History of medical hospitalization predicts future need for colectomy in patients with ulcerative colitis

[Intensive care and inflammatory bowel diseases (IBD). The severe and fulminant flare]

Inflammatory bowel disease (IBD) is a non-curable disease. Although we seem to have a definitive surgical solution for ulcerative colitis, patients are at risk of suffering from acute and chronic pouchitis as well as peri- and postoperative complications. In Crohn's disease medical treatment is able to prolong surgery-free survival, but no definitive healing strategy is as yet at hand. Moreover, effective medication exposes patients to potentially life-threatening complications. The severely compromised patient in particular needs careful surveillance and requires a balanced treatment strategy endorsed by gastroenterologists and surgeons. Treatment is still aimed at suppressing immune mechanisms and is far from being causal. Nevertheless, this approach has resulted in a reduction in surgical procedures and hospitalizations. The following overview covers special issues related to strategies for severe and fulminant flares of inflammatory bowel disease.

The pattern and outcome of acute severe colitis

BACKGROUND

The prognosis of acute severe ulcerative colitis (ASC) influences therapeutic decisions, but data on prevalence or long-term outcome are few.

METHODS

A systematic review of all patients with UC diagnosed in Oxford was performed to assess the prevalence of ASC defined by Truelove and Witts' (TW) criteria and determine whether outcome is related to disease activity on admission, likelihood of recurrence and long-term prognosis.

RESULTS

750 patients (median follow up 12.7 yr, range 0-648 mo) met inclusion criteria out of a total cohort of 1853 patients. 24.8% (186/750) had at least one admission for ASC (294 admissions in 186 patients). Overall, 12% (93/750) had a colectomy, compared to 39.8% (74/186) of patients with one or more episodes of ASC (p<0.0001) and 3.4% (19/564) in those with no admission. The colectomy rate on first admission (37/186, 19.9%) was lower than on the second or subsequent admissions (OR 2.35, 95% CI 1.33-4.14, p=0.003), being 29.0%, 36.6%, 38.2% after two, three, or subsequent episodes respectively. It was 8.5% (11/129) if patients had one TW criterion in addition to ≥6 bloody bowel motions/day, compared to 31% (29/94) if two additional criteria were present and 48% (34/71) if three or more additional criteria were present (p=1.4 × 10⁻⁵; OR 4.35, 95% CI 2.20-8.56 one criterion vs two or more).

CONCLUSIONS

A quarter of all patients with ulcerative colitis experience at least one episode of ASC; 20% come to colectomy on first admission, but 40% after two admissions. The likelihood of colectomy is related to biological severity on admission.

Impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis

BACKGROUND

The effect of narcotic use in the disease course of ulcerative colitis has not been studied. The aim of the study was to evaluate the impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis.

METHODS

All eligible patients with ulcerative colitis admitted to gastroenterology service for disease flare-ups between 2002 and 2008 were included. Excluded were patients with ulcerative colitis admitted to the colorectal surgery service for emergent or elective colectomy and patients with Crohn's disease. Demographic, clinical, and laboratory data were reviewed. The definition of narcotics use was oral or intravenous administration of the agents during hospital admission or at hospital transfer. Multivariable analysis was performed.

RESULTS

A total of 223 patients were included. One hundred six patients were males. The mean age was 38.7 +/- 18.1 years. Forty-four patients (19.7%) were on oral or intravenous narcotics during the hospitalization. Sixty-seven patients (30%) had colectomy during the hospitalization and the colectomy rate was similar between narcotic user and nonnarcotic users (29.5% vs 30.2%, P = .9). In multivariable analysis, only the serum albumin level remained in the model as an independent risk factor associated with colectomy (OR = 0.4; 95% CI, 0.2-0.9; P = .03). Narcotic use was not an independent risk factor for colectomy in this study (P = .5).

CONCLUSION

Narcotics were commonly prescribed to patients with ulcerative colitis who were admitted to the gastroenterology service. However, narcotic use appeared not to have a significant negative impact on the colectomy rate in inpatients with ulcerative colitis. In contrast, the low albumin level at flare was associated with an increased risk for colectomy.

Simple score to identify colectomy risk in ulcerative colitis hospitalizations

BACKGROUND

Patients hospitalized for ulcerative colitis (UC) are at high risk for colectomy. Despite growing interest in research using administrative data in inflammatory bowel disease, there is no available tool in such research to stratify disease severity or identify patients at high risk for colectomy.

METHODS

Using the Nationwide Inpatient Sample (NIS) 2004, we identified patients hospitalized for UC flare through appropriate ICD-9-CM discharge diagnosis codes (556.x). Our primary outcome of interest was undergoing total colectomy (45.8). Multivariate logistic regression models were constructed to identify independent predictors of colectomy. From this, a cumulative risk score was developed. Hospitalizations were divided into 3 strata (low, intermediate, high) based on the odds of colectomy.

RESULTS

There were a total of 15,142 hospitalizations with a discharge diagnosis of UC included in our study among whom 366 patients underwent total colectomy (2.4%). Anemia (odds ratio [OR] 2.13), requirement for blood transfusion (OR 2.22), malnutrition (OR 4.53), and total parenteral nutrition (OR 4.30) were independent predictors of colectomy as were transfer in from another hospital (OR 2.06) and admission to a teaching hospital (OR 1.73). The cumulative colectomy risk score ranged from 0-8, with significantly higher risk of colectomy in the high-risk stratum (13.7%) compared to the intermediate-risk (4.2%, P < 0.001) and low-risk (1.3%, P < 0.001) strata. The risk score performed well in its discriminative ability with an area under the curve of 0.70.

CONCLUSIONS

We propose a simple and novel risk score to stratify the severity of UC hospitalizations and predict colectomy in this population.

Does primary sclerosing cholangitis impact quality of life in patients with inflammatory bowel disease?

BACKGROUND

Impairment of health-related quality of life (HRQoL) is an important concern in inflammatory bowel disease (IBD; ulcerative colitis [UC], Crohn's disease [CD]). Between 2%-10% of patients with IBD have primary sclerosing cholangitis (PSC). There has been limited examination of the disease-specific HRQoL in this population compared to non-PSC IBD controls.

METHODS

This was a retrospective, case-control study performed at a tertiary referral center. Cases comprised 26 patients with a known diagnosis of PSC and IBD (17 UC, 9 CD). Three random controls were selected for each case after matching for IBD type, gender, age, and duration of disease. Disease-specific HRQoL was measured using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Disease activity for CD was measured using the Harvey-Bradshaw index (HB) and using the UC activity index for UC. Independent predictors of HRQoL were identified.

RESULTS

There was no significant difference in the age, gender distribution, or disease duration between PSC-IBD and controls. There was no difference in use of immunomodulators or biologics between the 2 groups. Mean SIBDQ score was comparable between PSC-IBD patients (54.5) and controls (54.1), both for UC and CD. Likewise, the disease activity scores were also similar (2.8 versus 3.1, P = 0.35). On multivariate analysis, higher disease activity score (-1.33, 95% confidence interval [CI] 95% CI -1.85 to -0.82) and shorter disease duration were predictive of lower HRQoL. Coexisting PSC did not influence IBD-related HRQoL. There was a higher proportion of permanent work disability in PSC-IBD (7.7%) compared to controls (0%).

CONCLUSIONS

PSC does not seem to influence disease-specific HRQoL in our patients with IBD but is associated with a higher rate of work disability.