Medical Therapy of Ulcerative Colitis

2015 ◽  
Author(s):  
Kristin E. Burke ◽  
Joseph D. Feuerstein ◽  
Adam S. Cheifetz
Keyword(s):  
Ulcerative Colitis ◽  
Severe Disease ◽  
Mucosal Healing ◽  
Mucosal Inflammation ◽  
Total Proctocolectomy ◽  
Moderate Disease ◽  
Inpatient Management ◽  
Inflammatory Bowel ◽  
Maintenance Of Remission ◽  
Severity Of The Disease

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease (IBD) characterized by continuous colonic mucosal inflammation that extends proximally from the rectum. Most patients present with bloody diarrhea, abdominal pain, tenesmus, and urgency. The course of UC is characterized by periods of flares and remission, and can significantly impact quality of life. Most patients are successfully treated medically, though 15 to 25% of patients require total proctocolectomy. Treatment of UC depends on the extent and severity of the disease, and response to prior therapies. This review outlines the medical treatment of UC and the therapies available for the induction and maintenance of remission. Figures include endoscopic and histologic images of UC, and algorithms cover outpatient inductions for mild-to-moderate disease and moderate-to-severe-disease, outpatient management of known steroid-refractory/steroid-intolerant patient, and approach to inpatient management of acute severe UC. Tables list disease severity by Truelove and Witts criteria, IBD medication adverse effects and monitoring parameters, induction dosing of 5-aminosalicylates, and rates of clinical response, remission, and mucosal healing in patients receiving anti-tumor necrosis factor (TNF) agents versus placebo by trial. This review contains 5 highly rendered figures, 4 tables, and 118 references. 

Ulcerative colitis

2020 ◽  
pp. 2937-2950
Author(s):  
Jeremy Sanderson ◽  
Peter Irving
Keyword(s):  
Ulcerative Colitis ◽  
Severe Disease ◽  
Stool Culture ◽  
Volume Depletion ◽  
Mild Disease ◽  
Gradual Onset ◽  
Moderate Disease ◽  
Variable Extent ◽  
Maintenance Of Remission ◽  
Intravenous Steroids

Ulcerative colitis is a chronic relapsing and remitting disease in which chronic inflammation affects the rectum and extends proximally to a variable extent. The precise aetiology remains unknown but involves an interplay between reduced diversity in the gut microbiota and a genetically dysregulated gut immune system and epithelial barrier. Typical presentation of mild or moderate disease is with a gradual onset of symptoms including diarrhoea, rectal bleeding, and the passage of mucus. Severe disease is characterized by anorexia, nausea, weight loss, and severe diarrhoea, with the patient likely to look unwell with fever, tachycardia, and other signs of volume depletion, and the abdomen may be distended and tympanitic, with reduced bowel sounds and marked colonic tenderness. Diagnosis is usually made on the basis of exclusion of infective colitis by stool culture and the finding of typical diffuse inflammation in the rectum and above at sigmoidoscopy. Management requires rapid control of symptoms with induction therapy followed by maintenance of remission. Mild disease is typically treated with 5-aminosalicyclic acid delivered both orally and by enema, and moderate disease by 5-aminosalicyclic acid and steroids. Patients with severe disease require hospital admission, intravenous steroids, and daily review by both a physician and a surgeon experienced in the management of ulcerative colitis. Ciclosporin or infliximab are used as rescue therapies for steroid-resistant acute severe ulcerative colitis, but colectomy should not be delayed when this is required. Maintenance therapy with immunomodulators and biological therapies are both effective at maintaining remission, and several new biologicals are in clinical trials.

scholarly journals The Role of Biomarkers in Surgery for Ulcerative Colitis: A Review

2021 ◽  
Vol 10 (15) ◽  
pp. 3362
Author(s):  
Jared Matson ◽  
Sonia Ramamoorthy ◽  
Nicole E. Lopez
Keyword(s):  
Ulcerative Colitis ◽  
Medical Management ◽  
Surgical Intervention ◽  
Severe Disease ◽  
Total Proctocolectomy ◽  
Surgical Decision ◽  
Inflammatory Bowel ◽  
Time Required ◽  
Surgical Decision Making

Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern. Surgical resection (total proctocolectomy) is the only cure for UC and is often necessary in managing complicated or refractory disease. However, recent advances in biologically targeted therapies have resulted in improved disease control, and surgery is required in only a fraction of cases. This ever-increasing array of options for medical management has added complexity to surgical decision-making. In some circumstances, the added time required to ensure failure of medical therapy can delay colectomy in patients who will ultimately need it. Indeed, many patients with severe disease undergo trials of multiple medical therapies prior to considering surgery. In severe cases of UC, continued medical management has been associated with a delay to surgical intervention and higher rates of morbidity and mortality. Biomarkers represent a burgeoning field of research, particularly in inflammatory bowel disease and cancer. This review seeks to highlight the different possible settings for surgery in UC and the role various biomarkers might play in each.

P110 ASSOCIATION OF FECAL CALPROTECTIN WITH ENDOSCOPIC AND HISTOLOGY ACTIVITY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

2020 ◽  
Vol 26 (Supplement_1) ◽  
pp. S16-S16
Author(s):  
Erin Crawford ◽  
Catherine Gestrich ◽  
Sindhoosha Malay ◽  
Thomas Sferra ◽  
Shahrazad Saab ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
Disease Severity ◽  
Bowel Disease ◽  
Severe Disease ◽  
Fecal Calprotectin ◽  
Mucosal Healing ◽  
Control Population ◽  
Moderate Disease ◽  
Endoscopic Remission ◽  
Inflammatory Bowel

Abstract Background Inflammatory bowel disease (IBD) treatment strategies have evolved to target mucosal healing, which has been shown to be associated with clinical remission and reduced complications. Fecal calprotectin (FC) is a non-invasive marker of intestinal inflammation, and has been shown to correlate with disease activity in IBD patients, though values which correlate with mucosal healing vary across studies. We aim to examine the association of quantitative FC levels with endoscopic and histologic severity, and compare FC in IBD patients with endoscopic remission with a control population. Methods We conducted a retrospective chart review of patients who had a FC completed between 30 and 1 days before colonoscopy at UH Rainbow Babies and Children’s Hospital between 2014 and 2018. IBD patients had disease severity endoscopically graded using the SES-CD or Mayo UC score, and had disease severity histologically graded using the Geboes method. Severity was classed as no disease, mild, moderate or severe. FC values of IBD patients with mucosal healing and the control population (those without gastrointestinal pathology or diagnosis on evaluation) were compared. Results 331 cases were included in the study; 107 IBD cases and 224 controls. 63 patients (19%) had a diagnosis of Crohn’s disease (CD) and 44 patients (13%) had ulcerative colitis (UC). When assessing endoscopic scoring of IBD patients, the median FC was lowest in those with no disease (181 ug/g), followed by those with mild and moderate disease (499, 599 ug/g) and highest in those with severe disease (921 ug/g). There was significance comparing no disease to moderate and severe disease (p=0.019, 0.003), and between mild and severe disease (p=0.012). When assessing histology, the median FC was lowest in IBD patients with no disease (328 ug/g), followed by those with mild and moderate disease (399 ug/g, 674 ug/g) and highest in those with severe disease (895 ug/g). There was significance comparing no disease to moderate and severe disease (p=0.021, 0.018). In CD patients, there was significance in FC between no disease and moderate and severe disease (p=0.047, 0.0047) on endoscopic scoring. In UC patients, there was significance in FC between no disease and moderate disease (p=0.023) for histologic scoring. When comparing FC of endoscopically normal patients, the control group had a significantly lower median FC than the IBD population with endoscopic remission (43 ug/g vs 181 ug/g, p=0.018). Conclusion FC showed association with disease severity on gross endoscopy and histology and significance between severities in our IBD cohort. Additionally, normal cut-off values of FC may depend on the presence or absence of underlying disease. While larger studies are needed, this noninvasive test may help mitigate frequency of invasive procedures.

scholarly journals Inflammatory Bowel Disease: An Overview of Immune Mechanisms and Biological Treatments

2015 ◽  
Vol 2015 ◽  
pp. 1-11 ◽  
Author(s):  
Bruno Rafael Ramos de Mattos ◽  
Maellin Pereira Gracindo Garcia ◽  
Julia Bier Nogueira ◽  
Lisiery Negrini Paiatto ◽  
Cassia Galdino Albuquerque ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Severe Disease ◽  
Biological Therapies ◽  
Promising Alternative ◽  
Biological Treatments ◽  
Bowel Diseases ◽  
Inflammatory Bowel ◽  
And Behavior

Inflammatory bowel diseases (IBD) are characterized by chronic inflammation of the intestinal tract associated with an imbalance of the intestinal microbiota. Crohn’s disease (CD) and ulcerative colitis (UC) are the most widely known types of IBD and have been the focus of attention due to their increasing incidence. Recent studies have pointed out genes associated with IBD susceptibility that, together with environment factors, may contribute to the outcome of the disease. In ulcerative colitis, there are several therapies available, depending on the stage of the disease. Aminosalicylates, corticosteroids, and cyclosporine are used to treat mild, moderate, and severe disease, respectively. In Crohn’s disease, drug choices are dependent on both location and behavior of the disease. Nowadays, advances in treatments for IBD have included biological therapies, based mainly on monoclonal antibodies or fusion proteins, such as anti-TNF drugs. Notwithstanding the high cost involved, these biological therapies show a high index of remission, enabling a significant reduction in cases of surgery and hospitalization. Furthermore, migration inhibitors and new cytokine blockers are also a promising alternative for treating patients with IBD. In this review, an analysis of literature data on biological treatments for IBD is approached, with the main focus on therapies based on emerging recombinant biomolecules.

scholarly journals An Overview of Novel and Emerging Therapies for Inflammatory Bowel Disease

2020 ◽  
pp. 91-101
Author(s):  
Sumona Bhattacharya Sumona Bhattacharya ◽  
Raymond K. Cross Raymond K. Cross
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Severe Disease ◽  
Gastrointestinal Symptoms ◽  
The Novel ◽  
Novel Therapies ◽  
Emerging Therapies ◽  
Sphingosine 1 Phosphate ◽  
Inflammatory Bowel

Inflammatory bowel disease, consisting of Crohn’s disease and ulcerative colitis, causes chronic gastrointestinal symptoms and can lead to morbidity and mortality if uncontrolled or untreated. However, for patients with moderate-to-severe disease, currently available therapies do not induce or maintain remission in >50% of patients. This underscores the need for additional therapies. In this review, the authors detail the novel therapies vedolizumab, tofacitinib, and ustekinumab and delve into therapies which may come onto the market within the next 10 years, including JAK-1 inhibitors (filgotinib and upadacitinib), IL-23 inhibitors (guselkumab, mirikizumab, and risankizumab), the anti-β4β7 and anti-βEβ7 integrin monoclonal antibody etrolizumab, the sphingosine-1-phosphate subtypes 1 and 5 modulator ozanimod, and mesenchymal stem cells. Further studies are required before these emerging therapies gain approval.

scholarly journals Cytomegalovirus and Inflammatory Bowel Diseases (IBD) with a Special Focus on the Link with Ulcerative Colitis (UC)

2020 ◽  
Vol 8 (7) ◽  
pp. 1078
Author(s):  
Alexandre Jentzer ◽  
Pauline Veyrard ◽  
Xavier Roblin ◽  
Pierre Saint-Sardos ◽  
Nicolas Rochereau ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Diseases ◽  
Viral Reactivation ◽  
Steroid Resistance ◽  
Mucosal Inflammation ◽  
Special Focus ◽  
Close Relationship ◽  
Bowel Diseases ◽  
Inflammatory Bowel ◽  
Cmv Colitis

Cytomegalovirus (CMV) infects approximately 40% of adults in France and persists lifelong as a latent agent in different organs, including gut. A close relationship is observed between inflammation that favors viral expression and viral replication that exacerbates inflammation. In this context, CMV colitis may impact the prognosis of patients suffering from inflammatory bowel diseases (IBDs), and notably those with ulcerative colitis (UC). In UC, the mucosal inflammation and T helper cell (TH) 2 cytokines, together with immunomodulatory drugs used for controlling flare-ups, favor viral reactivation within the gut, which, in turn, increases mucosal inflammation, impairs corticoid and immunosuppressor efficacy (the probability of steroid resistance is multiplied by more than 20 in the case of CMV colitis), and enhances the risk for colectomy. This review emphasizes the virological tools that are recommended for exploring CMV colitis during inflammatory bowel diseases (IBD) and underlines the interest of using ganciclovir for treating flare-ups associated to CMV colitis in UC patients.

scholarly journals Colorectal Cancer in Inflammatory Bowel Disease

2020 ◽  
Vol 33 (05) ◽  
pp. 305-317
Author(s):  
Martina Nebbia ◽  
Nuha A. Yassin ◽  
Antonino Spinelli
Keyword(s):  
Colorectal Cancer ◽  
Inflammatory Bowel Disease ◽  
Bowel Disease ◽  
Severe Disease ◽  
Critical Role ◽  
Mucosal Inflammation ◽  
Surgical Approaches ◽  
Increased Risk ◽  
Significant Difference ◽  
Inflammatory Bowel

AbstractPatients with inflammatory bowel disease (IBD) are at an increased risk for developing colorectal cancer (CRC). However, the incidence has declined over the past 30 years, which is probably attributed to raise awareness, successful CRC surveillance programs and improved control of mucosal inflammation through chemoprevention. The risk factors for IBD-related CRC include more severe disease (as reflected by the extent of disease and the duration of poorly controlled disease), family history of CRC, pseudo polyps, primary sclerosing cholangitis, and male sex. The molecular pathogenesis of inflammatory epithelium might play a critical role in the development of CRC. IBD-related CRC is characterized by fewer rectal tumors, more synchronous and poorly differentiated tumors compared with sporadic cancers. There is no significant difference in sex distribution, stage at presentation, or survival. Surveillance is vital for the detection and subsequently management of dysplasia. Most guidelines recommend initiation of surveillance colonoscopy at 8 to 10 years after IBD diagnosis, followed by subsequent surveillance of 1 to 2 yearly intervals. Traditionally, surveillance colonoscopies with random colonic biopsies were used. However, recent data suggest that high definition and chromoendoscopy are better methods of surveillance by improving sensitivity to previously “invisible” flat dysplastic lesions. Management of dysplasia, timing of surveillance, chemoprevention, and the surgical approaches are all areas that stimulate various discussions. The aim of this review is to provide an up-to-date focus on CRC in IBD, from laboratory to bedside.

scholarly journals Immunolocalization of leptin and leptin receptor in colorectal mucosa of ulcerative colitis, Crohn’s disease and control subjects with no inflammatory bowel disease

2020 ◽  
Author(s):  
Flavia Merigo ◽  
Alessandro Brandolese ◽  
Sonia Facchin ◽  
Federico Boschi ◽  
Marzia Di Chio ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Lamina Propria ◽  
Leptin Receptor ◽  
Gastrointestinal Symptoms ◽  
Lymphatic Vessels ◽  
Mucosal Inflammation ◽  
Colorectal Mucosa ◽  
Inflammatory Bowel

Abstract The expression of leptin and leptin receptor (Ob-R) has been partially elucidated in colon of patients with inflammatory bowel diseases (IBDs), even though leptin is involved in angiogenesis and inflammation. We previously reported overexpression of GLUT5 fructose transporter, in aberrant clusters of lymphatic vessels in lamina propria of IBD and controls. Here, we examine leptin and Ob-R expression in the same biopsies. Specimens were obtained from patients with ulcerative colitis (UC), Crohn’s disease (CD) and controls who underwent screening for colorectal cancer, follow-up after polypectomy or with a history of lower gastrointestinal symptoms. Immunohistochemistry revealed leptin in apical and basolateral membranes of short epithelial portions, Ob-R on the apical pole of epithelial cells. Leptin and Ob-R were also identified in structures and cells scattered in the lamina propria. In UC, a significant correlation between leptin and Ob-R in the lamina propria was found in all inflamed samples, beyond non-inflamed samples of the proximal tract, while in CD, it was found in inflamed distal samples. Most of the leptin and Ob-R positive areas in the lamina propria were also GLUT5 immunoreactive in inflamed and non-inflamed mucosa. A significant correlation of leptin or Ob-R expression with GLUT5 was observed in the inflamed distal samples from UC. Our findings suggest that there are different sites of leptin and Ob-R expression in large intestine and those in lamina propria do not reflect the status of mucosal inflammation. The co-localization of leptin and/or Ob-R with GLUT5 may indicate concomitance effects in colorectal lamina propria areas.

scholarly journals Beyond white light: optical enhancement in conjunction with magnification colonoscopy for the assessment of mucosal healing in ulcerative colitis

Endoscopy ◽  
2017 ◽  
Vol 49 (06) ◽  
pp. 553-559 ◽  
Author(s):  
Marietta Iacucci ◽  
Ralf Kiesslich ◽  
Xianyong Gui ◽  
Remo Panaccione ◽  
Joan Heatherington ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Pilot Study ◽  
Diagnostic Accuracy ◽  
Mucosal Healing ◽  
Mucosal Inflammation ◽  
Vascular Changes ◽  
Virtual Chromoendoscopy ◽  
Acute Changes ◽  
Inflammatory Changes ◽  
Targeted Biopsies

Abstract Background and study aim The I-SCAN optical enhancement (OE) system with magnification is a recently introduced combination of optical and digital electronic virtual chromoendoscopy, which enhances mucosal and vascular details. The aim of this pilot study was to investigate the use of I-SCAN OE in the assessment of inflammatory changes in ulcerative colitis (UC). Patients and methods A total of 41 consecutive patients with UC and 9 control patients were examined by I-SCAN OE (Pentax Medical, Tokyo, Japan). Targeted biopsies of the imaged areas were obtained. A new optical enhancement score focusing on mucosal and vascular changes was developed. The diagnostic accuracy of I-SCAN OE was calculated against histology using two UC histological scores – Robarts Histopathology Index (RHI) and ECAP (Extent, Chronicity, Activity, Plus additional findings). Results The overall I-SCAN OE score correlated with ECAP (r = 0.70; P < 0.001). The accuracy of the overall I-SCAN OE score to detect abnormalities by ECAP was 80 % (sensitivity 78 %, specificity 100 %). I-SCAN OE vascular and mucosal scores correlated with ECAP (r = 0.65 and 0.71, respectively; P < 0.001). The correlation between overall I-SCAN OE score and RHI was r = 0.61 (P < 0.01), and the accuracy to detect abnormalities by RHI was 68 % (sensitivity 78 %, specificity 50 %). The majority of patients with Mayo 0 had abnormalities on I-SCAN OE. Conclusion In UC, the new I-SCAN OE technology accurately identified mucosal inflammation, and correlated well with histological scores of chronic and acute changes.

scholarly journals DIAGNOSTIC AND MANAGEMENT APPROACH TO POUCHITIS IN INFLAMMATORY BOWEL DISEASE

2020 ◽  
Vol 57 (1) ◽  
pp. 100-106 ◽  
Author(s):  
Rocío SEDANO ◽  
Paulina NUÑEZ ◽  
Rodrigo QUERA
Keyword(s):  
Colorectal Cancer ◽  
Risk Factors ◽  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Sclerosing Cholangitis ◽  
Biological Therapy ◽  
Response To Therapy ◽  
Management Approach ◽  
Total Proctocolectomy ◽  
Inflammatory Bowel

ABSTRACT In patients with ulcerative colitis refractory to medical therapy, total proctocolectomy and posterior ileal-anal pouch anastomosis is the standard surgical therapy. One of the possible complications is pouchitis. Depending on the duration of the symptoms, it can be classified as acute, recurrent, or chronic. The latter, according to the response to therapy, can be defined as antibiotic-dependent or refractory. The treatment of pouchitis is based on the use of antibiotics and probiotics. Thiopurine and biological therapy have been suggested in patients with refractory pouchitis. Special care should be taken in the endoscopic surveillance of these patients, especially if they present risk factors such as dysplasia or previous colorectal cancer, primary sclerosing cholangitis or ulcerative colitis for more than 10 years.

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