LETTERS TO THE EDITOR
417
HEPAT 01129
revalence of pri
In a recent paper Olsson and co-workers (1) studied the incidence of primary sclerosing cholangitis in patients with ulcerative colitis. The diagnosis of primary sclerosing cholangitis was based on X-ray changes shown by endoscopic retrograde cholangiography (ERC) in patients with ulcerative colitis and pathological liver tests. Ulcerative colitis was diagnosed by chronic symptoms, negative fecal cultures, sigmoidoscopy and inflammatory changes in rectal biopsy. The extent of the disease was assessed by barium enema and/or colonoscopy. Patients with inflammatory changes in the rectum only (up to 15 cm from the anus) were excluded. Colitis was classified as distal when inflammatory changes did not extend beyond the splenic flexure, and substantial when the colon beyond this flexure was affected (I). Primary sclerosing cholangitis was found to occur in 3.7% of the patients with ulcerative colitis and particularly in those with so-called substantial colitis (5.5%). On the other hand, only 0.5% of those with distal colitis had signs of sclerosing cholangitis (I). It should, be realized, however that colonoscopy with biopsies is more sensitive than barium enema in diagnosing colitis or the extent of the inflammatory process (2,3). The ERC examination is based on retrograde filling of the biliary tree with contrast, and is accordingly more comparable to barium enema than endoscopy with histology. Thus, Olsson and co-workers used methods with different sensitivities when assessing the occurrence of sclerosing cholangitis in patients with ulcerative colitis (1). Changes in ERC due to sclerosing cholangitis represent a late fibrotic stage of inflammation, and should therefore be compared with fibrotic changes in the colon demonstrated by barium enema. Alternatively, endoscopic and histological colitis should be compared with choledochoscopy, accompanied by biopsy from the biliary tree. Moreover, Olsson and co-workers only performed ERC in patients with elevated se.‘um alkaline phosphdtase activity (ALP)( 1) and primary sclerosing cholangitis may occur also in patients with normal ALP (4).
atients wit
cerative
We have been trying to collect and examine the biliary tree at autopsy of patients with ulcerative colitis for years to assess the true incidence of sclerosing cholangitis in these patients. So far, however, we have not succeeded in performing an autopsy on sufficient patients with ulcerative colitis to have any results. In conclusion, the incidence of primary cholangitis in patients with ulcerative colitis may be much higher than demonstrated by ERC. The biliary tree and the colon seem to be the primary targets for the inflammatory process in this disease. Moreover, after years of latency, patients with ulcerative colitis/primary sclerosing cholangitis tend to develop carcinoma of the colon (5) or bile ducts (6). Similarities between a chronic viral infection like hepatitis B virus ir.fection and ulcerative colitis/ primary sclerosing cholar gitis should also be taken into consideration (7). Helge L. Waldum Department
of
MeJicine.
Unitersiry
Hospital.
N-7006
Trmiheirn.
Norwq
References I Olsson R, Danielsson A, Jlrnerot G et al. Prevalence of primary sclerosing cholangitis in patients with ulcerative colitis. Gastroenterology 1991; 100: 1319-23. 2 Warwick RRG, Sumerling MD. Gilmour HM, Shearman DJC. Colonoscopy and double contrast barium enema examination in chronic ulcerative colitis. Am J Roentgen01 1973; 117: 292-6. 3 Williams CB, Wayne JD. Colonscopy in inflammatory bowel disease. Clin Gastroenterol 1978; 7: 701-17. 4 Balasubramaniam K, Wiesner RN, LaRusso NF. Primary sclerosing cholangitis with normal serum alkaline phosphatase activity. Gastroenterology 1988; 95: 1395-8. 5 Ekborn A, Helmick C, Zack M, Adami H-O. Ulcerative colitis and colorectal cancer. N Engl J Med 1990; 323: 1228-33. 6 Wee A, Ludwig J, Coffey RJ et al. Hepatobiliary carcinoma associated with primary sclerosing cholangitis and chronic ulcerative colitis. Hum Pathol 1985: 16: 719-26. 7 Waldum HL, Bjorvatn B, Burhol PG. Gastritis, peptic ulcer disease, inflammatory bowel disease, and stomach and colon cancers - Are they all caused by viral infections? Med Hypotheses 1981; 7: 1329-38.
417
HEPAT 01129
revalence of pri
In a recent paper Olsson and co-workers (1) studied the incidence of primary sclerosing cholangitis in patients with ulcerative colitis. The diagnosis of primary sclerosing cholangitis was based on X-ray changes shown by endoscopic retrograde cholangiography (ERC) in patients with ulcerative colitis and pathological liver tests. Ulcerative colitis was diagnosed by chronic symptoms, negative fecal cultures, sigmoidoscopy and inflammatory changes in rectal biopsy. The extent of the disease was assessed by barium enema and/or colonoscopy. Patients with inflammatory changes in the rectum only (up to 15 cm from the anus) were excluded. Colitis was classified as distal when inflammatory changes did not extend beyond the splenic flexure, and substantial when the colon beyond this flexure was affected (I). Primary sclerosing cholangitis was found to occur in 3.7% of the patients with ulcerative colitis and particularly in those with so-called substantial colitis (5.5%). On the other hand, only 0.5% of those with distal colitis had signs of sclerosing cholangitis (I). It should, be realized, however that colonoscopy with biopsies is more sensitive than barium enema in diagnosing colitis or the extent of the inflammatory process (2,3). The ERC examination is based on retrograde filling of the biliary tree with contrast, and is accordingly more comparable to barium enema than endoscopy with histology. Thus, Olsson and co-workers used methods with different sensitivities when assessing the occurrence of sclerosing cholangitis in patients with ulcerative colitis (1). Changes in ERC due to sclerosing cholangitis represent a late fibrotic stage of inflammation, and should therefore be compared with fibrotic changes in the colon demonstrated by barium enema. Alternatively, endoscopic and histological colitis should be compared with choledochoscopy, accompanied by biopsy from the biliary tree. Moreover, Olsson and co-workers only performed ERC in patients with elevated se.‘um alkaline phosphdtase activity (ALP)( 1) and primary sclerosing cholangitis may occur also in patients with normal ALP (4).
atients wit
cerative
We have been trying to collect and examine the biliary tree at autopsy of patients with ulcerative colitis for years to assess the true incidence of sclerosing cholangitis in these patients. So far, however, we have not succeeded in performing an autopsy on sufficient patients with ulcerative colitis to have any results. In conclusion, the incidence of primary cholangitis in patients with ulcerative colitis may be much higher than demonstrated by ERC. The biliary tree and the colon seem to be the primary targets for the inflammatory process in this disease. Moreover, after years of latency, patients with ulcerative colitis/primary sclerosing cholangitis tend to develop carcinoma of the colon (5) or bile ducts (6). Similarities between a chronic viral infection like hepatitis B virus ir.fection and ulcerative colitis/ primary sclerosing cholar gitis should also be taken into consideration (7). Helge L. Waldum Department
of
MeJicine.
Unitersiry
Hospital.
N-7006
Trmiheirn.
Norwq
References I Olsson R, Danielsson A, Jlrnerot G et al. Prevalence of primary sclerosing cholangitis in patients with ulcerative colitis. Gastroenterology 1991; 100: 1319-23. 2 Warwick RRG, Sumerling MD. Gilmour HM, Shearman DJC. Colonoscopy and double contrast barium enema examination in chronic ulcerative colitis. Am J Roentgen01 1973; 117: 292-6. 3 Williams CB, Wayne JD. Colonscopy in inflammatory bowel disease. Clin Gastroenterol 1978; 7: 701-17. 4 Balasubramaniam K, Wiesner RN, LaRusso NF. Primary sclerosing cholangitis with normal serum alkaline phosphatase activity. Gastroenterology 1988; 95: 1395-8. 5 Ekborn A, Helmick C, Zack M, Adami H-O. Ulcerative colitis and colorectal cancer. N Engl J Med 1990; 323: 1228-33. 6 Wee A, Ludwig J, Coffey RJ et al. Hepatobiliary carcinoma associated with primary sclerosing cholangitis and chronic ulcerative colitis. Hum Pathol 1985: 16: 719-26. 7 Waldum HL, Bjorvatn B, Burhol PG. Gastritis, peptic ulcer disease, inflammatory bowel disease, and stomach and colon cancers - Are they all caused by viral infections? Med Hypotheses 1981; 7: 1329-38.
