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CME

Ulcerative Colitis in Adults

General Information

Description

  • chronic, inflammatory disease involving mucosa of the rectum, and proximal extension into colon toward cecum1

Also called

  • UC

Definitions

  • inflammatory bowel disease (IBD) includes both ulcerative colitis and Crohn disease in adults1
  • fulminant colitis2
    • sudden onset of severe and frequent (> 10 per day) bloody bowel movements
    • abdominal pain
    • dehydration
    • anemia
    • ≥ 2 of following symptoms
      • tachycardia
      • leukocytosis (> 10,500/mm3)
      • body temperature > 38.6 degrees C (101.5 degrees F)
      • hypoalbuminemia
  • toxic megacolon2,3
    • clinical diagnosis of significant colon dilatation (total or segmental nonobstructive dilation of at least 6 cm) with symptoms of fulminant colitis
    • may represent flare in patient with longstanding disease or can be initial presentation
    • may involve entire colon or isolated segment (usually transverse or left colon)
    • radiographic definition - dilatation of transverse colon > 5.5-6 cm on supine abdominal film

Types

  • distal ulcerative colitis - disease limited to below the descending colon, therefore potentially within reach of rectal therapy3
  • extensive ulcerative colitis - disease extending proximal to descending colon, therefore requiring systemic therapy3
  • ulcerative colitis often classified by extent of disease (rectum always involved and disease extends in contiguous fashion proximally)

References

General references used

  1. Feuerstein JD, Cheifetz AS. Ulcerative colitis: epidemiology, diagnosis, and management. Mayo Clin Proc. 2014 Nov;89(11):1553-63
  2. Grucela A, Steinhagen RM. Current surgical management of ulcerative colitis. Mt Sinai J Med. 2009 Dec;76(6):606-12
  3. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010 Mar;105(3):501-23, correction can be found in Am J Gastroenterol 2010 Mar;105(3):500
  4. Bernstein CN, Fried M, Krabshuis JH, et al. World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis. 2010 Jan;16(1):112-24
  5. Ross H, Steele SR, Varma M, et al; Standards Practice Task Force American Society of Colon and Rectal Surgeons. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014 Jan;57(1):5-22PDF
  6. Talley NJ, Abreu MT, Achkar JP, et al; American College of Gastroenterology IBD Task Force. An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am J Gastroenterol. 2011 Apr;106 Suppl 1:S2-25

Recommendation grading systems used

  • American Gastroenterological Association (AGA) uses Grading of Recommendation Assessment, Development, and Evaluation (GRADE) system for recommendations
    • strength of recommendations
      • Strong - most individuals should receive recommended course of action
      • Conditional - different choices will be appropriate for different patients
      • No recommendation - confidence in effect estimate is so low that any recommendation is speculative
    • levels of evidence
      • High-quality - very confident that true effect lies close to that of estimate of effect
      • Moderate-quality - moderately confident in effect estimate; true effect is likely to be close to estimate of the effect, but there is possibility that it is substantially different
      • Low-quality - confidence in effect estimate limited; true effect may be substantially different from estimate of effect
      • Very low-quality - very little confidence in effect estimate; true effect is likely to be substantially different from estimate of effect
  • American College of Gastroenterology (ACG) levels of recommendations
    • Grade A - consistent level 1 evidence (randomized controlled trials)
    • Grade B - level 2 or 3 evidence (cohort or case-control studies)
    • Grade C - level 4 studies (case series or poor-quality cohort studies)
    • Grade D - level 5 evidence (expert opinion)
    • Reference - ACG practice guideline on ulcerative colitis in adults (mnh20068560pmdc20068560pAm J Gastroenterol 2010 Mar;105(3):501)
  • American College of Gastroenterology (ACG) 2011 grading system for recommendations
    • strength of recommendation
      • Strong recommendation - benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients
      • Weak recommendation - benefits and risks closely balanced and/or uncertain
    • quality of evidence grades
      • High-quality evidence - randomized trials without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      • Moderate-quality evidence - downgraded randomized trials or upgraded observational studies
      • Low-quality evidence - well-done observational studies or randomized trials with many limitations
      • Very low-quality evidence - case series or expert opinion
    • Reference - ACG evidence-based systematic review on medical therapies for inflammatory bowel disease (mnh21472012pmdc21472012pAm J Gastroenterol 2011 Apr;106 Suppl 1:S2)
  • American Society of Colon and Rectal Surgeons (ASCRS) grading system for recommendations
    • strength of recommendation grades
      • Grade 1 - strong recommendation - benefits clearly outweigh risks and burdens (or vice versa) for most, if not all, patients
      • Grade 2 - weak recommendation - benefits and risks closely balanced and/or uncertain
    • quality of evidence grades
      • Level A - high-quality evidence - randomized trials without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      • Level B - moderate-quality evidence - downgraded randomized trials or upgraded observational studies
      • Level C - low- or very low-quality evidence - observational studies or case series
  • European Crohn′s and Colitis Organization (ECCO) uses the Oxford Centre for Evidence-Based Medicine 2011 grading system for evidence and recommendations
    • Level 1
      • treatment benefits - systematic review of randomized trials or n-of-1 trials
      • common treatment harms - systematic review of randomized trials, systematic review of nested case-control studies, n-of-1 trial with patient the question is raised about, or observational study with dramatic effect
      • rare treatment harms - systematic review of randomized trials or n-of-1 trial
    • Level 2
      • treatment benefits - randomized trial or observational study with dramatic effect
      • common treatment harms - individual randomized trial or observational study with exceptionally dramatic effect
      • rare treatment harms - randomized trial
    • Level 3
      • treatment benefits - nonrandomized controlled cohort/follow-up study
      • common and rare treatment harms - nonrandomized controlled cohort/follow-up study (postmarketing surveillance) provided there are sufficient numbers to rule out a common harm (for long-term harms the duration of follow-up must be sufficient)
    • Level 4 - case-series, case-control studies, or historically controlled studies
    • Level 5 - mechanism-based reasoning
    • Reference - second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease (25602023J Crohns Colitis 2015 Feb;9(2):107)
  • American College of Gastroenterology (ACG) grading system for recommendations
    • strength of recommendation
      • Strong recommendation - desirable effects of intervention clearly outweigh undesirable effects
      • Conditional recommendation - uncertainty over whether desirable effects of intervention outweigh undesirable effects
    • quality of evidence
      • High-quality evidence - further research very unlikely to change confidence in estimate of effect
      • Moderate-quality evidence - further research likely to have important impact on confidence in estimate of effect; estimate may change
      • Low-quality evidence - further research very likely to have important impact on confidence in estimate of effect; estimate will likely change
      • Very low-quality evidence - any estimate of effect very uncertain
  • American Gastroenterology Association (ACA) uses US Preventive Services Task Force (USPSTF) grading system for recommendations
    • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
      • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
      • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
      • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
      • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
      • Grade I - insufficient evidence to assess balance of benefits and harms
      • Reference - USPSTF Grade Definitions

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
  • DynaMed provides Practice-Changing DynaMed Updates, with support from our partners, McMaster University and F1000.

Special acknowledgements

  • Brian C. Weiner, MD, MS, FACP, AGAF (Deputy Editor of Gastroenterology; Clinical Associate Professor, Medicine, Gastroenterology/Hepatology/Nutrition, University of Florida, Florida, United States)
  • Dr. Weiner declares no relevant financial conflicts of interest.
  • Amir Qaseem, MD, PhD, MHA, FACP (Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network (GIN); Germany)
  • Dr. Qaseem declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD, FAAFP (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
Choosing Wisely Canada acknowledges dissemination of their recommendations through DynaMed Plus to reach the point of clinical decision-making.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114507, Ulcerative Colitis in Adults; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114507. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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