The Outcomes of Emergency Admissions With Ulcerative Colitis Between 2007 and 2017 in England

King, Dominic; Rees, James; Mytton, Jemma; Harvey, Philip; Thomas, Tom; Cooney, Rachel; Patel, Prashant; Trudgill, Nigel

doi:10.1093/ecco-jcc/jjz185

Cited by 26 publications

(27 citation statements)

References 34 publications

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“…31,34 Although randomised controlled trials (RCTs) do not suggest any difference in efficacy and safety between infliximab and cyclosporine as rescue therapies for steroid-refractory ASUC, 11,12 observational data suggest a lower risk of long-term colectomy with infliximab compared with cyclosporine. 3 This may be one of the reasons why infliximab is preferred over cyclosporine as rescue therapy but the experience of treating physicians and patient preferences, should also be taken into account. A theoretical advantage of infliximab over cyclosporine is that it is an easier treatment regimen with less monitoring and this may explain why many gastroenterologists are more familiar with infliximab than with cyclosporine.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 Although acute severe ulcerative colitis (ASUC) is a potentially life-threatening condition, its mortality rate has dropped dramatically over the past decades to approximately 1%. [3][4][5] This improved outcome is attributed to the introduction of intensive intravenous treatment (IIVT) with steroids and a policy of early surgery for non-responders. However, despite the use of steroids, at least 30% of patients fail to respond and, until recently, were candidates for colectomy.…”

Section: Introductionmentioning

confidence: 99%

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Long‐term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study

et al. 2021

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Background The long-term course of ulcerative colitis after a severe attack is poorly understood. Second-line rescue therapy with cyclosporine or infliximab is effective for reducing short-term colectomy but the impact in the long-term is controversial. Objective The purpose of this study was to evaluate the long-term course of acute severe ulcerative colitis patients who avoid early colectomy either because of response to steroids or rescue therapy. Methods This was a multicentre retrospective cohort study of adult patients with acute severe ulcerative colitis admitted to Italian inflammatory bowel disease referral centres from 2005–2017. All patients received intravenous steroids, and those who did not respond received either rescue therapy or colectomy. For patients who avoided early colectomy (within three months from the index attack), we recorded the date of colectomy, last follow-up visit or death. The primary end-point was long-term colectomy rate in patients avoiding early colectomy. Results From the included 372 patients with acute severe ulcerative colitis, 337 (90.6%) avoided early colectomy. From those, 60.5% were responsive to steroids and 39.5% to the rescue therapy. Median follow-up was 44 months (interquartile range, 21–85). Colectomy-free survival probability was 93.5%, 81.5% and 79.4% at one, three and five years, respectively. Colectomy risk was higher among rescue therapy users than in steroid-responders (log-rank test, p = 0.02). At multivariate analysis response to steroids was independently associated with a lower risk of long-term colectomy (adjusted odds ratio = 0.5; 95% confidence interval, 0.2–0.8), while previous exposure to anti-tumour necrosis factor alpha agents was associated with an increased risk (adjusted odds ratio = 3.0; 95% confidence interval, 1.5–5.7). Approximately 50% of patients required additional therapy or new hospitalization within five years due to a recurrent flare. Death occurred in three patients (0.9%). Conclusions Patients with acute severe ulcerative colitis avoiding early colectomy are at risk of long-term colectomy, especially if previously exposed to anti-tumour necrosis factor alpha agents or if rescue therapy during the acute attack was required because of steroid refractoriness.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Long‐term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study

et al. 2021

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“…The 2018 publication from Pollok's group, investigating nationwide temporal trends in medical and surgical admissions for IBD between 2003 and 2013, also suggests reducing elective surgery rates with non‐significant reductions in emergency surgery 17 . King et al, also using HES data, demonstrated a reduction in colectomies up to one year after emergency admission for UC between 2007 and 2017, but they do not state results beyond 29 . Bodger's group demonstrate widespread improvements in emergency UC admissions, including improvement in colectomy free discharge after emergency UC admissions during a similar time period to this study, but again focus on the emergency admission and early readmissions rather than longer term follow‐up 18 .…”

Section: Discussionmentioning

confidence: 99%

Colectomy rates for ulcerative colitis in England 2003‐2016

Worley

Almoudaris

Bassett

et al. 2020

Aliment Pharmacol Ther

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Summary Background Temporal trends in colectomy rate for ulcerative colitis (UC) are particularly relevant in the current era of published IBD standards and changing approach to salvage of acute severe disease. Aims To investigate temporal trends in colectomy for UC using English population data. Methods The Hospital Episode Statistics (HES) were interrogated between 2003‐2016 with two patient groups investigated independently. An ‘emergency’ cohort: emergency UC admission ≥ three days, age ≥18 and a ‘total population’ cohort: all English patients undergoing colectomy for UC. Mixed methods analyses were utilised. Results Emergency cohort: 37 981 patients, 49% female, median age 46. The one‐ and three‐year incidence of colectomy after acute admission was 0.17 and 0.21. Interrupted time series (ITS) analysis suggested reductions in colectomy rate of 4% per year after 2008 at 30 and 90 days following emergency admission, with no significant reduction ≥1 year. Mortality and laparoscopy rates improved when avoiding colectomy at index and emergency admissions; however, the proportion of emergency colectomies after salvage at index admission significantly increased during the study period. Total population cohort: 17 580 patients underwent colectomy for UC between 2003 and 2016, demonstrating a 3.1% annual reduction in total and elective colectomies after 2008, but no reduction in emergency colectomies. Conclusion Reductions in short‐term colectomy rates after emergency admission for UC do not persist beyond one year. Emergency colectomy rates remain unchanged. Reduced rates are probably due to multi‐modal improvements in IBD care. A lack of data regarding disease severity precludes further interpretation of appropriate medical salvage and timely surgery.

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“…We found no significant reduction in risk of further surgery for females. The phenomenon that males have been shown to be at increased risk of major abdominal surgery in CD has, however, been previously observed, 40 and we have previously shown a protective association of female sex in those with acute ulcerative colitis in relation to surgical intervention 41 . It may be that this study was underpowered to demonstrate a significant difference in the sexes.…”

Section: Discussionmentioning

confidence: 55%

The risk of later surgery at the anastomotic site following right hemicolectomy for Crohn's disease in a national cohort of 12 230 patients

King

Coupland

Dosanjh

et al. 2020

Aliment Pharmacol Ther

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SummaryBackgroundCrohn's disease (CD) has a high‐risk of bowel resection and later surgery for recurrent disease. Recent guidelines recommend colonoscopy 6‐12 months following surgery to reduce further surgical intervention through medical therapy intensification.AimsTo investigate the risk of further surgery at the anastomosis following right hemicolectomy for CD.MethodsHospital Episode Statistics were used to identify patients with CD and a right hemicolectomy between 2007 and 2016. Adherence to post‐resection colonoscopy guidance timing and risk of further surgery at the anastomosis were examined. Cox proportional hazards models assessed risk factors for further surgery.Results12 230 patients were identified: 45% male; median age 36 (IQR 26‐49) years. Median follow‐up was 5.9 (IQR 3.6‐8.6) years: totalling 74 960 person‐years. Median time to further surgery was 2.9 (IQR 1.2‐5.3) years. By 5 years 9% and by 10 years 16.9% of those with sufficient follow‐up had at least one further surgery involving the anastomotic site. Older, less deprived patients and those whose index surgery took place on an elective admission had a reduced risk of further surgery. The annual number of right hemicolectomies increased over the study from 1063 to 1317, driven by the increasing prevalence of CD. Overall, 78% of patients did not have a colonoscopy, as recommended, within 6‐12 months following index resection.ConclusionsFurther surgery involving the anastomotic site remains common following index right hemicolectomy for CD. Post‐surgical colonoscopy was only undertaken in 22% of patients within suggested timeframes. Increased colonoscopy may lead to a reduced need for surgery if early optimisation of medical therapy is undertaken for recurrence.

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The Outcomes of Emergency Admissions With Ulcerative Colitis Between 2007 and 2017 in England

Abstract: Abstract Background and Aims Patients with ulcerative colitis [UC] may present as emergencies and require rapid escalation of therapy. This study aimed to assess the mortality, colectomy, and readmission risks, during and following a first emergency admission with UC. Methods … Show more

Cited by 26 publications

References 34 publications

Long‐term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study

Long‐term outcomes of acute severe ulcerative colitis in the rescue therapy era: A multicentre cohort study

Colectomy rates for ulcerative colitis in England 2003‐2016

The risk of later surgery at the anastomotic site following right hemicolectomy for Crohn's disease in a national cohort of 12 230 patients

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