Ulcerative colitis: air enemas may help judge the depth of ulceration in acute attacks.

Clinical bottom line (level 4)

  1. Deep ulceration was common in patients with attacks of acute ulcerative colitis.
  2. Irregular mucosal contour, > 2 mm deep ulceration, or ulceration undermining the mucosa on air enema made deep ulceration more likely (LR+3.6) .
  3. Wide and shallow haustra or dehaustration on air enema made deep ulceration less likely (LR-0.040) , but could not safely exclude it.
Almer et al: Lancet 1996; 347: 1731-1735
Expires May 2003

The study

Setting: university hospital, Sweden

60 patients (aged range 13 to 82 years; median 35, 65% male) with acute attacks of ulcerative colitis who had colectomy
All patients had high-dose steroids (usually intravenous), and most had prednisolone enemas. Aminosalicylates were not given until some improvement had occurred. Parenteral nutrition was given to patients who lost weight.
Independent blinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
Reference standard:
  • histology following colectomy:
    • deep ulceration if extending into inner half of circular muscle (muscularis propria) or beyond
Diagnostic test: air enema (82% of patients) within 10 days of surgery: 500-800 ml air gently insufflated under fluoroscopic guidance:
  • severe if: irregular mucosal contour, > 2 mm deep ulceration, or ulceration undermining the mucosa
  • moderate: if wide and shallow haustra or dehaustration

  • Patients had colectomy if they had perforation, colonic dilatation, failure to improve on medical therapy or deep vein thrombosis.

The evidence

pre-test probability of deep ulceration: 67%, (95% CI: 54% to 81%)

diagnostic test deep ulceration shallow ulceration LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
severe changes with air enema 30 4 3.6
(1.6 to 8.6) 		88% 0.12
(0.040 to 0.37) 		20%
total 33 16

  • Patients with deep ulceration are more likely to suffer dilatation of the colon, but these signs have not been related to this outcome.

Citation

  1. Almer S, Bodemar G, Franzen L, et al: Use of air enema radiography to assess depth of ulceration during acute attacks of ulcerative colitis. Lancet 1996; 347: 1731-1735
Search Terms: colit* in Cochrane
Contributor: Chris Ball and Clare Wotton, October 2000
Reviewer:

Clinical Question.
Patient ulcerative colitis
Intervention or Exposure air enema
Outcome diagnosis of depth of ulceration