To the Editor:

Ulcerative colitis (UC) is an idiopathic, chronic, relapsing-remitting inflammatory disease that usually affects the rectum and colon at the same time. Emergency department visits, hospitalization, and short-term surgery have all decreased as a result of major advancements in medical care, particularly the introduction of biologics in the previous 20 years. Extensive trials of medical therapy are thought to minimize the need for urgent or emergent colectomy, which has poorer outcomes than elective surgery¹,².

Several biomarkers have been demonstrated to predict the course of disease. Their ability to perform this role has sparked speculation about whether they are likewise linked to the necessity for surgical intervention and has led to their inclusion in prediction algorithms. The capacity to correctly predict which patients will eventually undergo colectomy would be extremely beneficial in patient counseling. Although no one test will likely become the gold standard for determining who needs surgery, there are a few tests that may be useful in minimizing the length of ineffective medical treatment, especially when used in combination³.

Certain biomarkers such as C-reactive protein (CRP), hypoalbuminemia, and peripheral eosinophilia have been associated with surgical decision-making and have the potential to predict treatment failure. However, the precise significance of biomarkers in predicting which patients will require surgery and when they should undergo surgery is still being determined.

For decades, CRP has been regarded as an important component of UC evaluation. CRP elevation is highly associated with the absence of a functional gastrointestinal disorder, but it has limited sensitivity and is not specific for UC. Besides, the CRP response in UC is quite variable. Due to the short half-life of CRP, serial measurements can be utilized to evaluate treatment response. In hospitalized patients with acute illness, persistently and significantly increased CRP levels have been linked to steroid-resistant disease and the need for surgery⁴.

On the other hand, eosinophilia was assumed to be linked to active disease at the time. Recent research has found that peripheral blood eosinophilia (PBE) can be used as a biomarker for disease activity. Click et al. conducted a registry analysis of 2066 IBD patients in which they found a link between peripheral eosinophilia and a severe disease phenotype. PBE was linked to severe disease, active disease, primary sclerosing cholangitis, aggressive medical treatment, increased health-care utilization, hospitalization, and the requirement for surgery in people with UC. PBE was linked to hospitalization and surgery in UC, with adjusted odds ratios of 2.35 and 1.76, respectively, according to multivariate analysis. Furthermore, UC patients with PBE had a considerably shorter time to colectomy, according to time-to-event analysis. Additional research verifying the predictive capacity of PBE regarding surgical intervention will be necessary before this tool can be used in decision-making⁵. Multiple biomarkers have been combined to increase the accuracy of predicting which patients would need surgery to treat their disease. To develop best practices, more research is needed on the best usage and combination of biomarkers, as well as the effects of earlier surgical intervention as required by such a predictive model.