Residual Short-Segment Distal Inflammation Has No Significant Impact on the Major Relapse of Extensive Ulcerative Colitis

Abstract

Background Mucosal healing is a treatment target for patients with ulcerative colitis. However, the relevance of proactive treatment for residual inflammation limited to the distal colon is unclear. Materials and Methods Patients with ulcerative colitis who had extensive colitis in clinical remission and underwent colonoscopy were retrospectively enrolled and followed up for 2 years. Patients with complete endoscopic remission (CER; Mayo endoscopic subscore [MES] of 0) and those with short-segment distal inflammation (SS; active inflammation only in the sigmoid colon and/or rectum with a proximal MES of 0) were compared for the incidence of minor (only symptomatic) and major (need for induction treatments or hospitalization) relapses. Results A total of 91 patients with CER and 54 patients with SS were identified and 63 relapses (47 minor and 16 major) were analyzed. Univariate analysis showed that minor relapses were significantly more frequent in the SS group than in the CER group (hazard ratio [HR], 2.22; 95% confidence interval [CI], 1.25-3.97), but major relapses were not more frequent in the SS group than in the CER group (HR, 1.78; 95% CI, 0.65-4.83). Multivariable analysis showed that SS was the only risk factor significantly associated with minor relapse (HR, 2.38; 95% CI, 1.31-4.36). When the SS group was stratified by MES of 1 vs 2/3, minor relapses were significantly more frequent in the subgroup with MES of 2/3 than in the CER group, whereas the incidence of major relapse remained similar. Conclusions Residual short-segment distal inflammation is not a risk factor for major relapses as long as endoscopic remission is achieved in the proximal colon. Therefore, reactive but not proactive treatment may be appropriate for such lesions.

White Blood Cell Counts and Future Relapse in Ulcerative Colitis under Low-Dose Thiopurine Treatment in Real-World Practice: A 3-Year Japanese Multi-Center Retrospective Cohort Study

“…Clinical remission was assessed by the patient-reported outcome (PRO)-2 score, consisting of the rectal bleeding and stool sub-scores [ 23 ]. Clinical remission was defined as both “rectal bleeding sub-score = 0” and “stool sub-score ≤1” [ 24 ]. Patients with any following criterion were excluded: (1) proctitis, (2) after colectomy, (3) treated for UC other than thiopurine and/or 5-ASA (e.g., topical corticosteroids, systemic corticosteroids, tacrolimus, or Janus kinase inhibitors) within 1 month before the baseline, (4) under maintenance therapy with biologics, (5) past history of hematologic disorder, (6) pregnant woman, (7) after total gastrectomy, or (8) after ileocecal resection.…”

“…The primary outcome was the time to relapse, defined as the requirement of induction therapy for UC with the worsening of clinical symptoms [ 24 ]. The induction therapy included systemic corticosteroids, tacrolimus, cyclosporin A, leukocytapheresis, granulocyte and monocyte apheresis, biologic agents, Janus kinase inhibitor, indigo naturalis, any investigational new drug, or colectomy.…”

Letter: Modifying the Mayo endoscopic subscore for improved prognostic insights

“…We have previously reported that fewer than two endoscopically active (MES > 0) distal segments (sigmoid and/or rectum) yield a similar risk of clinically significant relapse to complete mucosal healing (MES of 0), while more than three inflamed segments carry a higher risk. 3 Additionally, Shimodaira et al 4 reported that inflammation limited to less than 3 cm exhibited a comparable clinical outcome to complete mucosal healing. These findings made us believe in the importance of considering the extent of active disease regardless of MES of 1-3.…”

The Prognostic Value of Residual Nonrectal Inflammation in Ulcerative Colitis

“…4,5 One study reported that residual short-segment distal inflammation is not a risk factor for major relapses, provided that endoscopic remission is achieved in the proximal colon. 6 I would like to raise a few questions to the authors of this study. First, the severity of nonrectal inflammation and rectal inflammation was significantly different (p<0.001) between the groups and there was a wide variation in Ulcerative Colitis Segmental Endoscopic Index (UCSEI) scores.…”

“… 4 , 5 One study reported that residual short-segment distal inflammation is not a risk factor for major relapses, provided that endoscopic remission is achieved in the proximal colon. 6 …”