well good morning everyone and we all know that endoscopy is an integral part of how we manage our patients with inflammatory bowel disease and I hope to leave you with a series of recommendations that you can use and take home to your practice many of the things that I will talk about you would have heard earlier today from John Fred but there's nothing wrong with repetition so obviously we start our day doing colonoscopy and there are a number of different images we may come across this one image with a purpose portion is perfectly well active colitis burnt-out colitis and then in the lower part doing chroma endoscopy so again integral part of our evaluation of patients there are a number of things that I want to point out to you this comes from the a s GE position paper on endoscopy in IBD and what they reviewed for you is that there are detailed information from the index colonoscopy and Alaska P before initiating therapy is crucial first for differentiating Crohn's disease for most of colitis now if you look at several different studies it's clear that the index colonoscopy was accurate and distinguishing you see from Crohn's disease in one study in about 90% of individuals who were followed for up to 22 months and in another study of 843 cases 739 of those patients follow for five years only 9% of the patients had a change in diagnosis so clearly that first procedure is crucial intubate the terminal ileum even if the patient has disease that appears to be proctor sigmoid itis take some biopsies from the proximal colon and after to see if there's any histologic evidence for inflammation now there are a number of unconventional wisdoms in IBD that I want to point out for example the patient especially the younger pediatric patient who present first procedure two weeks of bloody diarrhea you can see relative rectal sparing and that's not necessarily Crohn's disease so think about that in your pediatric patients I think everyone in this room is familiar with the concept of distal you see with the seco patch that subset of patients has the same prognosis as those who have just distal disease what we've learned over the last several years and we heard earlier today in terms of treating to targets we can take someone who has active inflammation in return there histologies are completely normal and again we often see patients who were diagnosed several years earlier had documented you see you then become their physician and you do an endoscopy and biopsies in is completely normal pathologist should be able to tell the difference between true granulomas and ruptured crypt anuloma so not all granulomas meet that the patient has Crohn's disease and there may also be an entity where a patient has a rare true granuloma but has no perianal disease and perhaps there's a subset we can call it indeterminate colitis or superficial mucosal crohn's disease now this comes from a review article from David Rubin and basically he pointed out that up to half of patients who are in clinical remission will have endoscopic evidence of active disease when you do a procedure and in addition clearly a high prevalence of clinical symptoms has been noted in patients who actually achieve new kozo healing so this comes from an old study that shows that there's no correlation between CDA I and the CDE is which is one of the endoscopic scoring modalities so clearly you need to look beyond clinical remission and this is something you've heard over and over today and over this past three days now one of the issues is that patients may either be under or over treated if you basically use symptoms so again endoscopic disease assessment is crucial and we now know and we heard earlier today that the rationale for an assessment of endoscopic disease activity is increasingly being applied to treatment algorithms now we know that endoscopic features predict outcomes many of you have seen this this is a group of patients for one year after treatment were in endoscopic healing and you follow the upper group of individuals who are an endoscopic healing with low rates of surgery as opposed to the lower group who at one year had ongoing endoscopic inflammation and at high rates of needing colectomy and we see the same type of data in Crohn's disease in dark blue these are individuals have no severe endoscopic lesions in light blue or purple you see folks that have endoscopic lesions and you're looking at years of follow and the need for surgery so those individuals with D pollsters found on colonoscopy have an increased risk of needing surgery and on the other screen you can see that individuals who have complete or partial healing or near complete healing have the same outcomes and again we heard earlier today from the panel from John Fred Colin Bell that perfection or trying to reach perfection may ultimately backfire getting there most of the way is often what we need to do now obviously we have heard that performing endoscopy or a surrogate test when escalating or abandoning medical therapy when you're ready to give up when you're ready to switch do not use symptoms you need to scope or use a surrogate test now when evaluating individuals in performing endoscopy you can classify IBD phenotypes according to a validated system and that validated system is the Montreal classification and it's used to describe both disease extent in patients with ulcerative colitis and Crohn's disease this is the Montreal classification for you see it's either II one for proctitis e two for website of colitis and anything proximal to the splenic flexure is e train again all this comes from the aste guideline on IBD and endoscopy so a little bit more complicated for Crohn's disease Crohn's disease you need to incorporate the age of onset the location and behavior so age is less than 16 17 to 40 greater than 40 ileal colonic ileal colonic or upper GI and then you also need to describe the phenotype structuring or penetrating and then you get to add a little addendum if the person has Terry anal Crohn's disease now document we all need to come up with ways to document the worst thing that could happen is when you see a patient with scope by someone else and the only report that you get is patchy erythema there's no other description it doesn't tell you what parts of the colon are involved so you need to do something and incorporate whether you're using probation or other endo writers to try to give you all the information because you're going to need that information when you scope the patient a year or two from now so the descriptors that we would like to include in all our reports would be the extent of the these continuous involvement versus skip areas patchy or continuous whether the terminal Illium isn't is involved and then erythema granularity friability erosions ulcerations and loss of vascular pattern now the real issue is is there a consensus for which of these scoring systems we should use so for you see we have the Mayo the UC EIS or the UCC is this is the UC e is which looks at vascular pattern leading and the presence of erosions or ulcers and you generate a sum but most of us clearly in practice are using the Mayo and we'll talk about recommendations as to which one would be perhaps the one that's easiest to incorporate into your practice so actually this is a Mayo zero this is a folk course we've got a completely normal exam this would be a male one mild erythema decreased vascularity mild friability a moderate disease or a Mayo two would be marked erythema complete lack of vascular pattern probability and erosions and then obviously we all know what a Mayo three score is so why has the Mayo score really become the preeminent scoring system for clinical trials and potentially for use in clinical practice it's easy to use and the healing of either a zero or one is considered healing in the Mayo score so we look at a Mayo two video this particular patient has marked erythema there's complete granularity of the mucosa there's some probability if you pass the scope in and out and towards the end of the video you'll see some small erosions now this is a kind of Mayo two bordering on a Mayo three again you put the scope in there spontaneous bleeding and as you move to the end of the video you'll see that there will be significant alteration out there at 12 o'clock so this would be a Mayo two bordering on a male three now what about scoring systems for Crohn's disease is more complicated you have the CDE is the SES CD and in the Rue Kurt's post-operative endoscopic index this looks at the various scoring systems so for example the CDE is you need to break the : into multiple segments the ilium the right to transverse and then you grade each of those segments presence of deep or superficial ulcers their percentage of ulcerated surface the presence or absence of stenosis and then we also have the SES and rubric so let's give you some examples again this is the SES CD things are graded at zero one two and three based on the size of ulcers being none two is greater than two centimeters the ulcerated surface none two greater than 30% the effective surface if it's unaffected one segment it's a zero and on your way up and then the presence or absence of narrowing so let's look at this one this is an SES CD score of nine the ulcers are greater than two centimeters their percentage of ulcerated surface is greater than 30% the affected surface almost the entire bowel is involved and there were no scriptures so this would be an SES score of nine in that segment of the bowel this is a picture of the ileum in this case you can see that the ulcers or video of the ileum in this case you can see that the ulcers are smaller the percentage of ulcerated space is less there are ports that are looked relatively normal and there's no stricture so this would be a less severe or an SES score of five now you have heard earlier today about this particular consensus group called the stride group and what it's basically trying to do is come up with recommendations of what scoring system should should be used in clinical practice and potentially or certainly in clinical trials and potentially in clinical practice and the bottom line for ulcer colitis it was that the Mayo sub score is generally recommended for UC rather than the UC EIS and a zero or one is basically recommended as the end point for being in remission now for Crohn's disease as pointed out earlier absence of alteration is the target resolution of symptoms alone is insufficient and objective evidence of inflammation of the bowel is necessary when making clinical decisions now the SC SC D was felt by this group to be the practical and Morstan alternative to the CDE is the values of the CDE is and the SES correlate relatively well and intra and Inter and intra observer variability has been shown to be less so we're moving towards using the SES CD in clinical trials now what are the endpoints for a Crohn disease patients again if you're using the CDE is it talks about this score score but if we really are concentrating on the SES CD as pointed out again earlier by dr. Colin bell is that often as change in score or a drop in score is a predictor so some studies look use ero to - as as endoscopic remission for patients with Crohn's disease but in other studies they look at a 50% or more reduction in the SES score and I think we're all familiar with the record score where an i0 or i1 is either no lesion to the neo terminal Illium or less than five axis lesions in the neo terminal Illium now another group that looked at endoscopic endpoints is this group the International Organization for the Study of inflammatory bowel disease this was an expert opinion publication and I just mentioned a little bit earlier endoscopic response to therapy would be about a 50% or more decrease in the SES CD and endoscopic remission was defined as an SES CD of 0 to 2 and for all the folks that were here this morning was saying to dr. Ruggiero stalk that I want eyes II wrote ooh I one is considered endoscopic remission after surgery because of a low risk of progression now the next question you need to address is when do you look to assess someone we heard again earlier today various recommendations it's clearly accepted that follow-up colonoscopy whether you're doing it for post op prophylaxis or in those individuals that you're treating that you should do an endoscopic assessment the controversial time is when you do it we heard earlier today six to nine months certainly with anti TNF which we work a little bit faster you can use the six months interval perhaps for the anti integrin agents perhaps little bit longer so again colonoscopy an ileostomy is critical in defining subtypes of IBD and distinguishing IBD from other causes of colitis for example an infectious colitis the montreal classification is certainly easy to use and something that you can incorporate into your practice for both UC and Crohn's disease we all certainly aware of the fact that endoscopic findings can predict clinical course the Mayo score is recommended by multiple consensus groups over the UC EIS and that the SES CD is recommended over the CDE is and then finally use endoscopy or historico tests equal calprotectin imaging when altering medical treatments thank you very much