Talk:Ulcerative colitis/Archive 2

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Photo

It's been pointed out to me that the photo on the top of the article has ulcers that look serpiginous (which is more Crohn's like). The purulent stuff is definitely UC like, but this probably isn't the most representative UC photo. Better photo would be appreciated! -- Samir धर्म 06:09, 24 June 2006 (UTC)

I would like to point out that I don't get mouth sores any more (that was the only one like that, which I ever got). There is a possibility that I DO have ulcerative colitis, or at least IBS. Nothing a steady intake of prune juice and avoidance of all fried foods couldn't fix. -- THEBlunderbuss (talk) 09:59, 11 December 2007 (UTC)

I was diagnosed with UC about 18 months ago, would anyone like to view the photo from the sigmoidoscopy in order to determine if it would be an improvement? (Yes, nowadays after a colonoscopy, you're given a shiny color photograph of your lower bowel. In case you ever wondered what it looked like.) Also, it would probably be too graphic, but does anyone think that this article would be improved by an image of the...crap, how does one properly refer to mucoprulient discharge? Anyway, I think that you get the drift. I'm in the middle of a flare-up, and any necessary photos should be obtained before I can get it under control, probably a week or two.LeeRamsey (talk) 00:45, 27 January 2008 (UTC)

Hydrogen peroxide and ulcerative colitis

I don't know if this should be included. It's not a mainstream view as far as a cause. I'll grant that there are case reports of hydrogen peroxide causing colitis, but I don't think there is consensus at all of it being a specific cause of UC now -- Samir धर्म 07:42, 18 July 2006 (UTC)

• Let me elaborate a bit: It is agreed that peroxide is a cause of chemical colitis. No question. It is also agreed that antioxidants have been hypothesized in pathogenesis of ulcerative colitis. However, with respect to peroxide being a specific cause of ulcerative colitis per se, there are only two references in the literature:
  • Sheehan JF, Brynjolfsson G. Ulcerative colitis following hydrogen peroxide enema: case report and experimental production with transient emphysema of colonic wall and gas embolism. Lab Invest. 1960 Jan-Feb;9:150-68. PMID 14445720
    • I think "ulcerative" colitis referred to in the title is literally colitis that ulcerates (i.e. chemical colitis with ulcers). I've asked for the abstract to be sent to my office and will clarify further when I can peruse it, but I don't think this paper cites peroxide as a cause of UC in any way.
  • Pravda J. Radical induction theory of ulcerative colitis. World J Gastroenterol. 2005 Apr 28;11(16):2371-84. PMID 15832404
    • This is really the only publication that espouses a putative causative relation between hydrogen peroxide and UC
• There are many chemicals that cause shallow confluent ulcers in the colon similar to ulcerative colitis that are unrelated to causality in UC. I don't think there's enough evidence that hydrogen peroxide is related enough to causality to merit a mention. -- Samir धर्म 08:11, 18 July 2006 (UTC)
• These unusual caues are important for two reasons. First, you should probably ask about these things when somebody presents with what appears to be UC. If the person has done something like this, one could hope this is the cause, and that the condition will clear up and not recur, so long as the person doesn't do it again. Second, a person who has a history of UC should be cautioned against doing things that might trigger the disease. It's fairly likely that somebody with UC would try a massive dose of vitamins without realizing that it could be a risk factor for an episode. And, there is probably somebody out there recommending peroxide enemas for whatever ails you.M dorothy 15:18, 18 July 2006 (UTC)
  • I agree with you that when someone presents with what appears to be UC, chemical colitis, including hydrogen peroxide must be considered. No question. And yes, people with UC should avoid peroxide enemas. Definitely. But the same hold true for so many other things: NSAIDS cause colitis; people with UC should avoid NSAIDS. Same with soap enemas. Same with some antibiotics. -- Samir धर्म 01:17, 20 July 2006 (UTC)
    • Here's the question to me: is this article is about colitis or ulcerative colitis? If we're discussing colitis as an umbrella term, it's only logical that H2O2 would cause chemical colitis if administered in an enema, because the stuff is so hard on sensitive tissues. (Hydrogen peroxide doesn't kill any bacteria - it is useful to bring dirt to the surface of a deep wound, but I think it does more harm than good especially now that less irritating agents are available.) If we're writing about UC, however, I think H2O2 causation is a pretty obscure theory, probably not notable enough to be included unless there are more relevant studies of which we're unaware. KrakatoaKatie 22:59, 20 July 2006 (UTC)
      • We don't (yet) have an article on chemical colitis. Perhaps we should create one, and merely note the possibility at this point. Also, perhaps we should distinguish a "cause" from a "trigger": there is a possibility (or liklihood) that a chemical insult could trigger an episode in somebody that has the disease, or has a predisposition to it. M dorothy 05:25, 21 July 2006 (UTC)

Radical Induction Theory

Although peroxide damage is central to the radical induction theory, I don't want to confuse people in the main article. The point under the unusual causes heading is that peroxide could be a cause of an episode, and you really shouldn't do this, or introduce any other harsh chemicals.

Although the free radical theory is not "mainstream", it is, so far as I can determine, the only theory explaining ulcerative colitis. This game is played by certain rules, and ignoring a reasonable hypothesis is not one of the options. Unless somebody comes forward with an objection to this theory in a peer-reviewed journal, or publishes an experimental result that disproves the theory, it will become, by default, the "mainstream theory".

The free radical theory does not call for much change in the treatment of the disease. The theory however suggests that the epithelial membrane is fragile in some people, and that this fragility is central to the disease. M dorothy 05:58, 21 July 2006 (UTC)

There are many theories for the cause of UC: Th1 v. Th2 responses (PMID 16831396, PMID 16548766, PMID 16378007, PMID 16083712, PMID 16048556, PMID 15146247, PMID 12876555, many more), hygiene hypothesis (PMID 16696783, PMID 15288007, PMID 11693209), autoimmune theories (PMID 16620017, PMID 16584867, PMID 16498309, PMID 15559364, PMID 12672398 and many more) and the radical induction theory.

Agreed that the radical induction theory is a different hypothesis, and should be mentioned in the article. Mention of B6, iron and peroxide as putative causes of ulcerative colitis under this hypothesis is fair also. But I don't think it's fair that it should be expanded more than that -- Samir धर्म 09:39, 23 July 2006 (UTC)

I do not wish to further introduce the radical induction theory into the main article at this time. I became aware if the peroxide association through this source, but that is not the reason peroxide needs to be here.

Thanks for providing me with these citations. I will try to read them. Do these theories provide a comprehensive explanation of the disease? Is there evidence that disproves these theories? Are the theories subsumed into the radical induction theory?

Can the autoimmune theory explain the observation that removal of the colon seems to cure the disease? With Crohn's, the disease returns following surgery, as though something outside the intestine continues to malfunction. With UC, whatever was malfunctioning is gone after surgery, as though the intestine itself were the cause. M dorothy 05:15, 24 July 2006 (UTC)

I agree with you that peroxide does play a role in motility in UC. No question that the literature is supporting that. But, it doesn't have a known role in pathogenesis yet (so it could be put down as a putative cause at best). It just comes down to the weight of the evidence: In the past 5 years, there are over 500 clinical and basic science citations on PubMed for immune mechanisms of ulcerative colitis and just one as H202 as a cause. We're not here to judge, we're here to report, and it's only fair to report according to what consensus in the IBD community is. There are also no case reports of peroxide causing a flare of UC either -- Samir धर्म 05:46, 24 July 2006 (UTC)

I do not seem to be able to gain full access to these citations on-line.M dorothy 05:56, 27 July 2006 (UTC)

Th2 response citations

Th1 v. Th2 responses (PMID 16831396, PMID 16548766, PMID 16378007, PMID 16083712, PMID 16048556, PMID 15146247, PMID 12876555, many more) Based on the abstracts, none of these citations is offering a theory of the disease; they are merely discussing interesting associations. It would be fair to say that all of these see damage to the epithelial membrane as a cause of immune response, although none are are endorsing peroxide damage. PMID 16831396 and PMID 16378007 seem to be looking at pre-existing membrane damage as a cause of immune response. On the other hand, PMID 16083712 seems to be suggesting that IL13 damages the membrane, suggesting causation from immune response.M dorothy 05:56, 27 July 2006 (UTC)

IL-13 is a Th2 cytokine that the authors of that citation suggest affects the permeability at tight junctions. It doesn't really make sense to say that the Th2 hypothesis is not offering a theory of causation for UC; it is, but there are just a lot of unknown variables. The hypothesis is that Th2 cytokines are invoked by some initiating stimulus leading to mucosal inflammation. It is an accepted hypothesis in the UC literature. The whole rigmarole around the ACT 2 trial was how infliximab was a useful therapy for UC given that TNF was a Th1 cytokine. It would be WP:OR to suggest that alternative hypotheses are more accepted than the ones I quoted -- Samir धर्म 07:25, 27 July 2006 (UTC)

Pravda's paper appears to be carefully crafted to meet the criteria of the Scientific method. I do not see anything comparable in the TH2 abstracts. There may, however, be a valid objection in that Pravda's paper does not, as I recall, specifically address the TH2 correlation or subsume this theory, such as it is.M dorothy 02:55, 28 July 2006 (UTC)

Well, it is an interesting citation and a hypothesis that's different from what's been in the literature. I'll show it to my residents next week at rounds. -- Samir धर्म 04:58, 28 July 2006 (UTC)

Hygiene hypothesis

(PMID 16696783, PMID 15288007, PMID 11693209). These citations do not really include a comprehensive theory of the disease. I believe, however, that there is a better cite out there that I have read. I agree that the radical induction theory needs to explain this observation or subsume this theory.M dorothy 05:57, 28 July 2006 (UTC)

Citation

We need to cite some of the treatment information -- Samir धर्म 03:25, 28 July 2006 (UTC)

One objection to both the UC and Crohn's articles is length. Althoough these have great detail, I believe we should shorten both articles by factoring the drugs and treatment into separate articles. I could write short summaries for the main articles, based on the American College of Gastro... practice guidelines.M dorothy 06:14, 28 July 2006 (UTC)

That is an excellent idea, we should definitely spin off therapy sections -- Samir धर्म 06:15, 28 July 2006 (UTC)

Autoimmune Disease

The List of Autoimmune Diseases shows UC as uncertain. Also, the practice guidelines for the American College of Gastro... make no mention as to whether the disease is regarded as autoimmune. This is in contrast to Crohn's, where a clear consensus appears.M dorothy 05:39, 28 July 2006 (UTC)

But the statement that I removed is factually incorrect. UC is not usually treated as if it were an autoimmune disease. Cytoreductive therapy works for most autoimmune diseases. Doesn't work for UC. 5-ASA isn't used to treat any autoimmune disease. Steroids are used to treat many conditions that are autoimmune and aren't autoimmune. I've removed it again. -- Samir धर्म 06:06, 28 July 2006 (UTC)

5-ASA, or at least sulfasalazine, is used to treat rheumatoid arthritis, which is widely regarded as an autoimmune disease. Nonetheless, I think we are more or less in agreement here. I will try to think of a way to word this so as to meet your objection.M dorothy 06:23, 28 July 2006 (UTC)

References

I've reworked the references. Please adhere closely to cite.php. One article was cited seperately on four different occasions. Some other points:

• Citing a study about sepsis to explain "benefits" of nicotine in UC is outrageous, especially when this is a SciAm article and not a peer-reviewed reference.
• What childhood infections are associated with UC? We're not talking rubella, are we?
• Why are we lending such enormous credence to the theories of Dr Pravda?

Something is not quite right. JFW | T@lk 23:43, 2 August 2006 (UTC)

Thank you for your assistance with the refs. The article is taking no position as to the validity of the radical induction theory. It is clearly presented as a theory. However, in taking an alternative look at the disease, Dr. Pravda mentions a lot of facts that other sources don't mention. These are relevant to the subject, regardless of relevance to the theoryM dorothy 05:20, 3 August 2006 (UTC)

• • Yes, but honestly it's only mentioned in one fringe paper in a third-tier journal. I'm removing the reference to Pravda save for a single line. The theory has its own article, and that's forking it enough. It's clearly not recognized as a theory for pathogenesis of ulcerative colitis in the GI community. I've put in an RfC, see below -- Samir धर्म 07:04, 28 August 2006 (UTC)

Pseudopolyps

Great pic! -- Samir धर्म 05:21, 4 August 2006 (UTC)

I got it from here -- which also has a (very) lame/incomplete English version.

If you're looking for some intestinal polyp pics... there are a few the German version. Most of the images are in the Wikicommons and annotated in English. Aside from the polyps, there are also some tasteful (yet juicy-looking) colonic adenocarcinoma pics. I briefly thought about adding one to Wikipedia... but thought they might be a bit much for people not desensitized to seeing body parts, blood et cetera... and just freshly diagnosed with a goomba of that variety. Nephron  T|C 06:37, 4 August 2006 (UTC)

I added a few more pictures from the German Wikipedia's UC article. To the best of my knowledge they do represent UC... but I've only seen about 3-4 pictures of UC and don't have the benefit of having done dozens of endoscopic procedures. Any case, the licencing of the pictures is messed, 'cause I couldn't choose public domain-- the choice wasn't in the drop-down menu. Perhaps you can sort throught that one. The German Wikipedia states they are public domain.[1][2] They originate from a gastroenterologist in Hamburg:

Mein Name in Dr. Joachim Guntau.

Ich bin leitender Oberarzt der Gastroenterologie im Albertinen-Krankenhaus Hamburg und habe mit meinen Kollegen 2 Internet-Atlanten veröffentlicht: Einen Endoskopieatlas und einen Sonographieatlas. Beim Recherchieren bin ich auf einige Ungereimtheiten auf medizinischen Seiten gestoßen, die ich versuche ein wenig zu verbessern.

Translation:

My name is Dr Joachim Guntau. I am a senior attending physician at the Albertinen Hospital in Hamburg in the department of gastroenterology. Together with two of my collegues we have published Internet-atlases: one endoscopic atlas and one sonography atlas. During the research, I came across a few inconsistencies on the medicine pages, which I have tried to correct. Nephron  T|C 07:51, 4 August 2006 (UTC)

RfC

The pathogenesis of ulcerative colitis is unknown, but basic and clinical researchers in gastroenterology have identified that it may be related to cytokine release from some stimulus (traditionally favouring the Th2 pathway), autoimmune causes, or the so-called "hygiene hypothesis", where environmental causes are considered as a primary factor in pathogenesis. There are more than a hundred PubMed citations on basic and clinical evidence to support this in the adult and pediatric populations. These theories are discussed at every major gastroenterology meeting by experts. I've listed representative citations at Talk:Ulcerative colitis#Radical Induction Theory

In April 2005, Jay Pravda published a paper entitled "Radical induction theory of ulcerative colitis" PMID 15832404 describing a putative pathogenic mechanism for ulcerative colitis. The paper was published in "World Journal of Gastroenterology", which has an unrecognized impact factor because it was dropped from the listings for excessive self-citation [3]. It has not been cited by a single other publication, and has not been presented at any major international gastroenterology conferences.

However, our article on ulcerative colitis cites Pravda's paper 4 times and contains 12 lines (in my browser) to the theory and its corollaries. This is entirely too much for a fringe theory, and, in my mind, is a violation of WP:SOAP.

I've reverted the reference to a single line, and request comment on the same. The pre- and post-diffs are here [4] -- Samir धर्म 07:20, 28 August 2006 (UTC)

I support your version and also feel that the fork article should be sent for AFD. Wikipedia is not in the business of promoting one little-known theory on a major disease. JFW | T@lk 15:59, 28 August 2006 (UTC)

I've nominated the fork for AFD: Wikipedia:Articles for deletion/Radical Induction Theory of Ulcerative Colitis. JFW | T@lk 16:29, 28 August 2006 (UTC)

I think that you've done a fair job of handling the theory and, until more information is gathered to support it, the article should remain as you have left it. InvictaHOG 17:05, 28 August 2006 (UTC)