Endoscopy 2017; 49(12): 1285
DOI: 10.1055/s-0043-119216
Letter to the editor
© Georg Thieme Verlag KG Stuttgart · New York

The role of confocal laser endomicroscopy in assessing mucosal healing in patients with ulcerative proctitis

Cristian Gheorghe
1   Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
2   Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
,
Gabriel Becheanu
1   Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
2   Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
,
Razvan Iacob
1   Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
2   Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
,
Bogdan Cotruta
1   Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
2   Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
,
Anca Dimitriu
1   Center for Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
2   Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
› Author Affiliations
Further Information

Publication History

Publication Date:
29 November 2017 (online)

We read with interest the article by Nakazato et al. [1] regarding the assessment of histological healing in ulcerative colitis (UC) using endocytoscopy. We would like to comment on two aspects of the study.

First, the study group included patients with UC in endoscopic remission. Endocytoscopy only evaluated the rectum in all patients, without taking into consideration the disease extension at diagnosis or the followed treatment. Treatment can change the classically described features of UC: patchiness, rectal sparing, and normalization of the mucosa can be observed [2]. Awareness of these treatment-related effects is important, otherwise patients with proximal persistent inflammation but spared rectum due to medical treatment may be misclassified as being in histological remission, and unnecessary therapeutic changes may be made.

Second, relapse was only clinically evaluated based on the abdominal symptoms. The weak correlation between clinical and endoscopic or histological scores is well known [3]. We consider that in patients with inflammatory bowel disease, a relapse of disease should only be considered in cases with biological and endoscopic confirmation (which also permits a differential diagnosis).

We conducted a similar study for assessing mucosal healing in patients with ulcerative proctitis using confocal laser endomicroscopy (CLE) [4]. We selected 24 patients with ulcerative proctitis who had been in clinical and endoscopic remission on 5-aminosalicylic acid for at least 2 years. A Baron score of 0 was used to define endoscopic remission and a score ≥ 1 was considered as active disease. The device used was an EC3870K (Pentax, Tokyo, Japan). A targeted biopsy was performed in all patients for histological analysis.

CLE and conventional endoscopy results agreed in diagnosing remission in 10 of these patients (41.7 %). In addition, CLE found features of active disease in 14 patients (58.3 %) who had been classified as in remission at conventional endoscopy examination: fluorescein leakage was present in all cases, an enlarged distance between crypts was found in 12 cases (85.7 %), and an irregular shape of crypts was found in 6 cases (42.9 %). Most of the patients (57.1 %) had a combination of two or all three features of active disease. The histological analysis confirmed the CLE description in all cases.

In conclusion, we consider that endocytoscopy or CLE can replace biopsy specimens only in selected cases of ulcerative proctitis. In more extensive disease, an adequate number of biopsies should be obtained from all colonic segments in order to confirm histological remission. A multidisciplinary approach (clinical, endoscopic, histological), or a specialist in inflammatory bowel disease should be involved in defining and selecting cases of histological remission for treatment cessation.

 
  • References

  • 1 Nakazato Y, Naganuma M, Sugimoto S. et al. Endocytoscopy can be used to assess histological healing in ulcerative colitis. Endoscopy 2017; 49: 560-563
  • 2 Magro F, Langner C, Driessen A. et al. European consensus on the histopathology of inflammatory bowel disease. J Crohns Colitis 2013; 7: 827-851
  • 3 Osada T, Ohkusa T, Okayasu I. et al. Correlations among total colonoscopic findings, clinical symptoms, and laboratory markers in ulcerative colitis. J Gastroenterol Hepatol 2008; 2: 262-267
  • 4 Gheorghe C, Cotruta B, Iacob R. et al. Endomicroscopy for assessing mucosal healing in patients with ulcerative colitis. J Gastrointest Liver Dis 2011; 20: 423-426