Considerable conflicting data have been published regarding complication rates following medical and surgical intervention in patients with indeterminate colitis versus ulcerative colitis. Some centers reported that indeterminate colitis was more refractory to medical interventions than ulcerative colitis, resulting in a greater relapse rate29 and subsequent need for colectomy.30 Colectomy rates averaged 36.1/1000 person-years in patients with indeterminate colitis versus only 7.5 for those with definite ulcerative colitis.30 In contrast, Witte et al described similar response rates to medical intervention in indeterminate colitis and ulcerative colitis.31 The European Collaborative Study on Inflammatory Bowel Disease (EC-IBD) reported 'complete relief of complaints' in 48% of ulcerative colitis patients versus 50% of those with indeterminate colitis; in addition, 37% of patients with ulcerative colitis 'improved' versus 33% with indeterminate colitis.31 Similarly, higher rates of pouch failure after ileal pouch-anal anastomosis (IPPA)32,33 and colorectal cancer34 have been reported by some groups, while others have reported lower rates of pouchitis for indeterminate colitis (29%) than ulcerative colitis (58%) and Crohn's disease (72%). However, this latter group observed a greater frequency of fistulae after IPAA in patients with indeterminate colitis (26%) versus for ulcerative colitis (10%).35 Post-IPAA complications resulting in pouch removal were higher for indeterminate colitis (19-28%) versus ulcerative colitis (0.4-8%) in some studies32,33 but not in others.35-37
It is our practice to repeat colonoscopy, usually with concurrent EGD, during selected periods of relapse to assess whether histological changes consistent with ulcerative colitis or Crohn's disease have developed. This is especially the case if colectomy and IPAA are being considered because of refractory disease. At this time, repeat small-bowel X-ray is usually obtained so that patients with ileal Crohn's disease would be excluded and patients with persistent indeterminate colitis would be counseled regarding the potentially greater risk of pouch complications. Often, patients with indeterminate colitis undergo a multi-staged operative procedure consisting of a subtotal colectomy with temporary ileostomy and Hartmann pouch. In this way, the entire resected colon can be assessed to exclude Crohn's disease prior to creating the IPAA.36
- Marion JF, Rubin TH, Present DH. Differential diagnosis of chronic ulcerative colitis and Crohn disease. In Kirsner JB, ed. Inflammatory Bowel Disease, 5th edn. Philadelphia: WB Saunders, 2000: 315-325.
- Shivananda S, Lennard-Jones J, Logan R et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut 1996; 39: 690-697.
- Hildebrand H, Brydolf M, Holmquist L et al. Incidence and prevalence of inflammatory bowel disease in children in southwestern Sweden. Acta Paediatr 1994; 83: 640-645.
- Gupta P, Hart J, Kirschner BS. Perinuclear antineu-trophilic cytoplasmic antibodies (pANCA) and anti-Saccharomyces cerevisiae (ASCA) antibodies in children with indeterminate colitis (abstract). Gastroenterology 2000; 118: 103, A687.
- Heikenen JB, Werlin SL, Brown CW et al. Presenting symptoms and diagnostic lag in children with inflammatory bowel disease. Inflamm Bowel Dis 1999; 5: 158-160.
- Kirschner BS, Heyman MB, Clemons T et al. The Pediatric IBD Consortium Database - initial demographic data. Gastroenterology 2002; 122: A-611.
- Geboes K, DeHertogh G. Indeterminate colitis. Inflamm Bowel Dis 2003; 9: 324-331.
- Joossens S, Reinisch W, Vermeire S et al. The value of serologic markers in indeterminate colitis: a prospective follow-up. Gastroenterology 2002; 122: 1242-1247.
- Moum B, Ekbom A, Vatn MH et al. Inflammatory bowel disease: re-evaluation of the diagnosis in a prospective population based study in south eastern Norway. Gut 1997; 40: 328-332.
- Meucci G, Bortoli A, Riccioli FA et al. Frequency and clinical evolution of indeterminate colitis: a retrospective multi-centre study in northern Italy. GSMII (Gruppo di Studio per le Malattie Infiammatorie Intestinali). Eur J Gastroenterol Hepatol 1999; 11: 909-913.
- Wells AD, McMillan I, Price AB et al. Natural history of indeterminate colitis. Br J Surg 1991; 78: 179-181.
- Kundhal PS, Stormon MO, Zachos M et al. Gastric antral biopsy in the differentiation of pediatric colitides. Am J Gastroenterol 2003; 98: 557-561.
- Mamula P, Telega GW, Markowitz JE et al. Inflammatory bowel disease in children 5 years of age and younger. Am J Gastroenterol 2002; 97: 2005-2010.
- Hassan K, Cowan FJ, Jenkins HR. The incidence of childhood inflammatory bowel disease in Wales. Eur J Pediatr 2000; 159: 261-263.
- Stewenius J, Adnerhill I, Ekelund GR et al. Ulcerative colitis and indeterminate colitis in the city of Malmo, Sweden. A 25-year incidence study. Scand J Gastroenterol 1995; 30: 38-43.
- Riddell RH. Pathology of idiopathic inflammatory bowel disease. In Kirsner JB, ed. Inflammatory Bowel Disease, 5th edn. Philadelphia: WB Saunders, 2000: 439-441.
- Farmer M, Petras RE, Hunt LE et al. The importance of diagnostic accuracy in colonic inflammatory bowel disease. Am J Gastroenterol 2000; 95: 3184-3188.
- Lenaerts C, Roy CC, Vaillancourt M et al. High incidence of upper gastrointestinal tract involvement in children with Crohn disease. Pediatrics 1989; 83: 777-781.
- Cucchiara S, Celentano L, deMagistris TM et al. Colonoscopy and technetium99m white cell scan in children with suspected inflammatory bowel disease. J Pediatr 1999; 135: 727-732.
- Durno CA, Sherman P, Williams T et al. Magnetic resonance imaging to distinguish the type and severity of pediatric inflammatory bowel diseases. J Pediatr Gastroenterol Nutr 2000; 30: 170-174.
- Laghi A, Borrelli O, Paolantonio P et al. Contrast enhanced magnetic resonance imaging of the terminal ileum in children with Crohn disease. Gut 2000; 52: 393-397.
- Kangas E, Matikainen M, Mattila J. Is 'indeterminate colitis' Crohn disease in the long-term follow-up? Int Surg 1994; 79: 120-123.
- Kirschner BS. Indeterminate colitis. Implications for management: medical approach. Inflamm Bowel Dis 2000; 6: 516-517.
- Kirschner BS. The safety of azathioprine and 6-mercap-topurine in children and adolescents with inflammatory bowel disease. Gastroenterology 1998; 115: 813-821.
- Fraser AG, Orchard TR, Jewell DP. The efficacy of azathioprine for the treatment of inflammatory bowel disease: a 30-year review. Gut 2002; 50: 485-489.
- Fellerman K, Tanko Z, Herrlinger KR et al. Response of refractory colitis to intravenous or oral tacrolimus (FK506). Inflamm Bowel Dis 2002; 8: 317-324.
- Bariol C, Meagher AP, Vickers CR et al. Early studies on the safety and efficacy of thalidomide for symptomatic inflammatory bowel disease. J Gastroenterol Hepatol 2002; 17: 135-139.
- Mamula P, Markowitz JE, Brown KA et al. Infliximab as a novel therapy for pediatric ulcerative colitis. J Pediatr Gastroenterol Nutr 2002; 34: 307-311.
- Stewenius J, Adnerhill I, Ekelund GR et al. Risk of relapse in new cases of ulcerative colitis and indeterminate colitis. Dis Colon Rectum 1996; 39: 1019-1025.
- Stewenius J, Adnerhill I, Ekelund GR et al. Operations in unselected patients with ulcerative colitis and indeterminate colitis. A long-term follow-up study. Eur J Surg 1996; 162: 131-137.
- Witte J, Shivananda S, Lennard-Jones et al. Disease outcome in inflammatory bowel disease: mortality, morbidity and therapeutic management of 796-person inception cohort in the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Scand J Gastroenterol 2000; 35: 1272-1277.
- Koltun WA, Schoetz DJJ Jr, Roberts PL et al. Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis. Dis Colon Rectum 1991; 34: 857-860.
- McIntyre PB, Pemberton JH, Wolff BG et al. Indeterminate colitis. Long-term outcome in patients after ileal pouch-anal anastomosis. Dis Colon Rectum 1995; 38: 51-54.
- Stewenius J, Adnerhill I, Ekelund GR et al. Incidence of colorectal cancer and all cause mortality in non-selected patients with ulcerative colitis and indeterminate colitis in Malmo, Sweden. Int J Colorectal Dis 1995; 10: 117-122.
- Rudolph WG, Uthoff SM, McAuliffe TL et al. Indeterminate colitis: the real story. Dis Colon Rectum 2002;45:1528-1534.
- Marcello PW, Schoetz DJ, Rogers PL et al. Evolutionary changes in the pathologic diagnosis after the ileoanal pouch procedure. Dis Colon Rectum 1997; 40: 263-269.
- Gramlich T, Delaney CP, Lynch AC et al. Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis. Colorectal Dis 2003; 5: 315-319.
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