Ulcerative colitis complications

Quan VA, Saunders BP, Hicks BH, Sladen GE. Cyclosporin treatment for ulcerative colitis complicated by fatal Pneumocystis carinii pneumonia. BMJ 1997 314(7077) 363 1. 

Pneumonitis developed after the administration of co-trimoxazole in a patient with intractable ulcerative colitis complicated by P. jiroveci pneumonia. This patient had also previously had sulfasalazine-induced pneumonitis (24). 

Colorectal cancer is a well-established complication of ulcerative colitis (Lennard-Jones era/., 1990 Ekbom et al., 1990). It has been shown that inflammation enhances the formation of colonic tumours in experimental animals given known carcint ens (Chester etal., 1986) and it is tempting to speculate that the longterm inflammatory response is respronsible for the increased risk of malignancy in ulcerative colitis. However, there is very little direct evidence to support this. It has also been postulated that free radicals may play a part in the development of sporadic cancers (Babbs,... 

Surgical intervention is a potential treatment option in patients with complications such as fistulae or abscesses, or in patients with medically refractory disease. Ulcerative colitis is curable with performance of a total colectomy. Patients with UC may opt to have a colectomy to reduce the chance of developing colorectal cancer. Patients with CD may have affected areas of intestine resected. Unfortunately, CD may recur following surgical resection. Repeated surgeries may lead to significant malabsorption of nutrients and drugs consistent with development of short-bowel syndrome. 

Local complications (involving the colon) occur in the majority of ulcerative colitis patients. Relatively minor complications include hemorrhoids, anal fissures, or perirectal abscesses. 

A major complication is toxic megacolon, a severe condition that occurs in up to 7.9% of ulcerative colitis patients admitted to hospitals. The patient with toxic megacolon usually has a high fever, tachycardia, distended abdomen, elevated white blood cell count, and a dilated colon. 

Approximately 11% of patients with ulcerative colitis have hepatobiliary complications including fatty liver, pericholangitis, chronic active hepatitis, cirrhosis, sclerosing cholangitis, cholangiocarcinoma, and gallstones. 

Complications of Crohn s disease may involve the intestinal tract or organs unrelated to it. Small-bowel stricture and subsequent obstruction is a complication that may require surgery. Fistula formation is common and occurs much more frequently than with ulcerative colitis. 

Systemic complications of Crohn s disease are common and similar to those found with ulcerative colitis. Arthritis, iritis, skin lesions, and liver disease often accompany Crohn s disease. 

For ulcerative colitis, colectomy may be performed when the patient has disease uncontrolled by maximum medical therapy or when there are complications of the disease such as colonic perforation, toxic dilatation (megacolon), uncontrolled colonic hemorrhage, or colonic strictures. 

The indications for surgery with Crohn s disease are not as well established as they are for ulcerative colitis, and surgery is usually reserved for the complications of the disease. There is a high recurrence rate of Crohn s disease after surgery. 

Gl Obstructive disease (eg, achalasia, pyloroduodenal stenosis or pyloric obstruction, cardiospasm) paralytic ileus intestinal atony of the elderly or debilitated severe ulcerative colitis toxic megacolon complicating ulcerative colitis hepatic disease. 

Treatments are broadly the same as for ulcerative colitis being based on appropriate supportive measures, and the use of corticosteroids, the cytokine infliximab or adalimumab for severe and complicated disease and immunosuppressants, typically azathio-prine, for reducing the chances of relapse. Full thickness disease leading to flstulation, free perforation, abscess formation and stricturing usually requires surgery. Aminosalicylates appear ineffective in reducing the chances of relapse. 

Contraindications Glaucoma, obstructive uropathy, obstructive disease of Gl-anti-cholinergic tract, paralytic ileus, intestinal atony of the elderly or debilitated patient, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis especially if complicated by toxic megacolon, myasthenia gravis, hiatal hernia associated with reflux esophagitis, hypersensitivity to any component of f he formulaf ion, acuf e infermiffenf porphyria. 

Proximal renal tubnlar proteinuria is a possible complication in patients treated with high doses of mesalazine, and it is clearly important to monitor renal function in these patients (SEDA-22, 394) (75). Two studies in 21 (76) and 95 (77) patients with ulcerative colitis and Crohn s disease have shown that proteinuria of tubular marker proteins is common and is related to disease activity rather than to treatment with mesalazine. Thus, tubular proteins are not useful predictors of an adverse renal response to the drug. Nephrotic syndrome with minimal change nephropathy has been described with sulfasalazine and mesalazine (SEDA-16, 427). 

Schroeder KW. Role of mesalazine in acute and long-term treatment of ulcerative colitis and its complications. Scand J Gastroenterol Suppl 2002 (236) 42-7. 

Greenstein AJ, Janowitz HD, Sachar DB. The extra-intestinal complications of Crohn s disease and ulcerative colitis a study of 700 patients. Medicine 1976 55(4) 401 -412. 

Yale Medical School investigators reported three cases of ulcerative colitis, in patients with no history of this disease, following the use of H202 in an enema.2 All three recovered, but they were seriously ill. As the authors observed, "sepsis invariably occurs in association with hydrogen peroxide colitis." Sepsis means bacteria in the blood, a potentially fatal complication. 

Common complications of IBD include rectal fissures, fistulas (Crohn s disease), perirectal abscess (ulcerative colitis), and colon cancer, in addition to hepatobiliary complications, arthritis, uveitis, skin lesions (including erythema nodosum and pyoderma gangrenosum), and aphthous ulcerations of the mouth. 

Ulcerative colitis can be accompanied by complications that may be local (involving the colon or rectum) or systemic (not directly associated with the colon). With either type the complications may be rmld, serious, or even life threatening. Local complications occur in the majority of ulcerative colitis patients. Relatively minor complications include hemorrhoids, anal fissures, or perirectal abscesses, and are more likely to be present during active colitis. Enteroenteric fistulas are rare. 

The inflammatory response seen in IBD has also been blamed for the systemic complications seen in both Crohn s disease and ulcerative colitis. The systemic extraintestinal complications of ulcerative colitis are summarized in the next section. 

Another potential joint complication is ankylosing spondylitis, which is often unresponsive to treatment. The incidence of ankylosing spondylitis in patients with ulcerative colitis is 30 times that of the general population and occurs most commonly in patients with the HLA-B27 phenotype. 

Ocular complications including iritis, uveitis, episcleritis, and conjunctivitis occur in up to 10% of patients with IBD. The most commonly reported symptoms with iritis and uveitis include blurred vision, eye pain, and photophobia. Episcleritis is associated with scleral injection, burning, and increased secretions. These complications may parallel the severity of intestinal disease, and recurrence after colectomy with ulcerative colitis is uncommon. 

Systemic complications of Crohn s disease are common, and similar to those found with ulcerative colitis. Arthritis, iritis, skin lesions, and liver disease often accompany Crohn s disease. Renal stones occur in up to 10% of patients with Crohn s disease (less frequently with ulcerative colitis) and are caused by fat malabsorption, which allows for greater oxalate absorption and formation of calcium oxalate stones. Gallstones also occur with greater frequency in patients with ileitis, possibly because of bile acid malabsorption at the terminal ileum. 

To treat IBD properly, the clinician must have a clear concept of realistic therapeutic goals for each patient. These goals may relate to resolution of acute inflammatory processes, resolution of attendant complications (e.g., fistulas and abscesses), alleviation of systemic manifestations (e.g., arthritis), maintenance of remission from acute inflammation, or surgical palliation or cure. The approach to the therapeutic regimen differs considerably with varying goals as well as with the two diseases, ulcerative colitis and Crohn s disease. 

---