Anal and rectal cancer in Crohn's disease.

Several epidemiological studies have been published regarding the risk of Crohn's disease- associated colorectal cancer. The findings are, however, contradictory and it has been particularly difficult to obtain indisputable information on the incidence of cancer limited to the rectum and the anus. During 1987-2000 rectal or anal cancer was diagnosed in 335 patients in Sweden (153 males, 182 females). In other words, approximately 3 Crohn patients per million inhabitants were diagnosed with rectal or anal cancer every year during that time period which is 1% of the total number of cases. At diagnosis of cancer 36% were aged below 50 years and 58% below 60 years. Corresponding figures for all cases of anal and rectal cancer were 5% and 18%, respectively. Present knowledge from the literature implies that there is an increased risk of rectal and anal cancer only in Crohn's disease patients with severe proctitis or severe chronic perianal disease. However, the rectal remnant must also be considered a risk factor. Multimodal treatment is similar to that in sporadic cancer but proctectomy and total or partial colectomy is added depending on the extent of the Crohn's disease. The outcome is the same as in sporadic cancer at a corresponding stage but the prognosis is often poor due to the advanced stage of cancer at diagnosis. We suggest that six high-risk groups should be recommended annual surveillance after a duration of Crohn's disease of 15 years including extensive colitis, chronic severe anorectal disease, rectal remnant, strictures, bypassed segments and sclerosing cholangitis.

Early predictors of glucocorticosteroid treatment failure in severe and moderately severe attacks of ulcerative colitis.

OBJECTIVE: To analyse the ability of simple clinical and biochemical parameters to predict glucocorticosteroid (GCS) treatment failure in patients with acute attacks of ulcerative colitis. DESIGN/METHODS: Retrospective analysis of clinical and biochemical data. SETTING: Four Swedish university hospitals. PATIENTS: Ninety seven patients with acute attacks of ulcerative colitis severe enough to warrant treatment with intravenous GCS, hospitalized during the years 1988-93. MAIN OUTCOME MEASURE: Colectomy within the first 30 days after hospitalization, defined as 'clinical steroid resistance'. RESULTS: Thirty days after admission, 39 patients (40%) were in complete clinical and endoscopic remission while 33 (34%) had undergone colectomy. During follow-up for 24 months, four patients among the 39 initially in remission underwent colectomy. Among the 25 patients (26%) not attaining remission after 30 days, an additional nine patients subsequently required colectomy. Steroid resistance was associated with duration of disease (2.7 vs 8.1 years, P=0.0037) and steroid treatment before hospitalization (70 vs 42%, P=0.010). In particular, elevation of body temperature (37.4 vs 36.9 degrees C, P=0.012), persistence of diarrhoea (6.8 vs 3.6 bowel movements/day, P<0.0001) and passage of blood (83 vs 42%, P=0.0003) as well as CRP elevation (36.3 vs 18.0 mg/l, P=0.007) on day 3 after treatment initiation were identified as predictors of a poor response. CRP > or = 25 mg/l and > 4 bowel movements/day on day 3 of hospitalization independently predicted a high risk for colectomy within 30 days. CONCLUSIONS: Sustained elevation of body temperature, persistent bloody diarrhoea and continued CRP elevation on day 3 of intravenous GCS treatment strongly predict clinical steroid resistance in acute attacks of ulcerative colitis. In the group of poor or non-responders, colectomy or more aggressive medical treatment should be considered at an early stage.