IBD Unit, San Filippo Neri Hospital, Rome, Italy.
Gastroenterology Unit, AO San Camillo Forlanini, Rome, Italy.
United European Gastroenterol J. 2021 May;9(4):507-516. doi: 10.1177/2050640620977405. Epub 2021 Feb 16.
The long-term course of ulcerative colitis after a severe attack is poorly understood. Second-line rescue therapy with cyclosporine or infliximab is effective for reducing short-term colectomy but the impact in the long-term is controversial.
The purpose of this study was to evaluate the long-term course of acute severe ulcerative colitis patients who avoid early colectomy either because of response to steroids or rescue therapy.
This was a multicentre retrospective cohort study of adult patients with acute severe ulcerative colitis admitted to Italian inflammatory bowel disease referral centres from 2005 to 2017. All patients received intravenous steroids, and those who did not respond received either rescue therapy or colectomy. For patients who avoided early colectomy (within 3 months from the index attack), we recorded the date of colectomy, last follow-up visit or death. The primary end-point was long-term colectomy rate in patients avoiding early colectomy.
From the included 372 patients with acute severe ulcerative colitis, 337 (90.6%) avoided early colectomy. From those, 60.5% were responsive to steroids and 39.5% to the rescue therapy. Median follow-up was 44 months (interquartile range, 21-85). Colectomy-free survival probability was 93.5%, 81.5% and 79.4% at 1, 3 and 5 years, respectively. Colectomy risk was higher among rescue therapy users than in steroid-responders (log-rank test, p = 0.02). At multivariate analysis response to steroids was independently associated with a lower risk of long-term colectomy (adjusted odds ratio = 0.5; 95% confidence interval, 0.2-0.8), while previous exposure to antitumour necrosis factor-α agents was associated with an increased risk (adjusted odds ratio = 3.0; 95% confidence interval, 1.5-5.7). Approximately 50% of patients required additional therapy or new hospitalisation within 5 years due to a recurrent flare. Death occurred in three patients (0.9%).
Patients with acute severe ulcerative colitis avoiding early colectomy are at risk of long-term colectomy, especially if previously exposed to antitumour necrosis factor-α agents or if rescue therapy during the acute attack was required because of steroid refractoriness.
重度溃疡性结肠炎发作后的长期病程尚不清楚。二线环孢素或英夫利昔单抗挽救治疗对降低短期结肠切除率有效，但长期疗效存在争议。
本研究旨在评估避免早期结肠切除的急性重度溃疡性结肠炎患者的长期病程，这些患者要么对类固醇有反应，要么接受挽救治疗。
这是一项多中心回顾性队列研究，纳入了 2005 年至 2017 年期间意大利炎症性肠病转诊中心收治的急性重度溃疡性结肠炎成年患者。所有患者均接受静脉注射类固醇治疗，对无反应者给予挽救治疗或结肠切除。对于避免早期结肠切除（从指数发作后 3 个月内）的患者，我们记录了结肠切除、最后一次随访或死亡的日期。主要终点是避免早期结肠切除的患者的长期结肠切除率。
纳入的 372 例急性重度溃疡性结肠炎患者中，337 例（90.6%）避免了早期结肠切除。其中，60.5%对类固醇有反应，39.5%对挽救治疗有反应。中位随访时间为 44 个月（四分位距，21-85）。无结肠切除生存概率分别为 1、3 和 5 年时的 93.5%、81.5%和 79.4%。挽救治疗组的结肠切除风险高于类固醇反应组（对数秩检验，p=0.02）。多变量分析显示，对类固醇的反应与较低的长期结肠切除风险相关（调整比值比=0.5；95%置信区间，0.2-0.8），而先前暴露于抗肿瘤坏死因子-α药物与较高的风险相关（调整比值比=3.0；95%置信区间，1.5-5.7）。约 50%的患者在 5 年内因复发发作需要额外的治疗或再次住院。3 例患者死亡（0.9%）。
避免早期结肠切除的急性重度溃疡性结肠炎患者有发生长期结肠切除的风险，尤其是那些先前暴露于抗肿瘤坏死因子-α药物或因类固醇抵抗而在急性发作期间需要挽救治疗的患者。
