Intractable ulcerative colitis caused by cytomegalovirus infection: a prospective study on prevalence, diagnosis, and treatment.

PURPOSE: Cytomegalovirus infection has been known to complicate ulcerative colitis. This study was designed to elucidate the prevalence and clinical features of ulcerative colitis that might point efficiently to the diagnosis of complicating cytomegalovirus infection in cases of ulcerative colitis. METHODS: The study included 47 consecutive patients diagnosed to have moderate-to-severe ulcerative colitis who were treated on an inpatient basis at our department during a two-year period. A prospective examination for cytomegalovirus antigenemia was conducted in all patients with moderate-to-severe ulcerative colitis to determine the prevalence of cytomegalovirus infection among these patients. Then, the characteristic clinical and endoscopic features of ulcerative colitis complicated by cytomegalovirus infection were investigated by comparison of the cytomegalovirus-infected group with the non-cytomegalovirus-infected group. The therapeutic effects of antiviral drugs also were assessed. RESULTS: Cytomegalovirus infection was detected in 16 of 47 patients (34 percent). Proportion of female patients, age at the time of determination, and proportion of patients showing corticosteroid resistance was significantly higher in the cytomegalovirus-infected group (59.1 percent) than in the non-cytomegalovirus-infected group (13.6 percent). The prevalence of endoscopically severe ulcerative colitis was higher in patients with cytomegalovirus antigenemia than in those without cytomegalovirus antigenemia (P = 0.016). Ganciclovir was administered to 12 of 16 ulcerative colitis patients with complicating cytomegalovirus infection, and was found to be effective in 8 (66.7 percent). CONCLUSIONS: It is not easy to make a diagnosis of cytomegalovirus infection complicating ulcerative colitis based on clinical features, including endoscopic biopsy. On the other hand, blood examination for the detection of cytomegalovirus antigenemia in corticosteroid-resistant patients, particularly in relatively elderly patients, may enable diagnosis of cytomegalovirus infection with a high sensitivity and allow effective treatment to be administered in these patients.

Clinical features and pattern of indeterminate colitis: Crohn's disease with ulcerative colitis-like clinical presentation.

BACKGROUND: Although an accurate diagnosis of inflammatory bowel disease (IBD) and differentiation between ulcerative colitis (UC) and Crohn's disease (CD) can be made in most patients, it is sometimes impossible to distinguish UC from CD even after thorough pathological study. Recently, clinicians have used the term indeterminate colitis (IC) for patients with features of both diseases that overlap temporarily or persistently. The frequency, reasons, and outcome of patients with a clinical diagnosis of IC based on radiological, endoscopic, and histopathological findings were investigated retrospectively. METHODS: Based on records of 735 patients with IBD, IC was defined as having features of both UC and CD, with differentiation from each other impossible at least once during the observation period (average 6.8 years) based on diagnostic criteria using endoscopic, radiological, and histological findings. RESULTS: Twenty-three patients were identified as having IC. They were classified into three patterns according to the clinical course and the final diagnosis: (1) UC changing to CD (n = 8); (2) CD changing to UC (n = 5); and (3) UC or CD (n = 10). The frequency of IC was 24.5%-43.4% of colitis-type CD (n = 53), 2.3%-6.5% of all CD (n = 352), and 3.1% of IBD (n = 735). The reasons for the indetermination were temporary (56.5%) or persistent (43.5%) overlapping of UC-like and CD-like presentations. Treatment of IC was inappropriate in only two patients, and the prognoses of all patients except one were fairly good. CONCLUSIONS: Overlapping of UC-like presentations (persistent bloody stool and diffuse colitis) was frequently observed with Crohn's colitis but less so in CD patients during their clinical course. The basis of differentiation and treatment of IC needs more attention.

Anti-Saccharomyces cerevisiae antibodies in Japanese patients with inflammatory bowel disease: diagnostic accuracy and clinical value.

BACKGROUND: The diagnostic accuracy of the determination of anti- Saccharomyces cerevisiae antibodies (ASCA) and its clinical significance in Crohn's disease (CD) have been reported in Western countries, but scarcely reported in Japan, where the dietary habits of people differ markedly from those of Western countries. Th present study was undertaken to examine the diagnostic accuracy and clinical significance of ASCA determination in Japanese patients with CD or ulcerative colitis (UC). METHODS: Seventy-five serum samples obtained from 68 patients with CD, 34 serum samples obtained from 30 patients with UC, 35 serum samples from 35 patients with liver cirrhosis, and 31 serum samples from 31 healthy controls were examined. The optical density of each sample was measured by an enzyme-linked immunosorbent assay (ELISA) method to quantify ASCA IgA and IgG. RESULTS: The cutoff level, as determined by discriminant analysis of the data, was 0.1502 for ASCA IgA and 0.156 for ASCA IgG. Of the 68 patients with CD, 31 (45.6%) were ASCA-positive, and of the 30 patients with UC, 4 (13.3%) were ASCA-positive according to these cutoff levels. The sensitivity and specificity of ASCA determination for the differential diagnosis of CD from UC were 45.6% and 86.7%, respectively. When the relationship between ASCA and the clinical features of CD was analyzed, ASCA positivity was found to be correlated with duration of illness. CONCLUSIONS: The specificity of ASCA was high; however, the sensitivity was not. ASCA titers were generally low in the Japanese population examined. It would be desirable to determine cutoff levels for ASCA tailored to the Japanese people for the diagnosis of inflammatory bowel disease.

Evaluation of the clinical course of acute attacks in patients with ulcerative colitis through the use of an activity index.

BACKGROUND: Because it is not easy to make a clinical decision regarding surgical treatment in patients with acute attacks of ulcerative colitis, an objective, simple, criterion is needed to determine the optimum timing for colectomy. The aim of this study was to retrospectively examine to what extent an activity index (AI) can evaluate the clinical course in such acute attacks. METHODS: One hundred and twenty-seven patients with moderate or severe attacks of ulcerative colitis were examined. AI values and the decline in AI values were compared between surgical and nonsurgical groups after 1 week and 2 weeks of medical therapy. To evaluate the clinical course of acute attacks, cutoff AI values were set at every 10 points between values of 180 and 210. The positive predictive value for surgery was examined. RESULTS: AI values in the surgical group were significantly higher than those in nonsurgical group at pretreatment, and after 1 or 2 weeks of medical therapy. The decline of AI values in the nonsurgical group was significantly higher than that in the surgical group after 1 or 2 weeks of medical therapy. At pretreatment, the prediction of colectomy was less than 50% at any of the cutoff values. After 1 week of therapy, approximately 60% of patients with an AI value greater than any of the cutoff AI values required colectomy. After 2 weeks of therapy, 30 of 43 (70%), 28 of 38 (74%), 24 of 29 (83%), and 17 of 21 (81%) patients with AI values greater than 180, 190, 200, and 210, respectively, required colectomy. Overall accuracy was 86%, 87%, 88%, and 83% for cutoff AI values of 180, 190, 200, and 210, respectively. Because the overall accuracy and positive predictive value for colectomy at AI values of 200 were significantly higher than these parameters at other AI values after 2 weeks of therapy, an AI value of 200 was regarded as the cutoff value most able to predict colectomy. CONCLUSIONS: We concluded that patients with an AI value in excess of 200 after 2 weeks of medical therapy would require surgical treatment.