Ulcerative Colitis: 5 Things to Know

Stephen B. Hanauer, MD


January 23, 2019

3. Clostridium difficile Infection Is Increasingly Problematic

There is an increasing incidence of Clostridium difficile infection (CDI) complicating UC over the past decade,[22] with a negative impact on the course of the disease, including increased rates of hospitalizations,[23] colectomies,[23] and death.[24,25] The risk for recurrent CDI is also substantially higher in patients with UC.[26] Risk factors for CDI in the setting of IBD include colitis, antibiotic exposure, and immune modulation (including biologics).[27]

The AGA recently published an expert opinion offering best-practice advice for managing CDI in patients with underlying IBD, including testing for CDI in patients who present with a flare of IBD; screening for recurrent CDI if symptoms persist or recur after antibiotic treatment; treating CDI with vancomycin instead of metronidazole; hospitalization for patients with IBD who have CDI and profuse diarrhea, severe abdominal pain, or marked leukocytosis; initiating therapy for CDI prior to escalation of steroids and other immunosuppressive agents during acute infection; and consideration of fecal microbiota transplantation for patients with recurrent CDI.[28]

We have several additional adages in our own practice, including a longer-term tapering of vancomycin for patients with the first course of CDI complicating UC who are being treated with corticosteroids, immunomodulators, or biologics, as well as ensuring that UC is remitted prior to attempting a microbial fecal transplant for patients with recurrent CDI.[29,30,31,32]

4. Mucosal Healing, However You Define It, Is an Effective Treatment Goal

With the advent of more effective therapies for UC, we have gained the ability to induce not only endoscopic normalization of the mucosa but also histologic normalization. Aiming for these therapeutic targets has improved outcomes, including reduction of clinical relapse,[33] hospitalizations, colectomies,[34,35] and most recently, the risk for neoplasia.[36,37] However, defining mucosal healing remains somewhat controversial.[38] Regulatory agencies are considering requisites of histologic healing to determine the validity of claims for mucosal healing in IBD.[39] In the setting of a "treat to target" algorithm, endoscopic and histologic healing remain an ultimate goal of medical therapies.[40]

5. New Approaches Are Reducing Cancer Risks

Over the last decade, a major accomplishment has been achieved by incorporating the assessment of disease activity, mucosal and histologic healing, and advances in surveillance. Indeed, patients with UC who achieve endoscopic and histologic remission and undergo regular surveillance examinations now have a risk for neoplasia that is comparable to that of the general population without UC.[41,42] This reduction is achieved regardless of whether high-definition colonoscopy, narrow-band imaging, or chromoendoscopy is used.[43,44] These observations are leading to an evolution in recommendations for increasing surveillance examination intervals for patients who have achieved endoscopic and particularly histologic healing.[45,46]

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