Management in Health, Vol 16, No 3 (2012)

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INCIDENCE AND ENDOSCOPIC FOLLOW-UP OF PATIENTS WITH ULCERATIVE COLITIS

INCIDENCE AND ENDOSCOPIC FOLLOW-UP OF PATIENTS WITH ULCERATIVE COLITIS

Olga BRUSNIC1 - MD, PhD candidate

Professor Dr. Daniela DOBRU1- Chief Physician, Head of Doctoral School,

Danusia ONIŞOR1 - MD, PhD candidate,

Ofelia PASCARENCO1 - MD, PhD candidate,

Mircea STOIAN2- MD, PhD candidate, Adina STOIAN3- MD, PhD candidate,

Dan COZMA4 - MD, PhD candidate

 

1 Mureş County Clinical Hospital, Clinical Department of Gastroenterology

2 Mureş County Clinical Hospital, Department of Anesthesia and Intensive Therapy

3 University of Medicine and Pharmacy Trgu Mureş

4 Mureş County Clinical Hospital, Surgery Clinic I

 

INTRODUCTION: Ulcerative colitis (UC) is an idiopathic inflammatory bowel disease, which is characterized by a chronic recurrent inflammation of the intestinal mucosa. Patients with UC have a high risk of developing colorectal cancer (CRC). In the UC, malignization is produced by dysplasia.

THE PURPOSE OF THE STUDY was to establish the incidence of adenomatous polyps, stenoses, dysplasia and CRC in patients with UC who were being monitored at Mureş County Clinical Hospital.

MATERIAL AND METHOD: We have performed an observational prospective study on a batch of 47 patients who were being monitored at our clinic in the period January 2007 - December 2011. The UC diagnosis was established based on symptomatology, colonoscopy and by histopathological analysis. The data were processed by means of statistic instruments in Excel (Microsoft Excel 2003).

RESULTS: In the period January 2007 - December 2011 there were 160 patients with UC under our clinic monitoring. According to the disease evolution, 99 patients (62%) had a < 5 years evolution, 48 patients (30%) between 5 and 10 years, and 13 patients (8%) over 10 years. From the total of 160 patients in the study were included 47. About 27 (57%) were men and 20 (43%) women, with an average age of 47,193 years. The presence of low-grade dysplasia was identified in 2 patients (4.25%), high-grade dysplasia was identified in 1 patient (2.12%) and CRC was identified in 2 patients (4.25%). For these patients the therapeutic indication was surgical intervention.

Conclusions: The correct approach in preventing CRC in UC should cover a clinical follow-up with regular visits, an intensive control of the activity of the disease by medical treatment associated with endoscopic monitoring of biopsy sampling. The purpose of the colonoscopic monitoring consists in detecting the preneoplasic lesions before the malign transformation. Thus, the detection and management of dysplastic lesions is a crucial element in reducing death rate by CRC.

 

Keywords: Ulcerative colitis, Low-grade dysplasia, High-grade dysplasia, Colorectal cancer, Endoscopy, Colectomy.

 

INTRODUCTION: Ulcerative colitis (UC) is an idiopathic inflammatory bowel disease which is characterized by a chronic recurrent inflammation of the intestinal mucosa. Patients with UC have a high risk of developing colorectal cancer (CRC) [1]. There is a tight correlation between chronic bowel inflammation (assessed by the extent, the period of the disease and the degree of inflammation during histological examination) and the risk of developing CRC as well as the genetic predisposition of an individual (family antecedents, coexistence of primary sclerosing cholangitis and young age at the moment of diagnosis) [2]. The major role of the chronic inflammation in cancerogenesis is sustained by the increased risk of CRC along with the period of the disease evolution, the colic extension and the coexistence of other inflammatory manifestations such as primary sclerosing cholangitis, and by multiple studies which showed that 5-ASA derivatives reduce the CRC incidence in UC [3,4]. In the UC, malignization is produced by means of a premalign lesion - dysplasia, characterized by precancerous cytologic or architectural changes and anomalies at the intestinal mucosa level. The present approach of monitoring is based on the existence of the sequence "inflammation - dysplasia - carcinoma", in which it may be intervened to prevent or to minimize the complications associated with invasive cancer. Precancerous lesions are represented by the dysplasia associated to a plane lesion or mass (DALM), but also by protrusive lesions similar to sporadic adenomas (ALM) or strictures [5,6,7].

At the moment, the recommended protocol for monitoring patients with high risk of CRC (pancolitis after 8 years of evolution and extended colitis after 15 years of evolution) consists in annual endoscopic follow-up or at a 2 year interval, with random multiple stratified biopsy samplings on the apparently normal mucosa, and targeted biopsies on the level of visible lesions. All the biopsy results, which confirm the presence of dysplastic changes, must be reevaluated and confirmed by a second anatomopathologist specialist. Detection of mild dysplasia requires an intensification of monitoring (every 3 months); detection of severe dysplasia or dysplasia associated with the presence of lesional masses or colonic stenoses constitute an indication for colectomy [8,9].

 

THE PURPOSE OF THE STUDY was to establish the incidence of adenomatous polyps, stenoses, dysplasia and CRC in patients with UC who were being monitored at Mureş County Clinical Hospital.

 

MATERIAL AND METHOD: We have performed an observational prospective study on a batch of patients who were being monitored at our clinic in the period January 2007 - December 2011.

 

All patients who participated in the study signed an informed consent prior to register for the study. From the total of 160 patients, there were selected 47 patients who had a period of disease evolution of over 5 years. The UC diagnosis was established based on symptomatology (diarrheic stools, presence of pathologic elements in the stool, rectal bleedings, abdominal pains, associated or not with weight loss), colonoscopy (presence of UC specific lesions). In all cases the diagnosis was confirmed by the results of the histopathological analysis.

The extension of the disease was determined based on the endoscopic exam. According to the Montreal Classification, we had the following clinical forms of UC: proctitis, left-sided colitis and extended colitis including pancolitis. Depending on the disease evolution we had batches of patients with < 5 years of evolution (this batch had been excluded from the study), 5-10 years, 10-20 years, and > 20 years.

From the total of 47 patients, for the program of colonoscopic follow-up, there were included 27 patients with left-sided colitis and 15 patients with extended colitis including pancolitis. The colonoscopies were performed at an interval of 12-24 months. Random biopsies were performed from various segments of the colon and targeted biopsies at the level of visible lesions (uneven areas of the mucosa, stenosis areas and polypoid formations). The bioptic samples have been analyzed by two anatomopathologists in order to establish the presence or the absence of dysplasia, the degree of dysplasia or the presence of CRC. In those cases where the histopathological diagnosis could not be definitely established because of a high degree of inflammation, the patients were reevaluated endoscopically and histopathologically after a treatment with 5-ASA products and obtaining remission. Patients found to have low grade dysplasia, were reevaluated by endoscopic biopsies at 3 months after the initial evaluation. Patients found to have high grade dysplasia were reevaluated endoscopically and histopathologically after 4 weeks. After the second endoscopic reevaluation and histopathological confirmation of the presence of high grade dysplasia, the patients were advised to undergo a surgical intervention - total colectomy. In patients with adenomatous polyps associated UC, biopsies were performed on the polypoid formations, and after receiving the results of the histopathological analysis, we resort to an endoscopic polypectomy and histopathological analysis of the excised piece.

All patients included in the study underwent a treatment with 5-ASA products. During the activity periods of the disease, it was associated corticotherapy (parenteral or oral) and antibiotic treatment.

Statistical analysis: the data were processed by means of statistic instruments in Excel (Microsoft Excel 2003).

 

 

RESULTS: In the period January 2007 - December 2011 there were 160 patients with UC in our clinic monitoring. According to the disease evolution, 99 patients (62%) had a < 5 years evolution, 48 patients (30%) between 5 and 10 years, and 13 patients (8%) over 10 years. From the total of 160 patients in the study were included 47. The newly diagnosed patients were excluded from the study (Table 1). 27 (57%) were men and 20 (43%) women, with an average age of 47,2 years.

From the point of view of location, 5 patients (11%) had proctitis, 27 (57%) left-sided colitis and 15 (32%) extensive colitis including pancolitis (Figure1).

The presence of low-grade dysplasia was identified in 2 patients (4.25 %); the disease evolution in these patients had a period of 12 years. High-grade dysplasia was identified in 1 patient (2.12 %) and disease evolution had a period of 5 years. CRC was identified in 2 patients (4.25 %), disease evolution had a period of 16 years, respectively 5 years. In these patients the therapeutic indication was surgical intervention. Among the latter ones, one case resulted in death because of associated hereditary defects and postoperative complications. In the cases which revealed dysplastic changes, the biopsies were performed in stenosis areas, fact that did not allow the endoscope to advance, or in the areas with inflammatory pseudopolyps. At these patients the therapeutic indication was surgical intervention, respectively total proctocolectomy.

In 8 patients (17%) were identified adenomatous polyps which were ectomized endoscopically. At 62% of the patients the polyps were in areas with UC lesions and at 38% of the patients the polyps were outside the areas with UC lesions. The histopathological result of the ectomized polyps was of "tubular adenomas". The characteristics of the patients included in this study are shown below in Table 2.

 

CONCLUSIONS: Patients with UC have a high risk of developing CRC. This risk seems to be related to the cumulative effect of the chronic inflammation and it is correlated directly with the extent and the period of the disease as well as with the severity of the inflammatory activity. Current therapies and surgical techniques may influence the CRC incidence in this group of high risk, so a careful approach in preventing the occurrence of CRC and a close monitoring of this group of patients is still justifiable. The correct approach in preventing CRC in UC should cover a clinical follow-up with regular visits, an intensive control of the activity of the disease by medical treatment associated with endoscopic monitoring of biopsy sampling. The purpose of the colonoscopic monitoring consists in detecting the preneoplasic lesions before the malign transformation. Thus, the detection and management of dysplastic lesions is a crucial element in reducing death rate by CRC. Our study confirms the information from literature that long evolution types of UC have an increased risk for developing CRC, but we have also demonstrated that the shorter evolution types (5 years) may present an equal high risk of CRC occurrence. These data prove the helpfulness of endoscopic follow-up in patients diagnosed long ago with the disease and those with extended type of the disease, including pancolitis, as well as the usefulness of early colectomy in patients with severe dysplasia.

 

Table 1 - The newly diagnosed patients excluded from the study

 

 


Yer of diagnostic

Number of patients

2007

14

2008

14

2009

24

2010

33

2011

28

Total pacients

113

 

Figure 1 - Extension of lesions in patients with UC

Table 2 - Characteristics of the patients included in this study

 

 


 

 

With dysplasia

CRC

 

Without dysplasia

 

 

 

LGD

HGD

 

 

Polyps

Stenosis area

 

Without lesions

 

Number of patients

2

1

2

 

8

5

 

29

Females

 

0

1

1

 

3

3

 

12

Men

 

2

0

1

 

5

2

 

17

Average age (mean age)

74

72

72

 

59.125

51

 

51.088

Extension of lesions

 

 

 

 

 

 

 

 

Proctitis

 

0

1

1

 

1

0

 

3

Left-sided colitis

2

0

1

 

5

3

 

20

Extensive colitis and pancolitis

0

0

0

 

2

2

 

10

Evolution of disease (years)

12

5

10.5

 

 

 

 

 

Number of endoscopy

3

3

3

 

2

2

 

3

 

 

 

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