Endoscopic tools in predicting clinical outcome in IBD patients

2. Endoscopic tools in predicting clinical outcome in IBD patients Dr. AbbasEsmaeilzadeh Assistant professor, Imam Reza (POH) hospital Mashhad university of medical sciences

3. Endoscopic tools in predicting clinical outcome in IBD patients • Endoscopy plays an important role in the diagnosis and management of inflammatory bowel disease (IBD ).

4. Endoscopic tools in predicting clinical outcome in IBD patients • It is useful to exclude other etiologies, differentiate between ulcerative colitis (UC) and Crohn’s disease (CD), and define the extent and activity of inflammation.

5. Endoscopic tools in predicting clinical outcome in IBD patients • Ileocolonoscopy is used for monitoring of the disease, which in turn helps to optimize the management. It plays a key role in the surveillance of UC for dysplasia or neoplasia and assessment of post operative CD. • Rajaratnam et al,World J GastrointestEndosc.

6. Endoscopic tools in predicting clinical outcome in IBD patients • One of the first and most important questions that a patient ask from her/ his physician is: • What is my disease course?

7. Endoscopic tools in predicting clinical outcome in IBD patients • There is not any strong and definite predictor of disease course in any given IBD patient, but grossly some evidences may predict some features of disease such as future extension, recurrence and complications. And one of them is endoscopic appearance.

8. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC could evaluate • Extension • Severity • Complications and • Mucosal healing Ulcerative colitis

9. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Proctitis • Rectosigmoid involvement • Left colitis • Extensive colitis • Pan colitis • Backwash ileitis Ulcerative colitis

10. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Disease extent and activity influence medical management, this is reflected in the choice of medical therapy and the route of administration as well as risk stratification of CRC. Florén et al, Scand J Gastroenterol Ulcerative colitis

11. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Endoscopic mucosal appearance alone might underestimate the extent when compared to the histological involvement. Rajaratnam et al, World J GastrointestEndosc. Ulcerative colitis

12. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • UC is not a static disease but at least partially, a dynamic one, and so the disease extension could be progress or regress during time Ulcerative colitis

13. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension could be increased • Proctitis up to 53% • Rectosigmoid and • Left colitis up to 23% • Extensive colitis 9% • So, with primary endoscopic involvement you could partially predict future extension Ulcerative colitis

14. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Endoscopic findings in UC • Redness • Vascular disappearance • Granularity • Friabilty • Erosions • Ulceration • Pseudopolyp • Stricture • Bleeding Ulcerative colitis

16. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • Mild • Moderate • Severe Ulcerative colitis

17. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • There are many scoring systems for evaluation of UC endoscopic severity Ulcerative colitis

19. Endoscopic tools to predict clinical outcome in IBD patients • Mayo score for assessing ulcerative colitis activity • Stool pattern • Patient reports a normal number of daily stools (0 points) • One to two more stools than normal (1 point) • Three to four more stools than normal (2 points) • Five or more stools than usual (3 points) • Most severe rectal bleeding of the day • None (0 points) • Blood streaks seen in the stool less than half the time (1 point) • Blood in most stools (2 points) • Pure blood passed (3 points) • Global assessment by physician • Normal (0 points) • Mild colitis (1 point) • Moderate colitis (2 points) • Severe colitis (3 points) Ulcerative colitis

20. Endoscopic tools to predict clinical outcome in IBD patients • Mayo score for assessing ulcerative colitis activity • Endoscopic findings • Normal or inactive colitis seen (0 points) • Mild colitis: mild friability, erythema, decrease in vascuality (1 point) • Moderate colitis: friability, marked erythema, vascular pattern absent, erosions seen (2 points) • Severe colitis: ulcerations and spontaneous bleeding (3 points) • Total score 0-12 Ulcerative colitis

21. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC could evaluate • Extension • Severity • Complications and • Healing Ulcerative colitis

22. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Complications • Chronic: CRC • Acute: Colectomy Ulcerative colitis

23. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Complications • Chronic: CRC • Acute: Colectomy Ulcerative colitis

24. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • Among patients hospitalized for a severe attack of UC, the presence of extensive and deep ulcerations at colonoscopy is associated with an increased risk of colectomy on that admission Ulcerative colitis

25. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • In their study , Carbonnel et al showed that colectomy was performed in 43 of the 46 patients who presented severe endoscopic lesions (93%) as compared to 10/39 (26%) of those without such lesions (OR 41). Carbonnel et al, Dig Dis Sci. 1994 Ulcerative colitis

26. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • The colonoscopies performed during severe attacks of UC have also an impact on the long term outcome, with an increased rate of surgery in the long term in patients who exhibit extensive and deep ulcerations at index colonoscopy Carbonnel Aliment PharmacolTher. 2000 Ulcerative colitis

27. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Complications • Chronic: CRC • Acute: Colectomy Ulcerative colitis

28. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Complications • CRC • Risk assessment of CRC also critically relies on endoscopic appearance of the severity of disease activity and extension: both endoscopic and histological inflammation was shown to be associated with increased risk.Gupta et al, Gastroenterology. 2007 Ulcerative colitis

29. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp Ulcerative colitis

31. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp • Is it a sign of more or less severe disease? Ulcerative colitis

32. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp • Backwash ileitis Ulcerative colitis

33. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp • Backwash ileitis • Is this just progression of disease extension or related to severity? Ulcerative colitis

34. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp • Backwash ileitis • Is this a progression of disease extension or severity? • In autopsy study of 217 UC pts 17% had backwash ileitis, and this was more common in pts with pancolitisHaskell et al, Am J SurgPathol. 2005 Ulcerative colitis

35. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Special items: • Pseudopolyp • Backwash ileitis • Is this a progression of disease extension or severity? • An association with an aggressive disease course, primary sclerosingcholangitis, and an increase risk of development of pouchitis following restorative proctocolectomy has also been reported. Abdelrazeq AS, Dis Colon Rectum. 2005 Ulcerative colitis

36. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Extension • Severity • Complications and • Mucosal healing Ulcerative colitis

37. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Mucosal healing • The International Organization of IBD proposed the following definition: absence of friability, blood, erosions and ulcers in all visualized segments of the gut mucosa. Ulcerative colitis

38. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Mucosal healing • Data from several studies suggest that mucosal healing may be associated with a better outcome in UC, more specifically a decreased risk of relapse. Ulcerative colitis

39. ACT 1 and ACT 2 Early mucosal healing a favorable prognostic factor in UC Infliximab-treated patients Week 8 endoscopy P<0.0001 Patients in Corticosteroid-free remission % Week 8 endoscopic score Colombel JF et al. Gastroenterology. 2011 Jun 29. [Epub ahead of print].

40. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Mucosal healing • In the ACT1 and 2 studies on infliximab maintenance in patients with moderately to severely active UC, 48.3% of the patients who achieved mucosal healing at week 8 were in remission at week 30 as compared to only 9.5% of those who did not achieve mucosal healing.Ardizzone S, Gut. 2006 Ulcerative colitis

41. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Mucosal healing • Mucosal healing may also be associated with reduced risk of surgery in UC. In the IBSEN population-based study, UC patients who achieved mucosal healing at 1 year (whatever the treatment) had a decreased risk of colectomy at 5 years (2% vs 7%, P = 0.02)Frøslie et al, Gastroenterology. 2007 Ulcerative colitis

42. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in UC • Mucosal healing • Finally, there is a clear relationship between the extension, grading and chronicity of inflammation in the colon and the risk of colorectal cancer. Allez et al, World J Gastroenterol. Ulcerative colitis

44. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in CD Crohn,s disease (CD)

45. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in CD could evaluate • Severity • Extension • Treatment response and • Complications Crohn,s disease (CD)

46. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in CD could evaluate • Severity Crohn,s disease (CD)

47. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in CD • Erythema • Swelling • Nodularity • Strictures • Aphtoid ulcerations and • Ulcers Crohn,s disease (CD)

49. Endoscopic tools to predict clinical outcome in IBD patients • Endoscopic features in CD • Extension and severity • The CD endoscopic index of severity (CDEIS) is based on the recognition of elementary lesions (non-ulcerated lesions, superficial and deep ulcerations), associated with the appreciation of their surface in five segments (ileum, right colon, transverse, left colon and sigmoid, and rectum Crohn,s disease (CD)