Ulcerative colitis – язвенныйколит
Overall – вцелом
Close links – тесныесвязи
To require – требовать
Appropriate – подходящий
underincreasingscrutiny – под пристальным вниманием
a variable extent – различнаястепень
spleen - селезенка
flexure – изгиб
bloody diarrhea – кровавый понос
lifelongdisease – пожизненное заболевание
severity of an attack – тяжестьприступа
widespread – широкий
Mortality – смертность
well-documentedassociation – хорошо задокументированная связь
escalating – возрастающий
dosing regimens – режимыдозирования
the judgement required – требуется решение
Ulcerative colitis is the most common type of inflammatory disease of the bowel. It has an incidence in the UK of approximately 10 per 100,000 people annually and a prevalence of approximately 240 per 100,000. This amounts to around 146,000 people in the UK with a diagnosis of ulcerative colitis. The cause of ulcerative colitis is unknown. It can develop at any age, but peak incidence is between the ages of 15 and 25 years, with a second, smaller peak between 55 and 65 years (although this second peak has not been universally demonstrated). The British Paediatric Surveillance Unit reported an incidence of ulcerative colitis in children aged younger than 16 years in the United Kingdom, of 1.4 per 100,000 with a greater proportion of Asian children having ulcerative colitis than other children. The median age for diagnosis of ulcerative colitis overall in this childhood cohort was 11.7 years (range 9.3 to 13.7 years).
Ulcerative colitis usually affects the rectum, and a variable extent of the colon proximal to the rectum. The inflammation is continuous in extent. Inflammation of the rectum is referred to as proctitis, and inflammation of the rectum and sigmoid as proctosigmoiditis. Left-sided colitis refers to disease involving the colon distal to the splenic flexure. Extensive colitis affects the colon proximal to the splenic flexure, and includes pan-colitis, where the whole colon is involved.
Symptoms of active disease or relapse include bloody diarrhoea, an urgent need to defaecate and abdominal pain.
Ulcerative colitis is a lifelong disease that is associated with significant morbidity. It can also affect a person’s social and psychological wellbeing, particularly if poorly controlled. Typically, it has a relapsing–remitting pattern. An estimated 50% of people with ulcerative colitis will have at least one relapse per year. About 80% of these are mild to moderate and about 20% are severe.
The Truelove and Witts’ criteria are outlined in Table 6. These are simple clinical and laboratory measures and are widely used in clinical practice to guide treatment. In addition, a number of laboratory, endoscopic and radiological features may reflect the severity of an attack, and have been assessed in terms of their ability to predict the need for colectomy (see section 5.48). These include measurements of C-reactive protein, colonic dilatation or the presence of colonic mucosal islands on a plain abdominal X-ray and deep ulceration on endoscopic assessment. The Truelove and Witts’ criteria were used as a definition of the severity of an attack on the basis of their widespread use and ease of applicability to clinical practice. The use of clinical scoring systems was a way of predicting the response to medical treatment, and the need for surgery was assessed in section 5.48.
Approximately 25% of people with ulcerative colitis will have one or more episodes of acute severe colitis in their lifetime, with a 29% colectomy rate.212 Although mortality rates have improved steadily over the past 30 years, acute severe colitis still has a mortality rate of up to 2%. Mortality is directly influenced by the timing of interventions, including medical therapy and colectomy. The most recent UK audit demonstrated an overall UK national mortality of 0.8%.
Current medical approaches focus on treating active disease to address symptoms of urgency, frequency of defaecation and rectalbleeding, and also to improve quality of life, and thereafter to maintain remission. The long-term benefits of achieving mucosal healing remain unclear. The treatment chosen for active disease is likely to depend on clinical severity, extent of disease and the person’s preference, and may include the use of aminosalicylates, corticosteroids or biological drugs. These drugs can be oral ortopical (into the rectum), and corticosteroids may be administered intravenously in people with acute severe disease. Surgery may be considered as emergency treatment for severe ulcerative colitis that does not respond to drug treatment. People may also choose to have elective surgery for unresponsive or frequently relapsing disease that is affecting their quality of life.
If an episode of acute severe colitis does not respond to standard first-line management with intravenous corticosteroids, ‘rescue’therapy with intravenous ciclosporin or infliximab may be required - though the most recent, third round, of the UK national IBD audit, described only 16.8% of patients who do not respond to intravenous steroids receiving anti-TNF therapy and 23% receiving ciclosporin.221 The use of infliximab in this situation is outlined in NICE TA 163.149 Response rate is variable-reported as 85% to anti-TNF agents and 64% to ciclosporin in the third round of the UK IBD audit.221
Most patients receive maintenance therapy with aminosalicylates. There may be variation in the doses of aminosalicylates and in whether a combination of treatment routes is used. Regarding immunosuppressive azathioprine or mercaptopurine, it appears that azathioprine and mercaptopurine are increasingly used to maintain remission in people with frequently-relapsing ulcerative colitis.
Elective surgery, in the form of pan-proctocolectomy, with formation of an ileoanal pouch or ileostomy, can be an effectivetreatment for eliminating the symptoms of ulcerative colitis where these symptoms are refractory to treatment or rapidly and frequently recur. However postoperative morbidity is associated with both a stoma and ileoanal pouch. Complications of pan-proctocolectomy may include: decrease in female fertility, male impotency, pouchitis and small bowel obstruction. Problems with urgency, leakage and nocturnal soiling may persist after surgery, and some patients may need a permanent ileostomy if ileal pouch anastomosis fails. Even in expert centres, panproctocolectomy has an operative mortality of between 1 and 4%, and postoperative lifelong morbidity of up to 15%.
Ulcerative colitis has a well-documented association with the development of colorectal cancer, with greatest risk in people with long-standing and extensive disease. The overall lifetime risk of colorectal cancer in people with ulcerative colitis is approximately 2.7%, with an annual incidence of dysplasia or cancer of between 3.7 and 5.7%. Moreover, the degree of colonic inflammation is a predictor of dysplasia or cancer development. This emphasises the importance of adequate and effective control of disease activity to reduce the risk of colorectal cancer. The approach to surveillance of people with ulcerative colitis for dysplasia or cancer is described in NICE clinical guideline 118.152
Advice and support for people with ulcerative colitis is important, in terms of discussing the effects of the condition and its course, medical treatment options, the effects of medication and the monitoring required. Around 10% of inpatients with inflammatory bowel disease reported a lack of information about drug side effects on discharge from hospital.220 Information to support decisions about surgery is also essential, both for clinicians and for people facing the possibility of surgery. This includes recognising adverse prognostic factors for people admitted with acute severe colitis to enable timely decisions about escalating medical therapy or predicting the need for surgery. It is also very important to provide relevant information to support people considering elective surgery.
The third round of the National IBD audit provided some evidence of variation in practice, including whether patients are admitted to a specialist gastroenterology ward, access to nurse specialist advice, prescription of bone protection for patients discharged on systemic corticosteroids and length of stay for admitted patients.220 A record of the paediatric ulcerative colitis activity index was recorded in 20% of admitted paediatric patients.222
The wide choice of drug preparations and dosing regimens, the judgement required in determining the optimum timing for surgery (both electively and as an emergency) and the importance of support and information may lead to variation in practice across the UK. This guideline aims to address this variation, and to help healthcare professionals to provide consistent high-quality care. Managing ulcerative colitis in adults, children and young people overlaps in many regards, so the guideline incorporates advice that is applicable to children and young people. This again should help to address potential inconsistencies in practice.
Care of people with ulcerative colitis is usually shared between primary care and specialist gastroenterology units working in collaboration with specialist colorectal surgical units. Close links are required to allow specialist input, rapid access to advice (especially when symptoms worsen) and coordinated monitoring of drug-side effects, and to ensure that associated issues (such as monitoring of bone density) are addressed. However, the number of adults with ulcerative colitis definitely under specialist care may not be as high as thought, and may be as low as 30%.184 The most appropriate setting for a person’s care is likely to come under increasing scrutiny as commissioning groups seek to provide more care in the community.