This thesis examines the role of autologous bone marrow stem cell intravenous injection in treating ulcerative colitis. It conducted a randomized clinical trial on 10 Egyptian patients with UC. The study found statistically significant improvements in diarrhea frequency, heart rate, and quality of life after stem cell therapy compared to before. No significant safety issues occurred. The study concludes that stem cell therapy may help reverse inflammation in UC and offers a potential new treatment option.

1. بسم الله الرحمن الرحيم
صدق الله العظيم
سورة البقرة – أية 32

2. Thesis
Submitted for Partial Fulfillment of Master Degree in Internal Medicine
By
Mohammed Fathy Sayed Mohammed Zaky
M.B.B.Ch. - Faculty of Medicine - Ain Shams University
Supervied by
Prof. Dr . Mohsen Mostafa Maher
Professor of Internal Medicine - Faculty of Medicine - Ain Shams University
Ass. Prof. Dr . Wesam Ahmed Ibrahim
Assistant Professor of Internal Medicine - Faculty of Medicine - Ain Shams University
Dr . Shereen Abou Bakr Saleh
Lecturer of Internal Medicine - Faculty of Medicine - Ain Shams University
Faculty of Medicine
2014

4. At first and foremost thanks to “ Allah ” the most merciful
who gave me the power to finish this work.
I wish to express my deepest appreciation to Prof. Dr. Mohsen Mostafa Maher,
for his precious help, support and valuable instructions.
My greatest respect and appreciation to Prof. Dr. Wesam Ahmed Ibrahim, for
her help & supervision. It was a great honor to me to work under her guidance.
It is a great honor to express my thanks to Prof. Dr. Shereen Abou Bakr Saleh,
who was very kind, supportive & helpful throughout all stages of this work.
I owe many thanks and appreciation to Prof. Dr. Alaa El Din Ismail, for offering
me much of his time & experience throughout the practical part of this work.
Also, I am grateful to Prof. Dr. Doaa Zakaria Zaki, for her help and guidance
that helped me to finish this project.

6.  Inflammatory bowel disease (IBD) represents a group of
idiopathic chronic inflammatory intestinal conditions. The
two main disease categories are Crohn’s disease (CD) and
ulcerative colitis (UC), with both overlapping and different
clinical and pathological features (Charles, et al., 2009).
 Ulcerative colitis is a chronic inflammatory condition causing
continuous mucosal inflammation of the colon, affecting the
rectum and a variable extent of the colon in continuity.
Common symptoms include bloody diarrhea, abdominal pain
and weight loss which may be mild, moderate or severe,
and it is characterized by a relapsing & remitting course
(Lakatos, et al., 2007).

7.  The disease pathogenesis is still incompletely understood.
Environmental, infectious, genetic, autoimmune, and host
factors have been suspected. Increasing evidence suggests that
there is a defect in the function of the intestinal immune system.
As a consequence, there is a breakdown of the defense barrier of
the gut, and the result is a chronic inflammatory process
mediated byT-cells (William Chiang, et al., 2008).
 Currently, standard medical therapy is directed against the
inflammatory and immune processes and is most often
implemented in a stepwise fashion, progressing through
aminosalicylates, corticosteroids, immunosuppressives, & finally
anti-TNF drugs. But failure to respond to therapies represents
unmet needs in treatment of IBD (Ricart E, et al., 2010)

8.  A novel and exciting approach could be offered through the
current development in the field of stem cell biology. Two
streams of research, experimental and clinical, are the origin of
the increasing utilization of stem cell therapies for severe
immune-mediated diseases including IBD (Masson et al, 2004;
Ricart E, et al., 2010).
 Other medical researches reflect that SCT has made
improvement in the quality of life to patients of UC but
the mechanism for the effect isn't clear but it explained
through the powerful immunomodulatory effects of SCs
and its ability to stimulate regeneration of intestinal mucosa
(Lazebnik, et al., 2010).

10. The aim of the current study is :
To investigate the role of autologous
bone marrow stem cells intravenous
injection in treatment for cases of
ulcerative colitis disease.

12. Study type & sampling:
 This pilot study is a phase II randomized add-on clinical trial .
 The patients included have been diagnosed as UC
according to European Crohn's & Colitis Organization (ECCO)
in journal of Crohn's and Colitis (2012).
 They were selected randomly with various extent and severity
according to the Montreal classification and Truelove & Witts
criteria; and evaluated according to the Mayo Scoring System
for Assessment of UCActivity.

13. Inclusion criteria:
 Adult Middle Eastern patients < 60 years old.
 Documented diagnosed Ulcerative Colitis.
 Written informed consent from every patient .

14. Exclusion criteria:
 Patients with Crohn's disease.
 Patients with advanced systemic disease.
 Patients with any malignancies or blood diseases.
 Patients with other autoimmune diseases.
 Refusal to sign a written consent.

15. Tools of study:
 Clinical assessment :
o History taking.
o Medical examination.
o Body mass index.
 Investigations :
o Laboratory markers (HB% - ALB - ESR - CRP).
 Endoscopy :
o Lower GI Endoscopy (Colonoscopy).
 Staging:
o (Mayo Scoring for Assessment of UC Activity)
 Treatment modifications :
o Any changes in the type, form or dose of different traditional
pharmacological lines of treatment according to case status.

16. 1st step: Bone marrow aspiration
2nd step: Bone marrow processing
3rd step: Bone marrow processing
4th step: Bone marrow injection

17. Bone marrow aspiration
A puncture in the right iliac crest to penetrate bone marrow of ilium using
standard BM aspiration needle to aspirate about 100 ml of BM

18. Bone marrow transferring
Slowly dispense 50 ml of bone marrow aspirate (BMA) into
the marrow chamber of Processing Disposables (PDs)

19. Bone marrow processing
Load centrifuge by placing the fully PDs into
the Smart PReP2 System (the Harvest instrument).

20. Bone marrow injection
IV infusion is performed through a cannula and plastic bag to transfer
100 ml of autologous BM mononuclear cell layer contains SCs.

22.  This study was conducted on 10 patients with confirmed
diagnose of ulcerative colitis. The cases were collected from
Internal Medicine Department and Out Patient Clinic from
Ain Shams, Nasser Institute and Electricity Hospital.
 This study hypothesized that infusion of HSCs may help to
reverse the inflammatory process in patients with UC. Thus,
we conducted a human trial to evaluate safety and feasibility
of autologous bone marrow HSCT in Egyptian patients with
UC and to evaluate it as a therapeutic option compared to
the conventional treatment.

23.  All patients assessed before and 3 months after autologous
HSCT and follow up includes comparison the changes in the
patient's clinical assessment, nutritional status,
biochemical profile, endoscopic findings, medication
requirement, and quality of life of those patients before and
after potential therapy.
 The patients included in this study are males (40%) and
females (60%). Their ages ranged from 24-50 years.
All the patients tolerated the treatment protocol well without
any complications or side effects related to the procedure.

24. Table (1): Showing comparison regarding the presence of diarrhea
Diarrhea Negative Positive Total
Before
N 0 10 10
% 0.00 100.00 100.00
After
N 9 1 10
% 90.00 10.00 100.00
Chi-square
X2 4.9
P-value 0.026*
There were statistically significant differences as
regard presence of diarrhea in patients with UC
before and after the SCT with P values <0.05.
We had started the study with 10 patients complianed of diarrhea in the initial clinical assessment but
only one of themcontinue complaining of it in the final clinical assessment during follow up period.

25. Table (2): Showing comparison regarding the rectal bleeding
Rectal bleeding Negative Positive Total
Before
N 4 6 10
% 40.00 60.00 100.00
After
N 8 2 10
% 80.00 20.00 100.00
Chi-square
X2 2.37
P-value 0.124
There were statistically non significant differences
as regard rectal bleeding in patients with ulcerative
colitis before and after the SCT with P values <0.05.
We had started the study with 6 patients complained of rectal bleeding in the initial clinical
assessment, 4 of them become free of rectal bleeding in the final clinical assessment during follow up
period.

26. Table (3): Showing comparison regarding the abdominal pain
Abdominal pain Negative Positive Total
Before
N 2 8 10
% 20.00 80.00 100.00
After
N 8 2 10
% 80.00 20.00 100.00
Chi-square
X2 1.011
P-value 0.315
There were statistically non significant differences
as regard abdominal pain in patients with ulcerative
colitis before and after the SCT with P values <0.05.
We had started the study with 8 patients complained of abdominal pain in the initial clinical
assessment, 6 of thembecome free in the final clinical assessment during follow up period.

27. Table (4): Showing comparison regarding the motion frequency
Frequency Paired t-test
Range Mean ± SD t P-value
Before 5.000 - 10.000 8.000 ± 2.000
9.731 0.000*
After 3.000 - 5.000 3.600 ± 0.843
There were statistically significant differences as
regard motion frequency of patients with UC as it was
declined from a mean of about (8) times per day
before to a mean of (3) times per day after SCT.

28. Table (5): Showing comparison regarding the body temperature
Temperature Paired t-test
Range Mean ± SD t P-value
Before 37.000 - 37.900 37.440 ± 0.381
1.354 0.209
After 36.900 - 37.500 37.220 ± 0.262
There were statistically non significant differences
as regard body temperature of patients with ulcerative
colitis before and after the SCT with P values <0.05.

29. Table (6): Showing comparison regarding the heart rate
Heart rate Paired t-test
Range Mean ± SD T P-value
Before 73.000 - 100.000 86.600 ± 10.679
3.321 0.009*
After 65.000 - 90.000 80.400 ± 8.809
There were statistically significant differences as
regard the heart rate of the patients with ulcerative
colitis before and after the SCT with P values <0.05.

30. Table (7): Showing comparison regarding the body mass index
BMI Paired t-test
Range Mean ± SD t P-value
Before 19.800 - 33.200 25.040 ± 4.739
0.178 0.863
After 20.500 - 32.300 24.980 ± 4.468
There were statistically non significant differences
as regard the BMI of the patients with ulcerative colitis
before and after the SCT with P values <0.05.

31. Table (8): Showing comparison regarding the serum albumin
ALB Paired t-test
Range Mean ± SD t P-value
Before 3.100 - 5.100 4.000 ± 0.772
-
0.309
0.764
After 3.100 - 4.700 4.040 ± 0.659
There were statistically non significant differences
as regard the s. albumin of the patients with ulcerative
colitis before and after the SCT with P values <0.05.

32. Table (9): Showing comparison regarding the hemoglobin %
HB Paired t-test
Range Mean ± SD t P-value
Before 7.300 - 14.000 10.840 ± 2.688
-0.739 0.479
After 9.500 - 16.500 11.340 ± 2.744
There were statistically non significant differences
as regard the HB% of the patients with ulcerative
colitis before and after the SCT with P values <0.05.

33. Table (10): Showing comparison regarding the ESR
ESR Paired t-test
Range Mean ± SD T P-value
Before 20.000 - 140.000 75.400 ± 49.332
3.628 0.006*
After 13.000 - 100.000 49.200 ± 32.913
There were statistically significant differences as
regard the ESR of the patients with ulcerative colitis as
it was declined from a mean of about (75) before to a
mean of about (50) after SCT.

34. Table (11): Showing comparison regarding the CRP
CRP Paired t-test
Range Mean ± SD t P-value
Before 16.000 - 24.000 20.667 ± 3.724
3.273 0.012*
After 11.000 - 19.000 14.500 ± 12.124
There were statistically significant differences as
regard the CRP of the patients with ulcerative colitis as
it was declined from a mean of about (20) before to a
mean of about (15) after SCT.

35. Table (12): Showing comparison regarding the activity score
Score Paired t-test
Range Mean ± SD t P-value
Before 7.000 - 9.000 7.800 ± 0.789
6.708 0.000*
After 5.000 - 7.000 5.800 ± 0.789
There were statistically significant differences as
regard the activity score of the patients with ulcerative
colitis as it was declined from a mean of about (8)
before to a mean of about (6) after SCT.

36. Table (13): Showing comparison regarding the disease extent
Disease extent E1 E2 E3 Total
Before
N 0 4 6 10
% 0.00 40.00 60.00 100.00
After
N 4 6 0 10
% 40.00 60.00 0.00 100.00
Chi-square
X2 0.277
P-value 0.599
There were statistically non significant differences
as regard disease extent in patients with ulcerative
colitis before and after the SCT with P values <0.05.
We had started the study with 4 patients having left sided colitis and 6 had pancolitis in the initial
endoscopic assessment but by the end of the study 6 patients have left sided colitis and 4 have proctitis
as recorded in the final endoscopic assessment during follow up period.

37. Table (14): Showing comparison regarding the disease severity
Disease
severity
After Total
cases
Mild to
moderate
Mild Moderate
(before)
Before
Moderate
N 2 2 0 4
% 20.00 20.00 0.00 40.00
Moderate
to sever
N 2 0 2 4
% 20.00 0.00 20.00 40.00
Sever
N 0 2 0 2
% 0.00 20.00 0.00 20.00
Total cases
(after)
N 4 4 2 10
% 40.00 40.00 20.00 100.0
Chi-square
X2 10.008
P-value
0.040*
There were statistically significant differences as
regard disease severity in patients with ulcerative
colitis before and after the SCT with P values <0.05.
We had started the study with 4 moderate, 4 moderate to severe and 2 severe cases in the initial
assessment but by the end of the study we had only 2 moderate case and 8 cases evaluated as a mild
or mild to moderate cases in the final assessment during follow up period.

38. Table (15): Showing comparison regarding the medical treatment
Medical
treatment
After Total
cases
(before)
Rectal
5-ASA
Oral
5-ASA
5-ASA +
Steroids
5-ASA
+ AZA
Before
5-ASA +
Steroids
N 1 2 2 0 5
% 10.00 20.00 20.00 0.00 50.00
5-ASA +
AZA
N 2 2 0 1 5
% 20.00 20.00 0.00 10.00 50.00
Total cases
(after)
N 3 4 2 1 10
% 30.00 40.00 20.00 10.00 100.0
Chi-square
X2 3.333
P-value
0.343
There were statistically non significant differences
as regard medical treatment in patients with UC
before and after the SCT with P values <0.05.
We had started the study with two groups of patients as regard the treatment, one group treated by
5-ASA with steroids and other group treated by 5-ASA with AZA. By the end of the study we had
7 patients treated with 5-ASA alone, 3 patient still on steroids and AZA but with lower doses during
follow up period.

39. Table (16): Sho wing comparison regarding the disease outcome
Disease outcome
After Total
cases
(before)
Mild
proctitis
Mild left
sided colitis
Mild to moderate
proctitis
Mild to moderate
left sided colitis
Moderate left
sided colitis
Before
Moderate active left
sided colitis
N 1 1 0 0 0 2
% 10.00 10.00 0.00 0.00 0.00 20.00
Moderate active
pancolitis
N 0 0 1 1 0 2
% 0.00 0.00 10.00 10.00 0.00 20.00
Moderate to severe
active left sided colitis
N 1 1 0 0 1 3
% 10.00 10.00 0.00 0.00 10.00 30.00
moderate to severe
active pancolitis
N 0 0 1 0 0 1
% 0.00 0.00 10.00 0.00 0.00 10.00
Sever active pancolitis
N 0 0 0 1 1 2
% 0 0 0 10.00 10.00 20.00
Total cases (after)
N 2 2 2 2 2 10
% 20.00 20.00 20.00 20.00 20.00 100.0
Wilcoxon Signed
Ranks Test
Z 17.27
P-value
0.038*
There were statistically significant differences as regard disease outcome of
patients with ulcerative colitis before and after the SCT with P values <0.05.

40. We had started the study with 5 cases of moderate, moderate to severe and severe pancolitis; and
5 cases of moderate and moderate to severe left sided colitis in the initial global assessment but we
end the study with only 2 cases of moderate left sided colitis case while other 8 cases evaluated
between mild proctitis and left sided colitis in the final global assessment during follow up period.

42. Hematopoietic Stem Cell transplantation to patients of UC
is a safe and feasible procedure without recorded complications
like bleeding, thrombosis or any system failure.
It can improve the quality of life of the patients as well
as the clinical illness, laboratory markers, inflammatory process
extent, activity degrees, & multiple usage of medical treatment.
This improvement may be transient needs for longer
period of follow up to assess if SCT can consider as an induction
therapy of remissions or acts only as adjuvant one helps to
deliver patient to inactivity much easier.

43. Endoscopic picture of a patient before and after SCT procedure.
Before After

44.  One of the limitations of our work was the fact that we didn't track the infused
SCs in the patients’ bodies. It is very important to understand the way stem
cells act to improve UC.
 Using different clinical trial protocol to evaluate effect of SCT.
 Clarify the SCT effect on the other used medications and vice versa.
 Compare the use of Hematopoietic and Mesenchymal stem cell therapy as
regard the efficacy and side effects.
 A larger number of patients and longer period of follow up are needed to
assess long lasting effects and complications.
 Evaluate SCT as a maintenance therapy & compare it with other medications.
 Try different routes for SCT as local injection & if it’s better than IV injection
 Evaluating the SCT in patients of other IBDs “Crohn’s disease”.