Endoscopy in Managing Inflammatory Bowel Disease (IBD)

Key Points

• Integral part of managing IBD patients
• Series of recommendations provided for clinical practice
• Emphasis on repetition for understanding

Starting the Day with Colonoscopy

• Various images encountered:
  • Active colitis
  • Burnt-out colitis
  • Chromoendoscopy
• Detailed index colonoscopy crucial for differentiating Crohn’s disease from ulcerative colitis
• Studies: Key Findings:
  • 90% accuracy in distinguishing IBD types over 22 months
  • Only 9% change in diagnosis after 5 years in 843 cases

Diagnostic Recommendations

• Intubate the terminal ileum even with proctor sigmoiditis
• Biopsies from proximal colon to check for histological inflammation

Pediatric Considerations

• Relative rectal sparing not always indicative of Crohn’s disease
• Distal UC with cecal patch has similar prognosis to distal disease

Clinical Remission vs. Endoscopic Evidence

• Up to 50% of patients in clinical remission show active disease endoscopically
• High prevalence of clinical symptoms despite mucosal healing

Importance of Endoscopic Disease Assessment

• Endoscopic features predict outcomes:
  • Higher rates of surgery with ongoing inflammation
  • Reduced surgery rates with endoscopic healing
• Guidelines recommend performing endoscopy or surrogate tests when modifying treatments

Classifying IBD Phenotypes

• Montreal Classification used:
  • UC: E1 (proctitis), E2 (left-sided colitis), E3 (extending past splenic flexure)
  • Crohn's Disease: Age, location, behavior, and perianal involvement

Documentation

• Important to document detailed findings:
  • Extent
  • Discontinuous vs. continuous involvement
  • Erythema, granularity, friability, etc.

Scoring Systems for Endoscopy

• Ulcerative Colitis:

  • Mayo Score: 0 (normal) to 3 (severe)
  • UC EIS (Vascular pattern, bleeding, erosions)
  • Mayo Score is preferred for ease of use

• Crohn's Disease:

  • CDEIS (Crohn’s Disease Endoscopic Severity Index)
  • SES-CD (Simplified Endoscopic Score for Crohn's Disease)
  • Rutgeert’s Post-operative Index

Scoring Systems Explained

• Mayo Score: Simple, widely used, and Mayo 0-1 considered as healing
• CDEIS and SES-CD: Involves grading segments for ulcers, affected surface, and narrowing

Recommendations from Stride Group

• Mayo subscore preferred for UC
• SES-CD for Crohn’s Disease in clinical practice
• Importance of endoscopic remission defined as SES-CD of 0-2

Endoscopic Endpoints for Therapy

• Endoscopic remission: SES-CD 0-2
• Post-surgery: i0 or i1 considered remission

Assessment Timing

• Follow-up colonoscopy is essential:
  • For post-op prophylaxis
  • In actively treated patients

Conclusion

• Endoscopy and classification systems (Montreal, Mayo, SES-CD) are vital
• Endoscopic findings predict clinical courses
• Use endoscopy or surrogate tests to inform medical treatment adjustments