Reviews
Endoscopy in inflammatory bowel disease: Indications, surveillance, and use in clinical practice

https://doi.org/10.1016/S1542-3565(04)00441-0Get rights and content

Endoscopy plays an integral role in the diagnosis, management, and surveillance of inflammatory bowel disease (IBD). Because there is no single pathognomonic test that establishes the diagnosis of IBD, endoscopy is useful in establishing the diagnosis, excluding other etiologies, distinguishing Crohn’s disease from ulcerative colitis, defining the patterns, extent, and activity of mucosal inflammation, and obtaining mucosal tissue for histologic evaluation. In established IBD, endoscopy helps define the extent and severity of involvement, which in turn influences medical and surgical decisions, aids in targeting medical therapies, and allows for the management of IBD-related complications. Furthermore, endoscopy plays a key role in the surveillance of patients with long-standing colitis who are at increased risk for dysplasia and the development of colorectal cancer.

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)

  • R.J. Lew et al.

    The role of endoscopic ultrasound in inflammatory bowel disease

    Gastrointest Endosc Clin N Am

    (2002)
  • J.D. Waye

    The role of colonoscopy in the differential diagnosis of inflammatory bowel disease

    Gastrointest Endosc

    (1977)
  • R. Kiesslich et al.

    Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis

    Gastroenterology

    (2003)
  • G. Meucci et al.

    The natural history of ulcerative proctitisa multicenter, retrospective study—Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII)

    Am J Gastroenterol

    (2000)
  • N.A. Buckell et al.

    Depth of ulceration in acute colitiscorrelation with outcome and clinical and radiologic features

    Gastroenterology

    (1980)
  • R. Modigliani et al.

    Clinical, biological, and endoscopic picture of attacks of Crohn’s diseaseevolution on prednisolone—Groupe d’Etude Therapeutique des Affections Inflammatoires Digestives

    Gastroenterology

    (1990)
  • A. Bitton et al.

    Clinical, biological, and histologic parameters as predictors of relapse in ulcerative colitis

    Gastroenterology

    (2001)
  • B. Landi et al.

    Endoscopic monitoring of Crohn’s disease treatmenta prospective, randomized clinical trial—The Groupe d’Etudes Therapeutiques des Affections Inflammatoires Digestives

    Gastroenterology

    (1992)
  • G. D’Haens et al.

    Endoscopic and histological healing with infliximab anti-tumor necrosis factor antibodies in Crohn’s diseasea European multicenter trial

    Gastroenterology

    (1999)
  • W.J. Sandborn et al.

    Pouchitis after ileal pouch-anal anastomosisa Pouchitis Disease Activity Index

    Mayo Clin Proc

    (1994)
  • P. Rutgeerts et al.

    Predictability of the postoperative course of Crohn’s disease

    Gastroenterology

    (1990)
  • M. Rutter et al.

    Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis

    Gastroenterology

    (2004)
  • C.E. Rubin et al.

    DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis

    Gastroenterology

    (1992)
  • P.H. Rubin et al.

    Colonoscopic polypectomy in chronic colitisconservative management after endoscopic resection of dysplastic polyps

    Gastroenterology

    (1999)
  • M. Engelsgjerd et al.

    Polypectomy may be adequate treatment for adenoma-like dysplastic lesions in chronic ulcerative colitis

    Gastroenterology

    (1999)
  • W.R. Connell et al.

    Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis

    Gastroenterology

    (1994)
  • T. Ullman et al.

    Progression of flat low-grade dysplasia to advanced neoplasia in patients with ulcerative colitis

    Gastroenterology

    (2003)
  • M.W. Thompson-Fawcett et al.

    Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis

    Gastroenterology

    (2001)
  • S. Friedman et al.

    Screening and surveillance colonoscopy in chronic Crohn’s colitis

    Gastroenterology

    (2001)
  • D.S. Pardi et al.

    Acute major gastrointestinal hemorrhage in inflammatory bowel disease

    Gastrointest Endosc

    (1999)
  • Y. Breysem et al.

    Endoscopic balloon dilation of colonic and ileo-colonic Crohn’s strictureslong-term results

    Gastrointest Endosc

    (1992)
  • N. Matsuhashi et al.

    Long-term outcome of non-surgical strictureplasty using metallic stents for intestinal strictures in Crohn’s disease

    Gastrointest Endosc

    (2000)
  • G. Bedogni et al.

    Endoscopic dilation of anastomotic colonic stenosis by different techniquesan alternative to surgery?

    Gastrointest Endosc

    (1987)
  • M.J. Wagtmans et al.

    Crohn’s disease of the upper gastrointestinal tract

    Neth J Med

    (1997)
  • P. Schmitz-Moormann et al.

    Endoscopic and bioptic study of the upper gastrointestinal tract in Crohn’s disease patients

    Pathol Res Pract

    (1985)
  • I.M. Jacobson et al.

    Gastric and duodenal fistulas in Crohn’s disease

    Gastroenterology

    (1985)
  • C.N. Bernstein et al.

    The prevalence of extraintestinal diseases in inflammatory bowel diseasea population-based study

    Am J Gastroenterol

    (2001)
  • A.R. Baluyut et al.

    Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis

    Gastrointest Endosc

    (2001)
  • M. Kaya et al.

    Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis

    Am J Gastroenterol

    (2001)
  • M. Barthet et al.

    Chronic pancreatitis and inflammatory bowel diseasetrue or coincidental association?

    Am J Gastroenterol

    (1999)
  • D.A. Schwartz et al.

    A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas

    Gastroenterology

    (2001)
  • R.K. Chutkan et al.

    Endoscopy in inflammatory bowel disease

  • G. D’Haens et al.

    Patchy cecal inflammation associated with distal ulcerative colitisa prospective endoscopic study

    Am J Gastroenterol

    (1997)
  • Y. Bouhnik et al.

    Inflammatory bowel diseases

  • Cited by (126)

    • New markers in ulcerative colitis

      2019, Clinica Chimica Acta
    • Evolution of treatment targets in Crohn's disease

      2019, Best Practice and Research: Clinical Gastroenterology
      Citation 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.

    View all citing articles on Scopus
    View full text