Ulcerative colitis: disease extension was common.

Clinical bottom line (level 2b)

  1. 60% of patients with ulcerative colitis had disease extension over 13 years.
  2. A third had surgery (mainly bowel resection).
  3. 17% had severe bleeding, 10% developed toxic dilatation, and 1% died.
  4. Systemic manifestations were uncommon: 8% had joint symptoms and 7% urinary stones.
  5. Disease extension was more likely in patients with:
    • toxic, fulminant or severe colitis (NNF = 2 for 13 years)
    • joint symptoms (NNF = 4 for 13 years)
    • left-sided disease at diagnosis (NNF = 5 for 13 years)
Farmer et al: Digestive Diseases and Sciences 1993; 38 (6): 1137-1146
Expires May 2003

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: university hospital, USA

1116 patients (aged mean 32 years, 55% male) with ulcerative colitis (confirmed by clinical findings, histology, endoscopy and radiography, and other forms of colitis excluded)

Excluded if
  • no assessment of extent of disease at initial examination
  • followed for < 5 years



    • Factors studied:
  • outcome, systemic manifestations
  • toxic, fulminant or severe colitis
  • left-sided disease extent at diagnosis
  • joint symptoms




    • Logistic regression analysis was performed to adjust for confounding factors.

    100% followed for mean 13 years
    Outcomes studied:
  • toxic, fulminant or severe colitis
  • toxic dilatation
  • bleeding
  • surgery
  • disease extension diagnosed on colonoscopy
  • death
  • systemic manifestations: joints
  • skin
  • liver
  • retarded growth
  • urolithiasis
  • cholelithiasis

    • Some of the patients were found prospectively.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    toxic, fulminant or severe colitis mean 13 years 141/1116 13%
    (11% to 15%)
    toxic dilatation mean 13 years 119/1116 11%
    (8.9% to 13%)
    bleeding mean 13 years 186/1116 17%
    (15% to 19%)
    surgery mean 13 years 420/1116 38%
    (35% to 41%)
    disease extension mean 13 years 506/828 61%
    (58% to 64%)
    death mean 13 years 11/1116 1.0%
    (0.41% to 1.6%)
    systemic manifestations: joints mean 13 years 95/1114 8.5%
    (6.9% to 10%)
    skin mean 13 years 38/1114 3.4%
    (2.3% to 4.5%)
    liver mean 13 years 15/1114 1.3%
    (0.7% to 2.0%)
    retarded growth mean 13 years 15/1114 1.3%
    (0.7% to 2.0%)
    urolithiasis mean 13 years 72/1114 6.5%
    (5.0% to 7.9%)
    cholelithiasis mean 13 years 46/1114 4.1%
    (3.0% to 5.3%)

    prognostic factor for
    disease extension     		time to outcome control rate (%) adjusted OR
    (95% CI)    		 NNF+
    (95% CI)
    toxic, fulminant or severe colitis ? 14.8
    (3.5 to 63.1)     		2
    (2 to 4)
    left-sided disease extent at diagnosis ? 2.5
    (1.6 to 3.9)     		5
    (4 to 9)
    joint symptoms ? 3.7
    (1.6 to 8.6)     		4
    (3 to 9)

    • 97% of operations were colectomy or ileostomy.

    Comments

    1. NNF calculated using total group rate as control rate - this will overestimate the NNF.

    Citation

    1. Farmer RG, Easley KA, Rankin GB: Clinical patterns, natural history and progression of ulcerative colitis: a long-term follow-up of 1116 patients. Digestive Diseases and Sciences 1993; 38 (6): 1137-1146
    Contributor: Chris Ball and Clare Wotton, September 2000
    Reviewer:

    Clinical Question.
    Patient ulcerative colitis
    Intervention or Exposure prevalence
    Outcome surgery, disease extension