Clinical Pearls & Morning Reports
Appropriate initiation of effective therapy is important in older patients with inflammatory bowel disease, since the alternatives of persistent disease activity and long-term glucocorticoid use may themselves confer an increased risk of infection and of death. Read the Case Records of the Massachusetts General Hospital here.
Q: Name two parasitic diseases that can mimic ulcerative colitis.
A: Intestinal amebiasis is subacute, with bloody diarrhea lasting weeks to months, and is associated with imaging and endoscopic findings that mimic ulcerative colitis, specifically diffuse inflammation, friable mucosa, and ulcerations. Strongyloides stercoralis colitis is another parasitic infection that can resemble ulcerative colitis.
Q: Is there an association between cytomegalovirus (CMV) colitis and ulcerative colitis?
A: There is ample evidence of an association between CMV colitis and ulcerative colitis. CMV is frequently found in tissue specimens from patients with inflammatory bowel disease; whether the detection of CMV signifies the presence of CMV reactivation colitis is a matter of debate. CMV reactivation colitis is common among patients with ulcerative colitis who are treated with glucocorticoids. CMV colitis is known to complicate the course of inflammatory bowel disease, and testing for CMV is recommended in patients with worsening ulcerative colitis, presumably because of the affinity of CMV for inflamed mucosal surfaces.
A: The onset of inflammatory bowel disease traditionally occurs during young adulthood, but patients older than 65 years of age represent a growing fraction of all patients with inflammatory bowel disease, accounting for up to 15% of patients with new diagnoses and an even greater percentage of patients who are hospitalized for the condition. The likelihood that competing diagnoses — such as infection, ischemic colitis, and cancer —will be present is higher in this population than among younger patients, and therefore, it is important to retain a high index of suspicion for inflammatory bowel disease in a patient with relevant clinical features, since timely endoscopic investigation is essential to establish a diagnosis and reduce diagnostic delay. Although some studies suggest that the disease course may be milder in older patients because of immunosenescence, others conclude that older patients with inflammatory bowel disease, particularly ulcerative colitis, are more likely to undergo surgery within 1 year after diagnosis, the period of the most unstable disease activity.
A: In up to one third of patients with ulcerative colitis, a fulminant presentation known as acute severe ulcerative colitis develops at a median of 14 months after diagnosis, leading to hospitalization for the administration of intravenous glucocorticoids. The first step in the management of acute severe ulcerative colitis is the initiation of intravenous glucocorticoid therapy, but up to one third of affected patients do not have an adequate clinical response and receive rescue therapy with either infliximab or cyclosporine. Early, objective assessment of response, with initiation of rescue therapy within 3 to 5 days in patients who do not have a response, is the preferred approach. Among patients with ulcerative colitis who need emergency hospitalization, a delay in surgery is associated with worsened outcomes.