Riesgo de Cáncer y Enfoque del Tratamiento Médico en Pacientes con EC

DR. LUIS FERNANDO PINEDA, MD
Hospital El Tunal, Centro de Enfermedades Digestivas- Almirante Colon, Bogotá.
DR. WILLIAM OTERO, MD
Clínicas Fundadores y Federman, Bogotá.
DR. VICTOR ARBELAEZ, MD
Hospital El Tunal, Centro de Enfermedades Digestivas-Almirante Colon, Bogotá.
DR. ELDER OTERO, MD
Clínicas Fundadores y Federman, Bogotá.
DR. JORGE LIZARAZO, MD
Clínica San Pedro Claver ISS, Bogotá.
DR. OSCAR BELTRAN, MD
Clínica San Pedro Claver ISS Bogotá.

Riesgo de Cáncer

Cada vez hay más evidencias que pacientes con EC y colitis extensa tienen mayor riesgo de cáncer de colon de manera similar a los pacientes con CU extensa (140).

El poco éxito de los programas de vigilancia en CU han desanimado a los médicos para iniciar estudios similares en la colitis de la EC, en la cual la incidencia de displasia es menor (141).

Sin embargo actualmente se sugiere estar atentos a los nuevos síntomas en aquellos pacientes con colitis, especialmente los que son sugestivos de estenosis, las cuales son frecuentes que pueden ser debidas a carcinomas (141). Esto exige que todas las estenosis sean investigadas con múltiples biopsias y cepillado para citología (141).

Si bien es cierto que existen menos publicaciones sobre la asociación de cáncer en EC que en CU. Actualmente se sabe los primeros tienen riesgo de cáncer 18 veces mayor que la población general, similar al riesgo descrito en CU (43, 142).

En el intestino delgado también hay una incidencia aumentada de cáncer en pacientes con EC aunque con menos de cien casos informados (141).

Así mismo se puede desarrollar carcinoma escamoso del ano en pacientes con EC perianal (141). Las lesiones que deben hacer sospechar esta complicación son las estenosis ano-rectales, la induración en una fístula crónica y las úlceras anales atípicas (141).

Enfoque General del Tratamiento Medico y Conclusiones

1. Antes de iniciar cualquier tratamiento en EC deben estudiarse situaciones agravantes como el tabaquismo, el consumo de AINES, las infecciones y el parasitismo intestinal y ante todo debe descartarse con seguridad la coexistencia de una complicación supurativa.
2. El paciente en buenas condiciones y sin síntomas de compromiso sistémico debe manejarse con mesalamina. La sulfasalazina no tiene acción terapéutica en enfermedad del intestino delgado por ello su uso es muy limitado en EC. Los antibióticos metronidazol y ciprofloxacina son una alternativa en enfermedad colónica o perianal.
3. Los pacientes que presentan enfermedad activa con compromiso sistémico deben hospitalizarse y la complicación séptica si existe debe investigarse y tratarse. Los corticosteroides o la dieta elemental son las opciones de tratamiento en este grupo. Si hay enfermedad severa con imposibilidad para la vía oral deben utilizarse esteroides intravenosos y soporte nutricional. La ciclosporina es una alternativa adicional en estas situaciones críticas pero existen pocos estudios que la respalden.
4. Los pacientes que responden en la fase aguda a aminosalicilatos o antibióticos, éstos deben continuarse luego de la lograda la remisión como terapia de mantenimiento. Los que requirieron esteroides en fase aguda deben ser progresivamente reducidos a su mínima dosis asociando azathioprina o 6 mercaptopurina.
5. La recurrencia post-operatoria se puede prevenir con mesalamina o metronidazol en altas dosis. Los inmunomoduladores están en evaluación clínica para definir esta indicación.
6. La enfermedad perianal no se beneficia con aimnosalicilatos o esteroides. El metronidazol sólo o en combinación con ciprofloxacina son la opción inicial. En enfermedad fistulizante los inmunomoduladores tipo azathioprina, 6 mercaptopurina y ciclosporina son los únicos fármacos que han demostrado beneficio.
7. El tratamiento quirúrgico está indicado para manejar las complicaciones (hemorragia masiva, perforación, obstrucción, megacolon tóxico) o la enfermedad activa refractaria. Esta última es la indicación mas frecuente. Se considera que el paciente agudo que no responda en 7 a 10 días a los tratamientos médicos enunciados debe ser llevado a cirugía. (143). La cirugía no debe ser vista como un fracaso terapéutico sino como un valioso recurso terapéutico.

En conclusión la EC es una enfermedad incurable que requiere de un manejo profesional interdisciplinario. Cualquier tratamiento, médico o quirúrgico debe ser individualizado. La toxicidad de los fármacos requiere una vigilancia estrecha por parte del médico y después de la cirugía frecuentemente hay recidivas.

Los medicamentos novedosos deben ser evaluados dentro de protocolos de investigación clínica. Los aspectos humanos y psicosociales merecen tanta importancia como los del manejo clínico.

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