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Ulcerative Colitis Practice Guidelines in Adults



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ACG PRACTICE GUIDELINES nature publishing group CME Ulcerative Colitis Practice Guidelines in Adults American College of Gastroenterology Practice Parameters Committee Asher Kornbluth MD1 David B Sachar MD MACG1 and The Practice Parameters Committee of the American College of Gastroenterology Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research Double blind placebo controlled studies are preferable but compassionate use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine When only data that will not withstand objective scrutiny are available a recommendation is identified as a consensus of experts Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem Guidelines are intended to be flexible and must be distinguished from standards of care which are inflexible and rarely violated Given the wide range of specifics in any healthcare problem the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees Each has been intensely reviewed and revised by the Committee other experts in the field physicians who will use them and specialists in the science of decision analysis The recommendations of each guideline are therefore considered valid at the time of composition based on the data available New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity The recommendations made are based on the level of evidence found Grade A recommendations imply that there is consistent level 1 evidence randomized controlled trials grade B indicates that the evidence would be level 2 or 3 which are cohort studies or case control studies Grade C recommendations are based on level 4 studies meaning case series or poor quality cohort studies and grade D recommendations are based on level 5 evidence meaning expert opinion Am J Gastroenterol 2010 105 501 523 doi 10 1038 ajg 2009 727 published online 12 January 2010 INTRODUCTION Ulcerative colitis UC is a chronic disease characterized by diffuse mucosal inflammation limited to the colon It involves the rectum in about 95 of cases and may extend proximally in a symmetrical circumferential and uninterrupted pattern to involve parts or all of the large intestine The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus The clinical course is marked by exacerbations and remissions which may occur spontaneously or in response to treatment changes or intercurrent illnesses 1 2 UC affects approximately 500 000 individuals in the United States with an incidence of 8 12 per 100 000 population per year the incidence has remained relatively constant over the last five decades 3 8 The disease accounts for a quarter million physician visits annually 30 000 hospitalizations and loss of over a million workdays per year 9 The direct medical costs alone exceed four billion dollars annually comprising estimated hospital costs of over US 960 million 10 11 and drug costs of 680 million 11 RECOMMENDATIONS FOR DIAGNOSIS AND ASSESSMENT In a patient presenting with persistent bloody diarrhea rectal urgency or tenesmus stool examinations and sigmoidoscopy or colonoscopy and biopsy should be performed to confirm the presence of colitis and to exclude the presence of infectious and noninfectious etiologies Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of UC 1 Dr Henry D Janowitz Division of Gastroenterology Samuel Bronfman Department of Medicine Mount Sinai School of Medicine New York New York USA Correspondence Asher Kornbluth MD The Dr Henry D Janowitz Division of Gastroenterology Samuel Bronfman Department of Medicine Mount Sinai Medical Center 1751 York Avenue New York New York 10128 USA E mail asher kornbluth mssm edu Received 2 February 2009 accepted 19 February 2009 2010 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY 501 502 Kornbluth and Sachar The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on proctosigmoidoscopy or colonoscopy biopsy and by negative stool examination for infectious causes 12 Inquiries should be made regarding factors that may potentially exacerbate symptoms of UC e g smoking cessation or nonsteroidal anti inflammatory drug use or possibly isotretinoin 13 16 Infections can also produce clinical findings indistinguishable from idiopathic UC so microbiologic studies for bacterial infection including specific assays for Escherichia coli 0157 H7 and parasitic infestation as well as serologic testing for ameba when clinical suspicion is high should be performed in each new patient 17 and should be considered in patients in remission or with mild stable symptoms who unexpectedly develop a severe or atypical exacerbation 18 19 Similarly patients who have recently been admitted to hospital or treated with antibiotics should have stools examined for Clostridium difficile although antibiotic associated diarrhea may be present even with a negative assay for C difficile toxin The incidence of C difficile is increasing in UC 20 23 and in inflammatory bowel disease IBD patients it is associated with a more severe course greater length of hospital stay higher financial costs greater likelihood of colectomy and increased mortality 22 24 Multiple stool assays may be required for diagnosis because of frequent falsenegative results 22 24 25 Proctosigmoidoscopy or colonoscopy will reveal the mucosal changes characteristic of UC consisting of loss of the typical vascular pattern granularity friability and ulceration 26 28 These changes typically involve the distal rectum both endoscopically and histologically 29 and proceed proximally in a symmetric continuous and circumferential pattern to involve all or part of the colon However isolated patchy cecal inflammation is


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