Surgical Management of Ulcerative Colitis

There is a common agreement has been reached by the Consensus about frequently used terms. Such terms reflect clinical decision-making and are considered helpful as a consequence. Ulcerative colitis (UC) is a chronic inflammatory condition causing continuous mucosal inflammation of the colon without granulomas on biopsy, affecting the rectum and a variable extent of the colon in continuity, which is characterized by a relapsing and remitting course,⁽¹⁾.

IBD unclassified (IBDU) is the term best suited for the minority of cases where a definitive distinction between UC, Crohn's disease, or other cause of colitis cannot be made after the history, endoscopic appearances histopathology of multiple mucosal biopsies and appropriate radiology have been taken into account, ⁽¹⁾.

 Indeterminate colitis is a term reserved for pathologists to describe a colectomy specimen which has overlapping features of ulcerative colitis and Crohn's disease. It has distinct prognostic factors related to further surgery, ⁽¹⁾.

Distribution of disease:  The Consensus favors use of the Montréal classification, (Table1) for defining the distribution of disease, (Table 2). This is used to describe the maximal, macroscopic extent of disease at colonoscopy. The implications of more extensive microscopic disease are still not understood, ⁽²⁾.

Disease onset: There is some evidence to suggest that patients with UC stratified by age (A1: <16; A2:16–40 and A3: >40 years) have different outcomes. Patients diagnosed before the age of 16 had a more aggressive initial course, while older age at diagnosis was found to be associated with a lower risk of colectomy. There is also some evidence that UC diagnosed in the very young has a different etiology and prognosis, ⁽²⁾.

 Active disease: Clinical disease activity is grouped into remission, mild, moderate and severe. This refers to biological activity and not to treatment-responsiveness. Our Consensus participants considered Truelove and Witts' criteria useful in clinical practice (Table 3), in conjunction with sigmoidoscopy to confirm active colitis. However, there is other classifications frequently used specially by gastroenterologists, ⁽¹⁾.

The term severe colitis (or ‘acute severe colitis’) is preferred to ‘fulminant’ colitis, because the term ‘fulminant’ is ill-defined. Severe colitis as defined according to Truelove and Witts' criteria is easy to apply in outpatients, mandates hospital admission for intensive treatment and defines an outcome (only 70% respond to intensive therapy) , ⁽¹⁾.

Moderate colitis has become necessary to distinguish from mildly active disease, because the efficacy of some treatments may differ. The simplest clinical measure to distinguish moderate from mildly active colitis is the presence of mucosal friability (bleeding on light contact with the rectal mucosa at sigmoidoscopy). The technique of assessing mucosal friability at flexible sigmoidoscopy has yet to be standardized, ⁽¹⁾.

Remission is defined as complete resolution of symptoms and endoscopic mucosal healing. In clinical practice, there is an agreement that ‘remission’ meant a stool frequency ≤3/day with no bleeding and no urgency. Remission defined by individual patients has an 86% sensitivity and 76% specificity for a regulatory-defined remission (absence of visible blood and absent mucosal friability), indicating that sigmoidoscopy to confirm mucosal healing is generally unnecessary in practice, ⁽³⁾.

Response is defined as clinical and endoscopic improvement, depending on the activity index used (table 4). In general, this means a decrease in the activity index plus a decrease in the rectal bleeding and endoscopy sub-scores, ⁽³⁾.

Relapse: The term relapse is used to define a flare of symptoms in a patient with established UC who is in clinical remission, either spontaneously or after medical treatment. Rectal bleeding an essential component of relapse, and we believe that a combination of rectal bleeding with an increase in stool frequency and abnormal mucosa at sigmoidoscopy was necessary to define relapse. In clinical trials, the criteria for relapse should be predefined with the score that is being used for an individual study.

Early relapse an arbitrary, but clinically relevant period of 3 months after achieving remission on previous therapy defines early relapse. The therapeutic significance needs to be defined.  Pattern of relapse may be infrequent (≤1/year), frequent (≥2relapses/ year), or continuous (persistent symptoms of active UC without a period of remission). Although the terms are arbitrary, they are considered clinically relevant and care should be taken to distinguish between terms that describe disease activity at a point in time and those that describe the longitudinal pattern (or ‘behavior’) of the disease), ⁽³⁾.

The term ‘chronic active disease’ has been used in the past to define a patient who is dependent on, refractory to, or intolerant of steroids, or who has disease activity despite immunomodulators. Since this term is ambiguous it is best avoided. Instead, arbitrary, but more precise definitions are preferred, including steroid refractory or steroid-dependence.

Steroid-refractory colitis: Patients who have active disease despite prednisolone up to 0.75 mg/kg/day over a period of 4 weeks. The definition is consistent with the definition for steroid-refractory Crohn's disease; however, it is likely to evolve, with a reduction in the duration of steroid therapy as the threshold for biologic therapy changes.

 Steroid-dependent colitis: Patients who are either unable to reduce steroids below the equivalent of prednisolone 10 mg/day within 3 months of starting steroids, without recurrent active disease, or who have a relapse within 3 months of stopping steroids. As with steroid-refractoriness, the definition is likely to evolve as the threshold for biologic therapy changes. There is an agreement that steroid-dependence requires that the total duration of steroids does not exceed 3 months before a threshold equivalent to prednisolone 10 mg/day is reached. Patients are still considered steroid-dependent if they relapse within 3 months of stopping steroids. Although these limits are arbitrary, they serve as guidance for clinical practice and may be used for uniformity in clinical trials. The aim should be to withdraw steroids completely, ⁽³⁾.

Immunomodulator-refractory colitis: Patients who have active disease or relapse in spite of thiopurines at an appropriate dose for at least 3 months (i.e. azathioprine 2–2.5 mg/kg/day or mercaptopurine 1 1.5 mg/kg/day in the absence of leucopenia). The definition is arbitrary, but has increasing clinical relevance when deciding on the place of biological therapy or surgery.

Refractory distal colitis defined as persistent symptoms due to colonic inflammation confined to the rectum (proctitis), or left-side of the colon, despite treatment with oral plus topical steroids and 5ASAs for 4–8 weeks. This represents a common clinical dilemma, although whether it is a separate entity is unclear, ⁽³⁾.

New patient: A patient with active UC presenting at, or shortly after diagnosis, with no previous therapy for UC