Predicting outcomes in acute severe ulcerative colitis

Abstract

Response to corticosteroid treatment in acute severe ulcerative colitis (ASUC) has changed very little in the past 50 years. Predicting those at risk at an early stage helps stratify patients into those who may require second line therapy or early surgical treatment. Traditionally, risk scores have used a combination of clinical, radiological and biochemical parameters; established indices include the ‘Travis’ and ‘Ho’ scores. Recently, inflammatory bowel disease genetic risk alleles have been built into models to predict outcome in ASUC. Given the multifactorial nature of inflammatory bowel disease pathogenesis, in the future, composite scores integrating clinical, biochemical, serological, genetic and other ‘-omic’ data will be increasingly investigated. Although these new genetic prediction models are promising, they have yet to supplant traditional scores, which remain the best practice. In this modern era of rescue therapies in ASUC, robust scoring systems to predict failure of ciclosporine and infliximab must be devised.

Keywords:

• acute severe colitis
• colectomy
• mortality
• outcomes
• ulcerative colitis

Financial & competing interests disclosure

NT Ventham is funded by EU FP7 Grant (IBD BIOM contract # 305479) and has received speakers fees from MSD; R Kalla is funded by EU FP7 Grant (IBD CHARACTER contract # 2858546); NA Kennedy is funded by the Wellcome Trust (WT097943MA) and has received speakers fees from MSD, Warner Chilcott and Ferring, and expenses to attend meetings from Norgine, Abbvie, MSD, Warner Chilcott, and Shire; J Satsangi has served as a speaker, a consultant and an advisory board member for MSD, Ferring Abbvie and Shire, consultant with Takeda, speaking fees from MSD and has received research funding from Abbvie; ID Arnott has been an advisory board member for Vifor and has had travel supported by Shire. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• Prediction scores assist the multidisciplinary clinical team to make important decisions regarding rescue therapy and surgery in a timely fashion, thereby preventing the increase in complications and mortality seen with delayed surgery without operating on those who will respond to medical therapy.

• Presently scoring systems encompassing clinical, biochemical and radiological parameters remain the mainstay of risk prediction in acute severe ulcerative colitis (ASUC) and outperform genetic and other recent biomarker-based scores.

• Stool frequency, temperature, heart rate, C-reactive protein, albumin, severe endoscopic appearances and radiological features are able to consistently predict outcome in ASUC.

• In adults, the Travis score, Ho score, Lindgren score and Seo index are among the most commonly used and best validated scores.

• In pediatric practice, the pediatric ulcerative colitis activity index is the best scoring system for children with ASUC.

• New scoring systems are required to predict response to rescue therapy in ASUC, and are likely to include similar parameters that are currently used to predict colectomy following intravenous corticosteroid treatment.

Notes