Histopathology predictors of medically refractory ulcerative colitis.

Objective: The ability of ulcerative colitis histology to predict medically refractory disease was evaluated.

Methods: Twenty patients who underwent colectomy for medically refractory disease were compared with 48 medically managed patients. All patients were followed up for > or =6 months. The study design was a retrospective longitudinal observational chart review to determine whether specific histologic parameters were predictive of a later colectomy for medically refractory disease.

Results: On initial biopsy, medically refractory patients were more likely to have severe cryptitis, 75% vs 49%; lymphoid follicles, 78% vs 48%; and erosions, 35% vs 11%. There was no significant difference in the prevalence of crypt abscesses, mucin depletion, crypt distortion, or mucosal ulceration between medically refractory and medically managed patients. Active inflammation on endoscopy was not statistically different between groups (P = .192). In a recursive partition model, the strongest predictors of future colectomy were age dependent. Among older patients (>38 y), severe cryptitis was the strongest determinant of refractory disease. Only 1 of 21 (5%) of the patients who initially did not have severe cryptitis progressed to colectomy. In younger patients (< or =38 y), the presence of lymphoid follicles was the strongest predictor of future colectomy; 9 of 14 (64%) patients with lymphoid follicles progressed to colectomy.

Conclusions: Medically refractory ulcerative colitis was associated with initial biopsy findings of severe cryptitis, lymphoid follicles, and erosions. Refractory disease was not predicted by the severity or extent of endoscopic findings. In younger patients, the presence of lymphoid follicles, and in older patients, severe cryptitis, were the most important predictors of medically refractory disease.