ReviewsEndoscopy in inflammatory bowel disease: Indications, surveillance, and use in clinical practice
Section snippets
Ulcerative colitis
None of the endoscopic features of IBD are specific, and the diagnosis should be based on the combination of clinical, endoscopic, and histologic findings. However, the characteristic patterns of inflammation in UC help to differentiate it from that of CD or that of enteric infections. Endoscopically the inflammatory changes begin just above the anorectal junction and spread proximally in a confluent and continuous fashion. The inflammation might be confined to the rectum (proctitis) or extend
Role of endoscopy in distinguishing inflammatory bowel disease from other disorders
Endoscopy with biopsy plays an important adjunct to the clinical and radiographic findings in distinguishing IBD from enteric infections, mesenteric ischemia, neoplasia, diverticulitis, radiation colitis, drug-induced colitis, and other etiologies. In a prospective study of patients presenting with acute mucoid bloody diarrhea with suspected IBD, up to one third were found to have an infectious etiology.19 However, complicating this picture is the propensity for patients with IBD to be
Endoscopic differentiation of ulcerative disease and Crohn’s disease
The differentiation of CD and UC has important medical, surgical, and prognostic ramifications. Although ileocolonoscopy can differentiate the characteristic appearances of inflammation of CD and UC in the majority of cases, 10% of patients have “indeterminate” colitis. In a prospective series of more than 350 IBD patients followed for more than 22 months, index colonoscopy and biopsy were accurate in distinguishing UC and CD in 89% of cases, the IBD diagnosis was revised in 4% of cases, and
Ulcerative colitis
Localization of disease aids in determining prognosis and appropriateness of medical therapies, helps to stratify risk of colon cancer, and can help decision making in those undergoing surgical therapy. Colonoscopy with mucosal biopsy is significantly more sensitive than barium contrast studies in defining the extent of disease.30 However, the endoscopic appearance alone tends to underestimate the extent when compared to histologic involvement.31 A recent study comparing chromoendoscopy to
Ulcerative colitis
Drug-induced clinical remission in active UC is associated with endoscopic and histologic remission in approximately 70% and 50% of patients, respectively. The endoscopic response often lags behind clinical response to therapy, and histologic abnormalities often persist longer. Early studies by Wright and Truelove39 demonstrated that 40% of patients who reached endoscopic remission after treatment remained symptom free during a 1-year follow-up compared with 18% if the endoscopic lesions
Ulcerative colitis
Endoscopy is an important modality in helping to establish the diagnosis of pouchitis in patients with ileoanal pouches or ileal reservoirs after surgical resection. Pouchitis is a heterogeneous disorder, and multiple studies have shown that the endoscopic appearance or clinical symptoms alone are poor predictors of pouchitis. Minor endoscopic abnormalities might be present in asymptomatic patients, often some localized perisuture ulcerations, whereas patients with increased stool frequency,
Dysplasia and colorectal cancer surveillance
Patients with long-standing UC and Crohn’s colitis are at increased risk for developing colorectal cancer, and despite the lack of randomized controlled clinical trials, colonoscopic surveillance is widely accepted.49 Despite guidelines there is a tremendous variation in clinical practice. Currently endoscopic surveillance is recommended for patients with extensive UC or Crohn’s colitis for longer than 8 years or left-sided UC or patchy Crohn’s colitis for longer than 15 years, IBD patients
Bleeding
Gastrointestinal bleeding is a common manifestation of IBD; however, acute major hemorrhage is uncommon, accounting for 0%–6% of hospitalizations for CD and 1.4%–4.2% for UC.62 The presence of an endoscopically treatable lesion is uncommon, and endoscopy plays more of a diagnostic and less of a therapeutic role in the management of these patients. Because of the diffuse nature of UC, the examination is usually limited to a flexible sigmoidoscopy, which is used to confirm a disease flare rather
Stricture
Benign stricture can occur as a result of repeated episodes of inflammation in both UC and CD, although more typically seen in the latter. In patients with long-standing disease, colonic strictures should be considered malignant until proven otherwise. Laparotomy should be considered for suspicious strictures that cannot be fully evaluated by radiology and endoscopic biopsy. Although most inflammatory strictures will respond to conservative therapy, obstruction caused by fibrotic strictures is
Toxic megacolon
Toxic megacolon occurs as a rare complication in UC and in even a smaller percentage of patients with Crohn’s colitis. Historically, endoscopy has been an absolute contraindication. However, because of successful reports of colonoscopic decompression in Ogilvie’s syndrome, several authors have attempted similar treatment in IBD patients. Riedler et al69 undertook colonoscopic decompression as a preoperative procedure and believed that subsequent colectomy was facilitated, whereas Banez et al70
Upper gastrointestinal disease
With the exception of the hepatobiliary manifestations, upper gastrointestinal tract lesions in IBD are limited to CD for the most part. There are no indications for upper endoscopy in asymptomatic CD patients, unless it is believed to yield information that will change the subsequent management course. As noted above, an upper endoscopy with biopsy might be indicated in indeterminate colitis, when finding granulomas would help to secure the diagnosis of CD. When the proximal gastrointestinal
Hepatobiliary tract and pancreas
Although a variety of hepatobiliary tract lesions have been described in association with IBD, PSC presents a particular challenge to therapeutic endoscopy. PSC occurs in approximately 3%–5% of patients with UC and in a smaller number of patients with CD.80 ERCP has played an important role in displaying the characteristic cholangiogram appearances of “beads on a string,” diminished arborization, ectasia, and stenosis. Magnetic resonance cholangiopancreatography has a sensitivity and diagnostic
Endoscopic ultrasonography
Ultrasonography has been used in the diagnosis and management of IBD for years. Recognizing that CD tends to be transmural and UC is a superficial mucosal inflammatory process, hopes were raised that EUS would be effective in discriminating cases of indeterminate colitis. However, although initial results were promising, there have been few conclusive studies, and EUS plays a limited role in differentiating UC from CD.
Currently the largest role of EUS is in the diagnosis of suspected perianal
Emerging endoscopic technology
The future of diagnostic endoscopy lies in the potential to make clinical decisions in real time and allow histologic interpretation without removing tissue. These future technologies might utilize alterations in cellular size, architecture, or metabolism to detect differences between healthy and disease tissues. Endoscopic magnification, chromoendoscopy, fluorescence endoscopy, spectroscopy, and optical coherence tomography all strive to make the “optical biopsy” a reality. These techniques
Conclusion
The major indications for endoscopy in IBD are to establish the diagnosis, differentiate UC from CD, define the extent and severity of disease activity, as well as diagnose and manage complications. Therapeutic endoscopy might ultimately play a role in delivering anti-inflammatory or biologic agents directly to local areas of inflamed bowel, whereas emerging endoscopic technologies might significantly improve our ability to diagnose and treat premalignant mucosal conditions.
References (89)
- et al.
Ulcerative colitis
Lancet
(2002) - et al.
Endoscopic and histological patchiness in treated ulcerative colitis
Am J Gastroenterol
(1999) - et al.
Patchiness of mucosal inflammation in treated ulcerative colitisa prospective study
Gastrointest Endosc
(1995) - et al.
Significance of appendiceal involvement in patients with ulcerative colitis
Gastrointest Endosc
(2002) - et al.
Ulcerative ileitis encountered at ileo-colonoscopylikely role of nonsteroidal agents
Clin Gastroenterol Hepatol
(2003) - et al.
Initial experience with wireless capsule enteroscopy in the diagnosis and management of inflammatory bowel disease
Clin Gastroenterol Hepatol
(2004) - et al.
Infectious colitis endoscopically simulating inflammatory bowel diseasea prospective evaluation
Gastrointest Endosc
(1983) - et al.
Culture of colonoscopically obtained biopsy specimens in acute infectious colitis
Gastrointest Endosc
(1994) - et al.
Rectal biopsy helps to distinguish acute self-limited colitis from idiopathic inflammatory bowel disease
Gastroenterology
(1984) - et al.
Colonoscopy in inflammatory bowel diseasediagnostic accuracy and proposal of an endoscopic score
Gastroenterology
(1987)
The role of endoscopic ultrasound in inflammatory bowel disease
Gastrointest Endosc Clin N Am
The role of colonoscopy in the differential diagnosis of inflammatory bowel disease
Gastrointest Endosc
Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis
Gastroenterology
The natural history of ulcerative proctitisa multicenter, retrospective study—Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII)
Am J Gastroenterol
Depth of ulceration in acute colitiscorrelation with outcome and clinical and radiologic features
Gastroenterology
Clinical, biological, and endoscopic picture of attacks of Crohn’s diseaseevolution on prednisolone—Groupe d’Etude Therapeutique des Affections Inflammatoires Digestives
Gastroenterology
Clinical, biological, and histologic parameters as predictors of relapse in ulcerative colitis
Gastroenterology
Endoscopic monitoring of Crohn’s disease treatmenta prospective, randomized clinical trial—The Groupe d’Etudes Therapeutiques des Affections Inflammatoires Digestives
Gastroenterology
Endoscopic and histological healing with infliximab anti-tumor necrosis factor antibodies in Crohn’s diseasea European multicenter trial
Gastroenterology
Pouchitis after ileal pouch-anal anastomosisa Pouchitis Disease Activity Index
Mayo Clin Proc
Predictability of the postoperative course of Crohn’s disease
Gastroenterology
Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis
Gastroenterology
DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis
Gastroenterology
Colonoscopic polypectomy in chronic colitisconservative management after endoscopic resection of dysplastic polyps
Gastroenterology
Polypectomy may be adequate treatment for adenoma-like dysplastic lesions in chronic ulcerative colitis
Gastroenterology
Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis
Gastroenterology
Progression of flat low-grade dysplasia to advanced neoplasia in patients with ulcerative colitis
Gastroenterology
Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis
Gastroenterology
Screening and surveillance colonoscopy in chronic Crohn’s colitis
Gastroenterology
Acute major gastrointestinal hemorrhage in inflammatory bowel disease
Gastrointest Endosc
Endoscopic balloon dilation of colonic and ileo-colonic Crohn’s strictureslong-term results
Gastrointest Endosc
Long-term outcome of non-surgical strictureplasty using metallic stents for intestinal strictures in Crohn’s disease
Gastrointest Endosc
Endoscopic dilation of anastomotic colonic stenosis by different techniquesan alternative to surgery?
Gastrointest Endosc
Crohn’s disease of the upper gastrointestinal tract
Neth J Med
Endoscopic and bioptic study of the upper gastrointestinal tract in Crohn’s disease patients
Pathol Res Pract
Gastric and duodenal fistulas in Crohn’s disease
Gastroenterology
The prevalence of extraintestinal diseases in inflammatory bowel diseasea population-based study
Am J Gastroenterol
Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis
Gastrointest Endosc
Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis
Am J Gastroenterol
Chronic pancreatitis and inflammatory bowel diseasetrue or coincidental association?
Am J Gastroenterol
A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas
Gastroenterology
Endoscopy in inflammatory bowel disease
Patchy cecal inflammation associated with distal ulcerative colitisa prospective endoscopic study
Am J Gastroenterol
Inflammatory bowel diseases
Cited by (126)
New markers in ulcerative colitis
2019, Clinica Chimica ActaEvolution of treatment targets in Crohn's disease
2019, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :Distinctive findings of CD include oedema, erythema, nodular mucosa and ulcerations. Friability, spontaneous bleeding in addition to ulceration depth and size correlates with disease severity [27]. The absence of ulceration is the most significant endoscopic target in CD.