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Endoscopy 2015; 47(08): 726-734
DOI: 10.1055/s-0034-1391863
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Complete mucosal healing defined by endoscopic Mayo subscore still demonstrates abnormalities by novel high definition colonoscopy and refined histological gradings

Marietta Iacucci
1   IBD Clinic, Division of Gastroenterology, University of Calgary, Alberta, Canada
,
Miriam Fort Gasia
1   IBD Clinic, Division of Gastroenterology, University of Calgary, Alberta, Canada
,
Cesare Hassan
2   Department of Gastroenterology, Nuova Regina Margherita, Rome, Italy
,
Remo Panaccione
1   IBD Clinic, Division of Gastroenterology, University of Calgary, Alberta, Canada
,
Gilaad G. Kaplan
1   IBD Clinic, Division of Gastroenterology, University of Calgary, Alberta, Canada
,
Subrata Ghosh   *
1   IBD Clinic, Division of Gastroenterology, University of Calgary, Alberta, Canada
,
Xianyong Gui   *
3   Department of Pathology and Laboratory Medicine, University of Calgary, Alberta, Canada
› Author Affiliations
Further Information

Publication History

submitted 12 August 2014

accepted after revision 30 January 2015

Publication Date:
31 March 2015 (online)

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Video Comment on Marietta Iacucci et al.Endoscopy 2015; 47(08): v14-v14
DOI: 10.1055/s-0034-1392579

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Commentaire du travail de Iacucci M et al., pp. 726Endoscopy 2015; 47(08): 770-770
DOI: 10.1055/s-0035-1547166

Background and study aims: A novel high definition colonoscopy imaging technique (i-Scan) can characterize, in detail, colonic mucosa in patients with ulcerative colitis, and may provide additional information about mucosal healing. The aim of this study was to create a more refined histological and endoscopic criteria based on this novel technique in order to redefine inflammatory activity and mucosal healing.

Patients and methods: A total of 78 patients with ulcerative colitis were assessed by high definition colonoscopy as well as by white light endoscopy (WLE). Mayo endoscopic subscores were assigned to patients according to WLE findings. Mucosal and vascular patterns on high definition colonoscopy were each graded from 1 – 4. A histological scoring system (ECAP system) was designed to reflect all histological changes in ulcerative colitis.

Results: The overall high definition imaging scores (mucosal and vascular patterns) were significantly correlated with Mayo endoscopic subscores (rs = 0.86, 95 % confidence interval [CI] 0.79 – 0.91; P < 0.0001). Of those with Mayo endoscopic subscore of 0, 30.4 % had an abnormal mucosal pattern and 73.9 % of them had an abnormal vascular pattern on high definition colonoscopy; a score of 6 or less had a sensitivity of 95.8 % (95 %CI 85.7 % – 99.3 %) and specificity of 75.9 % (95 %CI 56.5 % – 90.0 %) to detect mucosal healing as defined by Mayo endoscopy subscore of 0 or 1. Furthermore, mucosal and vascular pattern scores were also significantly correlated with most parameters of the proposed ECAP score.

Conclusion: The subtle histological abnormalities underlying the apparently healed mucosa in ulcerative colitis could be detected using high definition colonoscopy and the refined ECAP histology scoring system. These techniques detect residual abnormalities in the majority of patients with seemingly complete mucosal healing by conventional Mayo criteria.

* These authors contributed equally to the manuscript.


 

  • References

  • 1 Travis SP, Higgins PD, Orchard T et al. Review article: defining remission in ulcerative colitis. Aliment Pharmacol Ther 2011; 34: 113-124
    CrossrefPubMedGoogle Scholar
  • 2 Carbonnel F, Lavergne A, Lemann M et al. Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity. Dig Dis Sci 1994; 39: 1550-1557
    CrossrefPubMedGoogle Scholar
  • 3 Korelitz BI. Mucosal healing as an index of colitis activity: back to histological healing for future indices. Inflamm Bowel Dis 2010; 16: 1628-1630
    CrossrefPubMedGoogle Scholar
  • 4 Barreiro-de Acosta M, Lorenzo A, Mera J et al. Mucosal healing and steroid-sparing associated with infliximab for steroid-dependent ulcerative colitis. J Crohns Colitis 2009; 3: 271-276
    CrossrefPubMedGoogle Scholar
  • 5 Baert F, Moortgat L, Van Assche G et al. Mucosal healing predicts sustained clinical remission in patients with early-stage Crohn’s disease. Gastroenterology 2010; 138: 463-468
    CrossrefPubMedGoogle Scholar
  • 6 Colombel JF, Rutgeerts P, Reinisch W et al. Early mucosal healing with infliximab is associated with improved long-term clinical outcomes in ulcerative colitis. Gastroenterology 2011; 141: 1194-1201
    CrossrefPubMedGoogle Scholar
  • 7 Rutgeerts P, Van Assche G, Sandborn WJ et al. Adalimumab induces and maintains mucosal healing in patients with Crohn’s disease: data from the EXTEND trial. Gastroenterology 2012; 142: 1102-1111
    CrossrefPubMedGoogle Scholar
  • 8 Levy LC, Siegel CA. Endoscopic mucosal healing in ulcerative colitis. Aliment Pharmacol Ther 2011; 33: 1254-1255
    CrossrefPubMedGoogle Scholar
  • 9 Romkens TE, Kampschreur MT, Drenth JP et al. High mucosal healing rates in 5-ASA-treated ulcerative colitis patients: results of a meta-analysis of clinical trials. Inflamm Bowel Dis 2012; 18: 2190-2198
    CrossrefPubMedGoogle Scholar
  • 10 Sandborn WJ, Hanauer S, Van Assche G et al. Treating beyond symptoms with a view to improving patient outcomes in inflammatory bowel diseases. J Crohns Colitis 2014; 8: 927-935
    CrossrefPubMedGoogle Scholar
  • 11 Kiesslich R, Goetz M, Hoffman A et al. New imaging techniques and opportunities in endoscopy. Nat Rev Gastroenterol Hepatol 2011; 8: 547-553
    CrossrefPubMedGoogle Scholar
  • 12 Iacucci M, Ghosh S. Looking beyond symptom relief: evolution of mucosal healing in inflammatory bowel disease. Therap Adv Gastroenterol 2011; 4: 129-143
    CrossrefPubMedGoogle Scholar
  • 13 Sauk J, Hoffman A, Anandasabapathy S et al. High-definition and filter-aided colonoscopy. Gastroenterol Clinics North Am 2010; 39: 859-881
    PubMedGoogle Scholar
  • 14 Kodashima S, Fujishiro M. Novel image-enhanced endoscopy with i-scan technology. World J Gastroenterol 2010; 16: 1043-1049
    CrossrefPubMedGoogle Scholar
  • 15 Atkinson M, Chak A. I-Scan: chromoendoscopy without the hassle?. Dig Liver Dis 2010; 42: 18-19
    CrossrefPubMedGoogle Scholar
  • 16 Silverberg MS, Satsangi J, Ahmad T et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 2005; Suppl A 19: 5A-36A
    PubMedGoogle Scholar
  • 17 Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. A randomized study. New Engl J Med 1987; 317: 1625-1629
    CrossrefPubMedGoogle Scholar
  • 18 Travis SP, Schnell D, Krzeski P et al. Reliability and initial validation of the ulcerative colitis endoscopic index of severity. Gastroenterology 2013; 145: 987-995
    CrossrefPubMedGoogle Scholar
  • 19 Kudo T, Matsumoto T, Esaki M et al. Mucosal vascular pattern in ulcerative colitis: observations using narrow band imaging colonoscopy with special reference to histologic inflammation. Int J Colorectal Dis 2009; 24: 495-501
    CrossrefPubMedGoogle Scholar
  • 20 Esaki M, Kubokura N, Kudo T et al. Endoscopic findings under narrow band imaging colonoscopy in ulcerative colitis. Dig Endosc 2011; 23: 140-142
    PubMedGoogle Scholar
  • 21 Hefti MM, Chessin DB, Harpaz NH et al. Severity of inflammation as a predictor of colectomy in patients with chronic ulcerative colitis. Dis Colon Rectum 2009; 52: 193-197
    CrossrefPubMedGoogle Scholar
  • 22 Neumann H, Vieth M, Gunther C et al. Virtual chromoendoscopy for prediction of severity and disease extent in patients with inflammatory bowel disease: a randomized controlled study. Inflamm Bowel Dis 2013; 19: 1935-1942
    PubMedGoogle Scholar
  • 23 Rutgeerts P, Diamond RH, Bala M et al. Scheduled maintenance treatment with infliximab is superior to episodic treatment for the healing of mucosal ulceration associated with Crohn’s disease. Gastrointest Endosc 2006; 63: 433-442
    CrossrefPubMedGoogle Scholar
  • 24 Colombel JF, Sandborn WJ, Reinisch W et al. Infliximab, azathioprine, or combination therapy for Crohn’s disease. New Engl J Med 2010; 362: 1383-1395
    CrossrefPubMedGoogle Scholar
  • 25 D’Haens G, Baert F, van Assche G et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008; 371: 660-667
    CrossrefPubMedGoogle Scholar
  • 26 D’Haens GR. Top-down therapy for IBD: rationale and requisite evidence. Nature Rev Gastroenterol Hepatol 2010; 7: 86-92
    CrossrefPubMedGoogle Scholar
  • 27 Schreiber S. Certolizumab pegol for the treatment of Crohn’s disease. Therap Adv Gastroenterol 2011; 4: 375-389
    CrossrefPubMedGoogle Scholar
  • 28 Sandborn WJ. Mucosal healing with infliximab: results from the active ulcerative colitis trials. Gastroenterol Hepatol 2012; 8: 117-119
    PubMedGoogle Scholar
  • 29 Rutgeerts P, Sandborn WJ, Feagan BG et al. Infliximab for induction and maintenance therapy for ulcerative colitis. New Engl J Med 2005; 353: 2462-2476
    CrossrefPubMedGoogle Scholar
  • 30 Sandborn WJ, Colombel JF, D’Haens G et al. One-year maintenance outcomes among patients with moderately-to-severely active ulcerative colitis who responded to induction therapy with adalimumab: subgroup analyses from ULTRA 2. Aliment Pharmacol Ther 2013; 37: 204-213
    CrossrefPubMedGoogle Scholar
  • 31 Froslie KF, Jahnsen J, Moum BA et al. Mucosal healing in inflammatory bowel disease: results from a Norwegian population-based cohort. Gastroenterology 2007; 133: 412-422
    CrossrefPubMedGoogle Scholar
  • 32 Ardizzone S, Maconi G, Russo A et al. Randomised controlled trial of azathioprine and 5-aminosalicylic acid for treatment of steroid dependent ulcerative colitis. Gut 2006; 55: 47-53
    CrossrefPubMedGoogle Scholar
  • 33 Ferrante M, Vermeire S, Fidder H et al. Long-term outcome after infliximab for refractory ulcerative colitis. J Crohns Colitis 2008; 2: 219-225
    CrossrefPubMedGoogle Scholar
  • 34 Rutter M, Saunders B, Wilkinson K et al. Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis. Gastroenterology 2004; 126: 451-459
    CrossrefPubMedGoogle Scholar
  • 35 Ullman TA, Itzkowitz SH. Intestinal inflammation and cancer. Gastroenterology 2011; 140: 1807-1816
    CrossrefPubMedGoogle Scholar
  • 36 Allez M, Lemann M. Role of endoscopy in predicting the disease course in inflammatory bowel disease. World J Gastroenterol 2010; 16: 2626-2632
    CrossrefPubMedGoogle Scholar
  • 37 Moskowitz RL, Shepherd NA, Nicholls RJ. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir. Int J Colorectal Dis 1986; 1: 167-174
    CrossrefPubMedGoogle Scholar
  • 38 Gomes P, du Boulay C, Smith CL et al. Relationship between disease activity indices and colonoscopic findings in patients with colonic inflammatory bowel disease. Gut 1986; 27: 92-95
    CrossrefPubMedGoogle Scholar
  • 39 Geboes K, Riddell R, Ost A et al. A reproducible grading scale for histological assessment of inflammation in ulcerative colitis. Gut 2000; 47: 404-409
    CrossrefPubMedGoogle Scholar
  • 40 Saverymuttu SH, Camilleri M, Rees H et al. Indium 111-granulocyte scanning in the assessment of disease extent and disease activity in inflammatory bowel disease. A comparison with colonoscopy, histology, and fecal indium 111-granulocyte excretion. Gastroenterology 1986; 90: 1121-1128
    PubMedGoogle Scholar
  • 41 Odze R, Antonioli D, Peppercorn M et al. Effect of topical 5-aminosalicylic acid (5-ASA) therapy on rectal mucosal biopsy morphology in chronic ulcerative colitis. Am J Surg Pathol 1993; 17: 869-875
    CrossrefPubMedGoogle Scholar
  • 42 D’Haens GR, Geboes K, Peeters M et al. Early lesions of recurrent Crohn’s disease caused by infusion of intestinal contents in excluded ileum. Gastroenterology 1998; 114: 262-267
    CrossrefPubMedGoogle Scholar