uh V and uh it fell on to me rather uh belatedly that I will chare this uh Geo session uh I hopefully Prof Sandy uh like Thompson will uh join a bit later um so this uh session is looking at endoscopic uh scoring systems in IBD and and our presenter for this afternoon is Sean from deran so without further do I'm sure we all want to finish up as early as we can so we can have our supper uh I'm going to hand over to Sean so Sean do you want to start your screen sharing yeah thanks a okay can you see my slides yes we can uh yes okay good afternoon everyone um this afternoon session as to is endoscopic scoring systems in inflammatory B disease I'll take you through u a little bit of why we do it and uh we'll go through the major scoring systems that's currently uh available to us and U how they differ so endoscopy is uh assessment is currently the Criterion standard for both diagnosis and assessment of mucosal disease activity it affords us the ability to assist with prognosis as well as monitoring for displasia um in patients with inflammatory B disease and it further allows us to assess for a response to clinical therapy we look at the history of endoscopy over the years in the 1940s it started off with rigid sigmoidoscopy to true love and V in the 1950s having a simple scoring system um for their patients that had colitis later the bar index was developed in 1964 and quite a few years later in 1987 the mayor endoscopic uh scoring index was developed for assessment of patients with colitis and if you go down the path of Al of colitis wasn't until 2012 that a a new scoring system of colitis in this compli index of severity um was developed to assist with uh further prognostication in those patients regarding Cola Crohn's disease um soon after the Mayo endoscopic score the Cron's disease endoscopic index of severity was developed followed by the Redgate score and that was later modified in 200 for the simplified score then these are the scoring systems that we currently um have available to us in our current setting so why they important it's because targets have changed over time with the development and Improvement in endoscopic uh scoring systems and visualization due to technology and this has allowed us new targets for therapy and the target was then defined as treating all patients with high risks for disease preparation early and the goal here was to prevent or limit intestinal injury or disability and then end scope was deemed the tool to assist for both remission andos of healing in this patient so the International Organization for the study of inflammatory bow disease in 2015 first uh put together the The Stride committee which is selecting therapeutic targets and inflammatory B disease The Stride one set out uh set of um suggested guidelines of goals for the management and followup of patients with hos of colitis as well as those with um Crohn's disease and in a of GES you look at the uh the clinical patient reported outcomes was that of resolution of rectal bleeding and diarrhea but also endoscopically having a Mayo endoscopic score of originally 0 to one and later modified to endoscopic score of zero and the otive colitis endoscopic index of less than one to suggest mosal healing and they added ad junks of histological remission with Crone disease those patient clinical reported outcome was both resolution of the abdominal pain and diarrhea but endoscopic remission of ulceration in those patient and a simplified endoscopic score of less than three with a subcore of zero indicating mucosal healing was suggested um by The Stride committee this uh diagram uh is a quick uh look at what stri two in recently um try to uh put forward for your targets for imp patient with INF flammatory B disease and you can see that the St committee has broken those targets into both shortterm intermediate and long-term targets the endoscopy is used in in both the short and intermediate targets its emphasis was in its role um in the long-term targets being set at endoscopic healing with normalization of quality of life and again the adjunct of Poss isical healing so you can see endoscopy endoscopy um and the visualization of the mucosa important role for the management of these patients as set out by this two um criteria so in Cron's disease what you want to find is absence of ulceration and in alcera of GIS you want to have this resolution of variability and the tools for doing that and assisting you um with determining this is the use of colonoscopy or sigmoidoscopy or iloc colonoscopy in those patients that underwent some form of surgical restriction or intervention however currently there's no validated definition for endoscopic uh mucosal remission in most of these scoring systems but what endoscopic scoring systems do add to therapy is that you have uniformity and Reporting it gives objectivity with assessing the mucosa it aids standardization with the reporting of mucosa appearance and again clinical U decision making can be augmented as you can go from your patient not achieving short-term taret to re-evaluate um a patient for their long-term targets and vice versa so if you look at the endoscopic scores in Al of colitis that has currently um been used in studies the first first score to address these key points was the Bak score which was first published in 1978 there is a three-point score and the varibles that they looked at was predominantly mucosal bleeding but no endoscopic um score was given for suggested for healing or remission the Southerland index Al of colitis disease activity index was a 4 point scale developed 5 years later and here specifically they looked at the mucosal appearance but again no endoscopic score was put forward to suggest the mission Rait um developed a score with four variables with an absolute score between 0 and 12 and for the first time in ' 89 they looked at both vascular pattern granularity and and glucose of variability but they also suggested a cumulative score of less than four uh is comparative with endoscopic healing the original bom score that was developed in 64 was later modified in 2005 and they took it one step further with their five point scale where they looked at points of bleeding and allocated a degree of whether it was moderate or severe including both nodularity friability granular appearance and the presence of ales and they suggested that an Improvement in the grade by two scales down or healing was a accumulative score of zero currently the most common scores used for assessment endoscopic assessment in ative colitis is the Mayo endoscopic score originally developed in ' 87 and later modified in 2007 and it's a simple score it's a fourpoint scale that ranges from 0 to three and its primary variables is that of inflammation looking at the variability of the mucosa presence of bleeding looking for Alis and assessing the vascular pattern endoscopic healing was reported as a Mayo um endoscopy score of0 or one however the ACT Trial Act One trial suggested that a score of zero was comparable with a 50% reduction in collec rate at both one and three years post followup I mentioned later in 2012 the alos colitis endoscopic index of severity was developed and this was to address um shortcomings with regards to the May endoscopic score especially with regards to mucoso appearance and presence of bleeding it had three grades the three grades at four subgrades but it was a cumulative score and the variables that it looked at was the presence of bleeding erosions and houses with elimination of the probability which is key to endoscopic score and they suggested an endoscopic healing of U size of list one to be um significant in that patient another in system that has been that has taken Traction in The Last 5 Years is also of colitis col colonoscopic index of severity also a fourpoint scale but they added a global five segment assessment to the vascular pattern pleading gity and Alis but there's no endpoint set for what is deemed endoscopic healing within that score scoring system so you take a closer look at the alc of kius endoscopic index of severity you can see that in this table we have our three variables of both the vascular pattern bin of bleeding bin of erosions or ulceration and it's a numeric uh scale that is allocated um to each one of these components so you either have normal pattern with clear defined capilary sov vascular pattern and then numerically the score is added um with with regards to the abnormality that's detected so either it's Pat obliteration of the vascular pattern or it's completely obliterated regarding bleeding you can either have no bleeding and again numerically um a a value is allocated with the degree of bleeding if it's localized the Lua if there mild bleeding within the Lum or this franking and the same goes for Alis but Alis was defined erosion and Alis was defined based on the size of the defect and the depth so the erosions were present but less than 5 mm defects we get a score of one superficial Alis would be a larger defect of more than five and then deep um ouris would get the higher score so once you've allocated a score to the the vascular pattern the bleeding and the Pres of erosions ALC serations cumulative score would then be taken and that would be the alitis endoscopic inity total score for that patient at endoscopy this is just this is a video representation of what I just said and you can look at the images regarding to the vascular pattern you can see the first image there that looks the first image that uh has a normal appearance with its normal tricular form of its blood vessels and then as the blood vessels loses its normal appearance to be completely obliterated that score is then increased with regards to the bleeding again you can see that the bleeding at a mucosal level um it's just small visualized uh bleeding lumino M bleeding and then moderate Frank bleeding um which is quite clear in a to endoscopes same goes for the presence of erosions and superficial houses in that particular scoring system now the mayor endoscopic uh index of sity or endoscopic score uh is the most widely used endoscopic score currently by endoscopists for the assessment in patients with aritis now if we go through this particular diagram a male zero is both the images a b and c in this diagram they all refer um refer to the different aspects of what is in mayz score whereas a is completely normal colon your normal um flowing of your capillary blades at mosa B exactly the same uh picture and then C this is a patient that has had healing with some scaring that you can see but again there normal uh capillary blood vels in the background and may one uh score which looks at hyper pres of AUM is reflected in images d E and F if you look at images D and E you can see that there's either thema in D in E the vascular pattern is um is abnormal it's not quite as clear um as that in image a and if you look at image F you can again see that there's normal patches of normal vascular pattern um with some um areas of aea and abnormal blood vessels so basically a combination of DN and all three of those images de NF would alloc would be equivalent to a Mayo endoscopic score of one regarding Mayo endoscopic score two this is the presence of a granular appearance as well as um the presence of mucosal um either thema or mosal bleeding so image G if you can look at that you can see that the vascular pattern is completely absent and there's presence of erosions in both IM whiches is ghn I and then a Mayo endoscopic score of three is whether you have images J and K where you can see that there's deep um ulceration superficial ALC serations um that's present and in L with luminal hem that's present so any combination of that on its own would then be a May endoscopic score three so we take a closer look we look at this particular image here um of the colon you can see that there's there's no Etha in this uh image the vascular pattern is completely normal there's no granularity or variability there's no mucosal bleeding and there's no Alis so that would equate to a May endoscopic score of zero you look at this particular image the the normov vascular pattern has been lost in the background there's a bit more Emma present but there's no granularity there no reability of that mucosa there's no mucosal bleeding and there's no Alis present here and this would then equate to a m endoscopic score of one this particular image over here shows complete loss of that normal vascular pattern as in the first example there's more granularity that's present you can see that there's mucosal uh some mucosal bleeding but there's no clear um also that you can see and the surface has a granular appear in appearance inter dispersed with the erosions that is present and that would be a equivalent two my endoscopic score of two and that granular appearance in dispers with the erosions in some mucosal bleeding is what is often to referred to as the soal varability of the mucosa and in this image you can clearly see that this is abnormal mucosa lots of variability to this mucosa there's a linear ala and there mu coal beting that's monoscopic score of three so the M endoscopic score was modified to improve its uh validity um across uh um various inter um users and first thing that they did to the m endoscopy score the modified M endoscopy score was to divide the colon into five segments so if you look at the image on the right the from to to AO the colon is divided into the rectum the sigmoid the descending colon transverse colon and the ascending colon first uh part of the modified score is any degree of variability in any of the segments would automatically upgrade that score to a May endoscopic score of two within that segment however your the for each segment the endoscopist is required to assess um whether there is presence of disee or not so you need to have a May endoscopic score for both for each segment and then the extent or maximum extent of the inflammation is then calculated um when you are in that uh segment and that's recorded in decimeters you then take the total uh of the M endoscopy score in the five segments you add it up multiply it by the maximum extent and then you divide it um over five and you get a um and you get a value and this value is um is quite comparable with collec rates about three and five years in a small randomized thr however um it is more tedious than this uh than the May endoscopic score that we currently use if you compare the two scoring systems the endoscopic scoring uh system and the U size you can see that monoscopic score has four clear this uh this distinct classes whereas the AL endoscopic is continuous focus in the May oscopy score is at hyperia with mucosal lesions whereas usze has basically removed probability and looks at vascular pattern lesion and the presence of bleeding the range of the score is between Z and three and not to8 in U size whereas moso healing is a score of either M score of zero or a May score of one originally not specified what is mucosal endoscopic healing for the uze but it is proposed at a score of less than three would suggest remission and a score of less than accumulate score of less than one which is just mucosal healing and severe diseases is well defined in both the scoring systems score of of three or more in the May endoscopy score or score more than seven in the use size the differences between the two is the m endoscopic score is an easy score to remember it's it's uh much wider use in clinical practice and the use as as a new scoring system that has more variables is not that frequently used but it does have the value that it is more objective than the M endoscopic score and it has a clear prognostic value has shown in validated um uh studies post the release of the scoring system that's also of colitis what about um Cron's disease So currently the three commonest scoring systems more frequently used Corin system Crohn's disease is the Crohn's disease index of severity and here it assesses luminal Crohn's disease and it measures the variation with regards to endoscopic activity and mucosal healing it assess the whether the superficial and deep offes whe it looks at the surface of the mucosa that's been affected by the disease and then it also assesses for ulcerative and non-ulcerative stenosis it's a cumulative score and it ranges from 0 to 44 and the suggested uh evidence for remission is a reduction in Baseline by 3 to five from the original score though the Sonic trial suggested that a 50% reduction from the index uh score is sugges of endoscopic remission quite a tedious score it's has a lot of um varibles and takes a lot of time to complete the simplified endoscopic score for Cron's dise was then developed to sort of simplify the um the CI score so it looks at exactly the same parameters as as the C and otherwi assisting lumino cron disease um and looking at its variations in endoscopic activity but its variables is has been well defined so it looks at the Alum presence its size looks at the surface that is affected by the Alum it looks at the surface that is affected by the disease itself and it looks at any type of bow narrowing again a numeric cumulative numeric score of 0260 but endoscopic uh remission is suggested by a score of less than three and mucosal healing in um these patients is a score of zero then the rate score the rate score is developed to assess for postoperative recurrence in Cron's disease and this important to remember that it looks at the site of the ILO andos iloc colonic and asmosis it's a five SC score ranging from i0 to I4 and I Z is indicative of mucosal healing in that um particular patient so the Chon disase endoscopic index of severity has has six variables um and these six variables needs to be assessed in every segment of the colon that is visualized by the endoscopist so the first of the variables is pres of alus so the alus there deep Alis present then you get a new numeric value allocated um for their presence if they're superficial get a numeric value allocated the next part is looking at the surface involved by the disease and here the endoscopist has to look at the surface of of the segment that is being reviewed so how much of the actual um segment that is being visualized is involved with the disease how much of that segment has ala in it and then the second part is looking at the surface involved by the Ala so the first part is which part of the segment has actual alus or thema in it the second part is looking at the surface that is involving the Ala itself and you get numeric value allocated to to it and then it looks at stenosis so either ulcerated stenosis and this can be anywhere along the colonic pathway during endoscopy or non-ulcerated um stenosis so for each of these parameters score is allocated and you get a cumulative score um for the patient now the simplified endoscopic score only looks at four variables the first two is houses and um with regards to the houses they f it is it was better defined as to um the type of ales so the Ala was either called actus alus and if it was between 1 and 5 mm you would allocate one point um for the presence of that ala large ala was defined as ala between 5 and 20 millim and you would then allocate two points for that and then very large was more than 20 millim and you'd get a three point score to that regarding the alculated surface it was again also well defined and it looked at the percentage of that segment that had ulcerated surface in it so you would visualize the segment and if it was less than 10% of that segment that had the Ala in it you would get it would allocate one point if it was between 10 and 30% of that segment two points would be allocated and if it was more than 30% of the segment then you would get three points allocated the third um descriptor is the actual affected surface of the segment and you would look at whether it was more less than 50% of the segment that you are currently visualizing between 50 75% of that segment and more than 75% of that segment um and then regarding narrowing which is the last descriptor narrowing was split into three um subgroups so it was either a single narrowing but you were still able to pass the scope and you would allocate a single point there's multiple narrowings um but the scope was then still possible beyond each of these narrowings you get two points and if it was not possible and it was Frank no this nois you would get three points so for each one of these descriptors in the simplified score the maximum points that you could get the maximum points that you could possibly get for um each of these descriptors was three and the cumulative points so the simplified incopy score would then work out to 12 at its maximum um for patients that you're evaluating with Cron's disease now if we look at this endoscopic uh image in front of us here you can see that there's an Alon and that ala is some somewhere between 10 and 20 millim in size and it's covering just about 10% of the surface um just more than 10% of the surface of this visualized um of where the Elsa is and it's making up roughly almost 50% of the segment but there's no narrowing so this p uh score would end up being six as you allocated two points to both the size the surface and the S and the segment but no points allocated because of the absence of n you can see in the distance over there that the um colon is extending well when look at this particular endoscopic uh image you can see that this is a large ala this Al is making up more than 30% of the visualized uh surface of where the El is present the presence of disease involves more than 75% of the segment of colon that we're currently looking at and if you look this uh in the distance I'm not sure if it projects quite well um you can see that the Lumin is starting um to narrow so this uh particular image would you would get three points for each segment and you get a total C score of 12 this particular example you can you can see that there's apus alus um they're quite small they're less than 5 mm and the Ala surface is less than 10% um of the affected area and it's making up less than 50% of the segment that's being visualized there images on a fold but beyond my word for Beyond The Fold there's no narrowing in the spti so each of these uh segments would then get a score of one one one and zero and give you a score of three what about the R R gits grading for postoperative cres so in the rits grading for postoperative cres five variables whereas i z tells you that there's no lesions within the neot terminal ien i1 is the presence of apis Alis but it's clearly defined it's less than five apis Alis um indicates that this is an i1 an I2 however is act Alis more than five Alis with a normal mucosa interpers between them or they sort of the skip areas with larger lesions and the larger lesions are usually lesions or houses that is less than 10 mm and these Legions can either be confined um to the colonic anastomosis and if the lesion is confined to the colonic anastomosis the modify I2 I2 becomes modified to an i2a and if there's moderate lesions within the rest of the neoterminal in other words more than five Al with some Emma it becomes an i2b I3 is well defined as having diffused atus alitis with extensively inflamed mucosa and then an i4 is diffuse inflammation is large hous there's noes and there's pres of stenosis active disease okay we look at this particular image in a patient that's had colonic reection NE terminal ISM and you can see that the there's absolutely no lesions present at this endoscopic view this this is reflective of an i z this particular endoscopic example you can see to the left of the image there's few oses over there this few there's only three of them present there's less than five and there's no other lesion so there should be an i1 these two images first spell attention to image a this is a lesion that is confined to the anastomosis um and you can see it's a large near circular ala that is under Leo colonic an asmosis with Associated Hema and that would be classified as an I2 a whereas image B is in the ne terminal ium and you can see on the top of the image there's at least the five small um oses at the top and three smaller ales at the bottom so clearly more than five um small oses and that would also be an I2 but that would be an i2b um as the disease is not defined or confined to the iloc colonic an asmosis this particular image you can see that there's Emma with the f i you can see that also with EMA over there in the um in your terminal IIM and this is an I um three and this particular image is clear narrowing um at the anotic site with diffuse em this uh the surface mucosal bleeding with ulcerations um in this particular patient you can even see a small R to Salis um in the bottom part of the endoscopic emission this would be classified as a rats I4 now mobile capsule endoscopy scores do exist they're quite new um and they are available and currently there's uh only two scores um that have been both used and validated um they're quite a complex scoring system so um and the two that has been used is the lower score which divides bow into three equal parts so they call in and This Ss as well as EMA um the score is is obtained from images at capsule endoscopy and the it's a um complex arithmetic that needs to be done to get a um a score for uh the L score the capsu endoscopy activity index or the N score um had a bit more defined subia so they have three subgroups again looking at inflammation looking at Cent of disease looking at strictures again some complex algebra needs to be done um to get a final um score for uh both the n and the sesa die score um they're not very commonly used in clinical practice so um but you can I would suggest that listeners go and read about them I really cover them in the store but they do exist so in saying all of that with regards to endoscopy and all these different uh endoscopic scores um that need to be recorded at endoscopy the question then Remains What should be on the report and it's important to remember that as an endoscopist doing Endoscopy in patients with inflammatory B disease when you do uh um your colonal scope sigos Scopes or colonoscopes you want to achieve four goals in these patients you should Define the proximal margin of the disease and the distribution of the disease that you encounter and you need to grade the disease activity and irrespective of what scoring system you use whether you use the S CD score you use the bio endoscopic score the usai score or the rate score in patients with postoperative Cronos disease you need to be clear when you grade these scores um especially for uh post followup of these patients and you need to try to assess whether the appearance is consistent with alones but this is not always possible in the cute setting of um both uh colitis is and it might only become apparent later on but you should at least uh attempt to try and differentiate and then you should always identify complications such as strictures presence of masses and conceal neoplasia within your report at Endoscopy in conclusion I'm going to leave you with this uh quote from it's not mine it's a quote from um from limy and it states that the real world impact of rapid strides and artististic Pursuits of meaningful targets however hinges on the universal adoption of clinical and endoscopic scor EX system within practice it's only then that we will realize the virtues of such personalized medicine which is exemplified by our urge to treat to Target uh approach and I'm going leave it there and thank you for your time and open the floor to some questions thank you hi um I'm not sure if Chris is there but uh forgive me I got way laid on the way to this meeting so um I was meant to be nomally down to chair it um I caught the last three quarters of it so um I have one question to start start the ball rolling and that is with all these endoscopic scoring systems and with um the Holy Grail being endoscopic healing how do you marry that with reduction in the number of endoscopies because endoscopy is an expensive modality especially if you're confirming histology um in in these uh situations so when is is are these scoring systems increasing the number of endoscopies necessary or what what is the the algorithm for when you should scope the patient once you've obviously established the disease and the diagnosis yeah thanks BR the um it's not a easy answer to that question because yes the if you're going to apply all of these scoring systems you you are leaning yourself to frequent colonoscopies and the important part should be that the endoscopist itself should familiarize themselves first and foremost with um what is a Mayo endoscopic score of two um what is a a um CD score of six what what are the parameters that you're actually looking for um so that when you go and uh recope patient for evaluation for response therapy um at either 8 to 12 weeks um post initial diagnosis you exactly what you are looking for U to sort of minimize the amount of time that you're going to re uh scope a patient so the first part would be um to upscu the endoscopes himself with recognizing what is um abnormal and normal um and with regards to what specifically you're going to look for um in these patients the striker um two committee did uh allude to um the need for endoscopic healing uh um and it all it opened up was having more and more endoscopies and how that would be managed um so it was a concern with the with a working group um when they suggested uh um the endoscopic healing as a as a endpoint Target for um uh inflammatory B disease um so it was a concern but again when you're going to repeat it you're going to have to really um if that first assessment and second assessment followup after initial therapy um is quite concise with what you're seeing um then that should guide you um with regards to how frequently you would scope the patient in that setting so in some ways yeah I I I find that whole whole thing very interesting because it is it is a costly exercise to do that and also a volume exercise when you do it and obviously some in some ways once the T patient is stable your managing them without endoscopy you're managing them based on their CRP or their Cal protectant and uh trying to avoid endoscopy so it seems a bit of a catch 22 so to speak to to to an outsider and a simple surgeon I don't know if any VG do you have any thoughts um on uh some of these uh quandries that that the endoscopic scoring systems pose yeah yeah uh firstly Sean uh appreciate the overview of endoscopic scoring systems uh I think uh with crohn's disease it's actually a little bit harder I don't think in terms of our routine uh uh everyday practice when we scope somebody with crohn's disease do we actually uh religiously score them um what's fair important I can understand how come because the Cron's disease scoring system is a bit of you know you'll be uh trying to do your and and trying to work out a calculation it does become a bit um like you tedious um so I always emphasize especially for Cron's disease and also for alra citis to an extent as well that you have to use your English like sort of language and go through and describe the ERS that you've seen the location the extent of them uh the shape of the ulcers the morphology subus and obviously in ours circumstances we also trying to distinguish endoscopically between Crohn's disease and intestinal uh tube osis uh how frequently should we scope them um I think that is an area that is evolving I don't think there's any clear consensus which I have seen on that up front that first scope and I was always uh when I started out was actually uh told us that first scope that somebody does on an IBD uh patient is usually the most important scope it gives you uh severity it tells you the extent of disease uh Etc because after you Institute any form of uh like a treatment that's going to alter completely and um so uh uh I think with intestinal Ultras sound feal alpro you can safely go ahead and do those however if the patient hasn't achieved clinical REM Miss and your feal Cal protector is inconclusive or you aren't able to hold on for for it then I think you would probably want to have a relook and uh scope to see that you're not dealing with IBS or some other in effective iology uh we do not routinely repeat scopes on individuals who have achieved a clinical REM mission in Crohn's unless we are concerned about the development of a stricture or they had really severe cronn on that first scope and we are concerned that over time that they may they at high risk for developing uh structuring uh and we may choose to have a relook there so it really depends on the symptoms and uh the fal calpro and the you know other indices like CRP Etc uh with Al of colitis it's a little bit easier because yes that first scope gives you an idea of the extent of the disease and um but subsequent to that if you do need to go back and your relook because a patient is not uh responding well or they have responded uh clinically but the feal Calo remains elevated and you don't have to do a full scope on those individuals you can just do a quick look spmo um uh and that should give you your endoscopic score to and to say whether they have improved or if they haven't or this may be uh ostop Colitis with an overlap of some you know IBS um so yeah so with Al of kitis it's actually a bit easier and with Al of kitis it's also you maybe maybe we can see if anyone else has some questions Fiji that's that's really good of of you summarizing at your level that's fantastic I have um perhaps one other question and then I'd like to just see if there's any other comments but um what about we've heard of AI for adenoma detection where is AI with these scoring systems and is that coming and when are we going to move I see all the endoscopic companies are now um converting to dcom so you'll be able to store all your videos now on your uh your uh Hospital Systems so where are we with AI and where are we with routine video because then obviously you have a a record and a reproducible record that you can go back to um when you're scoping your p next so so regarding ai ai is not actually being included in any of the um update recommendations at endoscopy however the modified Mayo index uh what they for you to assess a patient on a modified mayor index you have to both either short video document or photo document those five segments um of the colon at endoscopy um so that then so one of the suggestions was to improve time with the endoscopy was you would do the Scopes photo document um uh where you went and then at the end of the scope slate um you would then go back to do the actual calculations um with some of the algorithms but a has not been included as part of um the endoscopic scoring systems there's none of none of the scoring systems actually have an an AI algorithm the the one um video endoscope score does have an AI algorithm in it so when the images are produced at video endoscopy it actually gives you this little um ner score attached uh to it and then all you have to do is then to go and uh verify that the scores that whatever the AI picked up was there but it hasn't been validated Pro um for use in clinical practice but it is there and the the one suggestion by um the authors of the uh out of kittis endoscopic index uh of severity was that um short videos um of segments should be um recorded uh and stored for U Future rels to sort of minimize time but it was just it was suggested it wasn't um a um what for a a recommendation um from them thank you yeah are you do are you routinely recording your your ala of colitis and UC patients in your practice not not not video recording uh we try and photo document uh um as much as um where we can um and we always uh we always tell us to take pictures um so yeah um but most of these pictures and then we can take from there we try and upload it onto patient's filing systems uh if I can add the proper video uh to do a video record and it's actually a problem all over the world where people are saying we should video record is storage space because after a year you're GNA you're going to need a fair amount of storage for AO yes I I think that most of the big units now and most of the endoscopes now will be dcom compatible the same as the x-rays so I I would imagine that that the video storage is now on certainly in in European countries and in America is going to be on the the pack system and you'll be able to access it so I don't think it will be such a problem I think it is a problem just now uh it's a big problem um but again it depends on the volume of your endoscopy practice and exactly how that would be factored in Chris do you have any words of wisdom for for the scoring systems no no excellent Sean no covered most things thank you Sean I mean AI is coming not only from an endosc comic mucosal point of view but integrating um the histology activity as well which I think is is very exciting um just as far as Cal protectant concerned I mean that has changed the way we endoscope patients with inflammatory B disease and watch out uh for Cal protection when it comes to small B Crohns you can often U be let down but I think there's good correlation between um colonic IBD and FAL CPR uh thank thanks EG for taking care of the introduction and also your comments is there anyone else who has got some questions I think we really have had well I've been treated to three quarters of it and uh thank you again VG for standing in for me um I try usually to honor my commitment yeah sorry I was also late today yeah Sean no problem I was here because Sean was speaking and he reminded me to be yes well he's I think you you should be proud of your training he did a good job um near he nearly had experience in caring as well I think we were we were we were asked by vikos to actually specifically about is also away uh and uh I think the reason why we were asked to do this is there was some concern that the fellows were not from with the endoscopic scoring uh systems in IBD so I think for the uh fellow it is definitely worth your reading over and I think if you're in a training and I'm assuming all of you are doing Scopes every uh like other day at least um you should try and score these patients especially the aler of citis patients it's fairly easy and we do know there is Observer variability and that is a issue but it's more of issue in those who are inex experien as you develop experience with scoring these patients into a Mayo one or Mayo 2 Mayo 3 you will see that that interobserver variability becomes uh uh far yes so rehearse your scoring systems in Real uh time and preferably with a supervisor in the room as well if you are if you are starting out so I think um we've come to an end um thank you very much to to everyone um especially um our speaker and uh just to remind us that um we're sort of hosted by Echo India from the echo um platform and that these um this this talk today will be available on the gastro Foundation website for those who missed it or want to refresh their memory on the scores and uh I'd like to thank the the ladies as always in the background who are who are keeping us honest or trying to keep me honest and um thanks again to to the many people who who uh who are responsible for helping us to put the the funding together to to run these sessions next week I believe is truly IBD and um what what what better of a lead in than that to uh the the realm of all these uh biosimilars and other fancy uh fancy drugs for the management of these uh conditions so thanks again and I think um we call a close to the meeting thank you thanks Sandy thanks everyone thanks