any IBD therapy. Cholangiocarcinoma, colorectal cancer, and gallbladder cancer developed in 8 (11.6%), 1 (1.4%), and 1 (1.4%) PSC-IBD patients, respectively. 16 (23.2%) patients required partial or total colectomy. Indication for surgery was inflammation or stenosis, dysplasia, and neoplasia in 13 (81.3%), 2 (12.5%), and 1 (6.3%) patients, respectively. Conclusions The majority of this cohort had UC with mild disease activity. Pancolitis was common, with frequent rectal sparing and more severe right-sided inflammation. Despite the predominance of low-grade colitis, a large portion of patients required treatment with biologics. The incidence of adverse outcomes underscores the need for strict adherence to recommended surveillance practices. Low grade endoscopic activity, typical of the quiescent IBD course in PSC-IBD, may mask low grade histologic inflammation, which in turn may contribute to the increased risk of colonic neoplasia. Further studies are needed to determine the best management strategy for IBD in patients with PSC. Funding Agencies None

scholarly journals Is Isotretinoin Innocent from Causing Inflammatory Bowel Disease?

2016 ◽  
Vol 6 (2) ◽  
pp. 21-33
Author(s):  
Saad M. Alrajhi
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Confidence Interval ◽  
Bowel Disease ◽  
Odds Ratio ◽  
Random Model ◽  
P Value ◽  
Inflammatory Bowel

Objectives: Multiple case reports suggesting isotretinoin causes inflammatory bowel disease leading to compensations reaching millions of dollars. New larger studies question this effect. This is a meta-analysis to study the association. Methods: We searched PubMed, Cochrane, Google Scholar, and WorldCat. We extracted six articles measuring drug exposure and disease incidence. We measured the effects of isotretinoin on inflammatory bowel disease, Crohn’s disease and ulcerative colitis, using pooled odds ratio. The effect can be measured using the fixed or the random model. The fixed effect assumes studies have the same effect in the same population, while the random assumes heterogeneity. The correct model is chosen based on a Q-heterogeneity test. Results: Sample size was 9723864. Inflammatory bowel disease in isotretinoin exposed had an odds ratio of {1.075, 95% confidence interval (0.78, 1.49)}, Crohn’s disease{0.97, 95% confidence interval (0.65, 1.43)} and ulcerative colitis {1.28, 95% confidence interval (0.88, 1.86)}. All odds ratios had a p-value > 0.05 using the random-model which was chosen due to significant Q and I-squared score p value < 0.05. There was significant heterogeneity of the six studies, which lack consistency in adjusting for important co-variables (dose, family history, smoking, etc.)    

scholarly journals Venous Thromboembolism in Hospitalized Children with Inflammatory Bowel Disease Is Associated with Increased Health and Financial Burdens

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4708-4708
Author(s):  
Nicole Kucine ◽  
Victoria Cooley ◽  
Fisnik Prishtina ◽  
Linda M Gerber ◽  
Kimberley A Chien
Keyword(s):  
Inflammatory Bowel Disease ◽  
Venous Thromboembolism ◽  
Bowel Disease ◽  
Odds Ratio ◽  
Hospitalized Children ◽  
Icu Stay ◽  
Increased Risk ◽  
Inflammatory Bowel ◽  
Pediatric Ibd ◽  
First Admission

Introduction: Venous thromboembolism (VTE) is a known complication in children with inflammatory bowel disease (IBD) and can be associated with significant morbidity and mortality. Central lines, inflammation, hospital stays, and protein losses are among risk factors that contribute to this elevated risk. While it is known that children with IBD have an increased VTE risk, there are no standard guidelines for prevention of this unwanted complication. Decreasing the rate of hospital-acquired VTE in all hospitalized children is of national interest, especially in this unique patient population. However, there are no clear data regarding the true impact of VTE on the pediatric IBD population to guide practitioners in prevention and management. Given that IBD patients are known to have an increased risk of VTE, we sought to assess the burden associated with VTE development in hospitalized IBD patients. Methods: The Pediatric Health Information System database (PHIS), a database that includes both clinical and resource utilization data for over 45 children's hospitals, was utilized to gather inpatient data from 2009-2017. ICD9 (IBD - 555.xx, 556.xx and VTE - 325, 415.1x, 451.x, 452, 453.0-.9, and 572.1) and ICD10 (IBD - K50.0-.919, K51.0-.919 and VTE - I80.0-.9, I81, I82.0-.91, I63.6, I67.6) diagnostic codes for IBD and VTE were applied to identify hospitalized IBD patients who experienced a VTE event. First admissions during the time period were used to avoid capturing the same VTE event more than once. Demographic data, as well as data regarding hospitalization, were reviewed. The Institutional Review Board of Weill Cornell Medicine approved this study. Results: 19,004 first admissions were identified for patients with IBD. Of those, 475 had documented episodes of VTE, demonstrating an incidence of having a VTE at first admission of 2.5%. There were no significant differences in gender, age at first admission, ethnicity, or geographic region between hospitalized IBD patients who did and did not have a VTE event. Hospitalized IBD patients with VTE had a significantly greater median length of stay, significantly higher likelihood of ICU stay, and a significantly higher discharge mortality rate (Table 1). Children with IBD and VTE had an odds ratio of 8.63 [95% CI 7.02-10.62, p=<0.001] for ICU stay, and an odds ratio of 6.14 [95% CI 2.76-13.69, p=<0.001] for discharge mortality compared to children with IBD and no VTE. Median billed charges and total costs were significantly higher in the hospitalized IBD patients with VTE compared to those without VTE - both were approximately 3 times greater in IBD patients who developed a VTE (Table 2). When looking at the annual incidence rate of VTE among hospitalized IBD patients for first admission, rates ranged from 1.7 to 3.4 per 100 patients, with an average number of cases of 53 per year (Figure 1). Conclusion: Our data demonstrate that hospitalized children with IBD and a VTE event are at greater risk for mortality and increased likelihood of ICU stay than those without VTE. They are also shown to incur significantly higher hospital costs when compared to children without a VTE episode. Our study is limited due to the possibility of missing data due to coding errors, which can occur in large database studies such as this. Despite this limitation, our data demonstrate that a significant medical and financial burden is placed on hospitalized children with IBD who develop a VTE. Our evidence, and the work of others, support the need for larger, prospective, multi-center studies focused on prevention of VTE in hospitalized pediatric IBD patients. Disclosures Cooley: off-label: Other: drug use.

scholarly journals Ulcerative colitis has an aggressive course after orthotopic liver transplantation for primary sclerosing cholangitis

Gut ◽  
1998 ◽  
Vol 43 (5) ◽  
pp. 639-644 ◽  
Author(s):  
G V Papatheodoridis ◽  
M Hamilton ◽  
P K Mistry ◽  
B Davidson ◽  
K Rolles ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Liver Transplantation ◽  
Primary Sclerosing Cholangitis ◽  
Bowel Disease ◽  
Sclerosing Cholangitis ◽  
De Novo ◽  
Increased Risk ◽  
Inflammatory Bowel

Background—The course of inflammatory bowel disease after liver transplantation has been reported as variable with usually no change or improvement, but there may be an increased risk of early colorectal neoplasms. In many centres steroids are often withdrawn early after transplantation and this may affect inflammatory bowel disease activity.Aims—To evaluate the course of inflammatory bowel disease in primary sclerosing cholangitis transplant patients who were treated without long term steroids.Methods—Between 1989 and 1996, there were 30 patients transplanted for primary sclerosing cholangitis who survived more than 12 months. Ulcerative colitis was diagnosed in 18 (60%) patients before transplantation; two had previous colectomy. All patients underwent colonoscopy before and after transplantation and were followed for 38 (12–92) months. All received cyclosporin or tacrolimus with or without azathioprine as maintenance immunosuppression.Results—Ulcerative colitis course after transplantation compared with that up to five years before transplantation was the same in eight (50%) and worse in eight (50%) patients. It remained quiescent in eight and worsened in four of the 12 patients with pretransplant quiescent course, whereas it worsened in all four patients with pretransplant active course (p=0.08). New onset ulcerative colitis developed in three (25%) of the 12 patients without inflammatory bowel disease before transplantation. No colorectal cancer has been diagnosed to date.Conclusions—Preexisting ulcerative colitis often has an aggressive course, while de novo ulcerative colitis may develop in patients transplanted for primary sclerosing cholangitis and treated without long term steroids.

Sign in / Sign up

Export Citation Format

Share Document