Risk Factors Predicting Severe Ulcerative Colitis

By Dr. Adam Weizman

Risk factors

Ulcerative colitis (UC) is chronic inflammatory condition of the large intestine, also known as the colon. It results in inflammation in the inner lining of the colon and rectum which can result in a number of symptoms such as bloody diarrhea, cramping, and urgency.

The symptoms of UC vary by person and range from mild, with long periods between flare-up of symptoms (called remission), to severe symptoms that can result in frequent hospitalizations and have a major impact on peoples quality of life. In some individuals, poor prognostic factors are present that may indicate a more severe disease course. Identifying those with a high risk of severe disease course is important because it may allow the physician to consider a more proactive approach early in treatment to avoid or delay potential complications that may develop.

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Some of these risk factors include:

Being diagnosed with UC at an early age

Ulcerative colitis diagnosed at an early age has been shown to be a reliable predictor of a more complicated disease course that might warrant an increased need for early immunosuppressive treatment. Approximately 20-30% of UC diagnoses occur in persons aged 20 years or younger. In most studies, UC incidence peaks between adolescence and early adulthood. In contrast, there is some research that indicates a later diagnosis is associated with worse outcomes. But, generally speaking, those diagnosed with UC at age 45 and older experience fewer relapses.

Early hospitalization

Patients that required hospitalization at diagnosis have been shown to be more likely to have a severe course of UC and need immunosuppressive therapy early in the treatment process. Early hospitalization is also a risk factor for a future colectomy (surgical removal of the colon).

Steroid use early in the course of treatment

Early use of corticosteroids (commonly called steroids) in treatment is also a predictor of severe disease. Corticosteroids are powerful anti-inflammatory drugs used for treating ulcerative colitis Because they carry significant side effects, steroids are typically reserved for those with moderate-to-severe disease or those who relapse after other therapies. They can be very effective short term therapies, but avoiding long or repeated treatments with corticosteroid is an important goal in treating UC. Other medications can help reduce the need for corticosteroids.

Treatment considerations

About one-third of patients has a severe course of UC and will not respond to medications. In these patients, surgery may be necessary to remove the sick colon. Surgery is also needed if there are pre-cancerous changes noted on colonoscopy (called dysplasia) since longstanding UC is associated with an increased risk of colon cancer. Rarely, emergency surgery is needed to remove the colon in or to address hemorrhage, perforation of the colon, or toxic megacolon (rapid swelling of the large intestine that can be life-threatening). Surgery usually involves the removal of the colon and formation of an ileal pouch.

Even with severe symptoms, there is no standard regimen for managing UC and treatment must be customized to each individual. The early introduction of immunosuppressive agents or biologic therapies (e.g. anti-tumor necrosis factor (TNF)) may have a positive influence on the course of UC. Immunosuppressant drugs suppress or limit actions of the immune system and therefore the inflammatory response that causes UC. The use of anti-tumor necrosis factor (TNF) targets the inflammatory immune response. Early identification of risk factors for severe disease with immunosuppressive or biologic treatments may alter the course of UC and delay or prevent related complications.

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Patients with risk factors indicating a possible poor prognosis should discuss with their doctor the advantages and disadvantages of a more proactive treatment strategy if these risk factors are present.

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