The peri-appendiceal red patch in ulcerative colitis: review of the University of Chicago experience.

BACKGROUND: Previous case series have described patients with a limited extent of ulcerative colitis (UC) and an area in the cecum with focal activity surrounding the appendiceal orifice ["peri-appendiceal red patch" (PARP)]. The clinical significance and prognostic implications of this finding are unknown. We used a tertiary care center database to review the clinical characteristics of UC patients with PARP. METHODS: Patients with a clinical diagnosis of UC, less than pancolitis, and in whom a PARP was described were identified and clinical characteristics were reviewed at the University of Chicago. RESULTS: Of the 622 UC patients, 367 did not have pancolitis. Twenty-nine (7.9%) patients had endoscopically described PARP. Of the 29 patients, 23 (79%) were male, eight had a history of smoking, and none had prior appendectomy. Twenty of 30 (67%) exams that obtained biopsies showed that the histologic activity in the PARP paralleled the activity of the distal colitis. Of the patients, 24 of 29 had a median of 8 years follow-up (range 2-16 years), and these patients had a disease duration of median 12 years (range 0.08-22 years). Eleven of 21 patients with endoscopic follow-up had progression of the extent of disease. CONCLUSIONS: We have confirmed the association of peri-appendiceal inflammation in a subset of patients with the otherwise clinical features of UC. The lack of appendectomy, male preponderance, and parallel histologic activity to the distal colitis are important observations that warrant further investigation into the potential relationship of PARP and UC.

Outcome after surveillance of low-grade and indefinite dysplasia in patients with ulcerative colitis.

BACKGROUND: The management of low-grade (LGD) and indefinite dysplasia (IND) in patients with ulcerative colitis (UC) remains controversial, as outcomes after a diagnosis of LGD or IND in previous studies vary widely. METHODS: All patients evaluated were from a single institution referral center who had a history of UC and a diagnosis of either LGD or IND between 1994 and 2008 as confirmed by 2 expert gastrointestinal (GI) pathologists. Data were collected by chart review of electronic and paper medical records. All patients who did not undergo a colectomy within 90 days of their dysplasia diagnosis were included in the final analysis. Hazard ratios for risk factors as well as incidence rates and Kaplan-Meier estimates were used to calculate the progression to high-grade dysplasia (HGD) or colorectal cancer (CRC). RESULTS: Thirty-five patients were included in the analysis, of whom 2 patients with IND and 2 patients with LGD developed HGD or CRC over a mean duration of 49.8 months. In total, the incident rate for advanced neoplasia for all patients was 2.7 cases of HGD or CRC per 100 person-years at risk. For flat and polypoid LGD the incident rate of advanced neoplasia was 4.3 and 1.5 cases per 100 person-years at risk, respectively. Patients with primary sclerosing cholangitis (PSC) had an incident rate of 10.5 cases per 100 years of patient follow-up. CONCLUSIONS: We report a low rate of progression to HGD or CRC in patients who underwent surveillance for LGD or IND; polypoid dysplasia showed less risk of progression than flat dysplasia.

Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?

BACKGROUND: Dysplasia and colorectal cancer (CRC) in ulcerative colitis (UC) develop via pathways distinct from sporadic CRC and may occur in flat mucosa indistinct from surrounding tissue. Surveillance guidelines, therefore, have emphasized the ;roach of periodic endoscopic examinations and systematic random biopsies of involved mucosa. Given the imperfect nature of this random approach, recent work has focused on improved surveillance techniques and suggests that neoplasia is endoscopically visible in many patients. OBJECTIVE: To assess the endoscopic visibility of dysplasia and CRC in UC. DESIGN: This was a retrospective review that used the University of Chicago Inflammatory Bowel Disease Registry and the clinical administrative database. All cases of dysplasia or CRC in UC between November 1994 and October 2004 were identified. The approach to surveillance in these patients included both random biopsies at approximately 10-cm intervals throughout the involved colon and directed biopsies of polypoid lesions, masses, strictures, or irregular mucosa distinct from surrounding inflamed tissue. Findings on endoscopy were compared with pathologic findings from biopsy or surgical specimens. Visible dysplasia was defined as a lesion reported by the endoscopist that led to directed biopsy and that was confirmed by pathology. Invisible dysplasia was defined as dysplasia diagnosed on pathology but not described on endoscopy. Per-lesion and per-patient sensitivities were determined. SETTING: Tertiary referral center. PATIENTS: Database of patients with inflammatory bowel disease seen at the University of Chicago. MAIN OUTCOME MEASUREMENTS: Endoscopically visible neoplasia. RESULTS: In this database, there were 1339 surveillance examinations in 622 patients with UC. Forty-six patients were found to have dysplasia or CRC at a median age of 48 years and with median duration of disease of 20 years. Of these patients, 77% had pancolitis, 21% had left-sided colitis, and 2% had proctitis. These patients had 128 surveillance examinations (median 3 per patient; range, 1-9 per patient), and, in 51 examinations, 75 separate dysplastic or cancerous lesions were identified (mean, 1.6 lesions per patient; standard deviation, 1.3). Thirty-eight of 65 dysplastic lesions (58.5%) and 8 of 10 cancers (80.0%) were visible to the endoscopist as 23 polyps and masses, 1 stricture, and 22 irregular mucosa. The per-patient sensitivities for dysplasia and for cancer were 71.8% and 100%, respectively. The overall per-lesion and per-patient sensitivities were 61.3% and 76.1%, respectively. LIMITATIONS: Retrospective review of clinical databases and medical records. CONCLUSIONS: Dysplasia and cancer in UC are endoscopically visible in most patients and may be reliably identified during scheduled examinations. Future surveillance guidelines should incorporate this information.