Endoscopy in Inflammatory Bowel Disease DR. REENA KHANNA

Transcription

1 Endoscopy in Inflammatory Bowel Disease DR. REENA KHANNA ASSISTANT PROFESSOR, UNIVERSITY OF WESTERN ONTARIO

2 Background Clinical trials in ulcerative colitis and Crohn s disease require validated instruments to determine disease activity Endoscopy is a relatively objective measure of inflammation Central reading of videos allows blinded, standardized assessment

3 Background: Endoscopic Indices EI are currently used as gold standard for inclusion into clinical trials and to assess outcome Endoscopy is rater-dependent and poor agreement can be a limitation to clinician based instruments NOTE: none of the instruments currently used have been fully validated

4 Endoscopic Scoring Indices for Evaluation of Disease Activity in Ulcerative Colitis Mayo Score Baron Score UCEIS

5 Mayo Mayo Score = 0 Mayo Score = 1 Mayo Score = 2 Mayo Score = 3 Normal or Inactive Disease Mild Disease (erythema, decreased vascular pattern, mild friability) Moderate disease (marked erythema, absent vascular pattern, friability, erosions) Severe disease (spontaneous bleeding, ulceration)

6 Modified Mayo Modified Mayo Endoscopic Sub-score 0 Normal or inactive disease 1 Mild disease (erythema, decreased vascular pattern) 2 Moderate disease (marked erythema, absent vascular pattern, any friability, erosions) 3 Severe disease (spontaneous bleeding, ulceration) Note the difference between Mayo and Modified Mayo: friability (score 1 and score 2). Any friability is considered as 2.

7 Baron

8 Modified Baron Modified Baron Endoscopic Grading for Assessment of Disease Activity 0 Normal mucosa 1 Granular mucosa with an abnormal vascular pattern 2 Friable mucosa 3 Microulceration of the mucosa with spontaneous bleeding 4 Denuded mucosa (gross ulceration) Note the difference between Baron and Modified Baron (not only are friability and spontaneous bleeding are taken into account, but ulceration also)

9 UCEIS Descriptor (Score most severe lesions) Vascular Pattern Score Likert scale anchor points Definition 1 Normal Normal vascular pattern with arborisation of capillaries clearly defined, or with blurring or patchy loss of capillary margins 2 Patchy obliteration Patchy obliteration of vascular pattern 3 Obliterated Complete obliteration of vascular pattern 1 None No visible blood Bleeding Erosions and Ulcers 2 Mucosal Some spots or streaks of coagulated blood on the surface of the mucosa ahead of the scope, which can be washed away 3 Luminal Mild Some free liquid blood in the lumen 4 Luminal moderate or severe Frank blood in the lumen ahead of endoscope or visible oozing from mucosa after washing intraluminal blood, or visible oozing from a haemorrhagic mucosa 1 None Normal mucosa, no visible erosions or ulcers 2 Erosions Tiny (< 5mm) defects in the mucosa of a white or yellow colour with a flat edge 3 Superficial ulcer Large (2-5 mm) defects in the mucosa which are discrete fibrincovered ulcers in comparison with erosions but remains superficial 4 Deep ulcer Deeper excavated defects in the mucosa with a slightly raised edge Comments

10 Definitions Vascular Pattern branching blood vessels visible through the mucosa. Can be normal or abnormal (patchy or complete obliteration). Normal normal vascular pattern with arborisation of capillaries clearly defined, or with blurring or patchy loss of capillary margins Patchy Obliteration patchy obliteration of vascular pattern Obliterated complete obliteration of vascular pattern

11 Bleeding (intestinal) Leak of blood from intestinal blood vessels. None no visible blood Mucosal some spots or streaks of coagulated blood on the surface of the mucosa ahead of the endoscope, which can be washed away Luminal mild some free liquid blood in the lumen Luminal moderate or severe frank blood in the lumen ahead of endoscope or visible oozing from mucosa after washing intraluminal blood, or visible oozing from a haemorrhagic mucosa

12 Erosions and Ulcers a patch of the tissue that is discontinuous with the surrounding tissue because the tissue has decayed or died. Superficial ulcer a large (2-5mm) defect in the mucosa which is a discrete fibrin-covered ulcer in comparison with an erosion but remains superficial Deep ulcer deeper excavated defect in the mucosa with a slightly raised edge

13 Additional Examples of Endoscopic Descriptors Normal (note normal vascular pattern, no erythema, no erosions, no ulcers, no bleeding) Decreased vascular pattern Absent vascular pattern Erosions (< 5mm) Ulcer (> 5mm) Ulceration

14 Examples of Endoscopic Descriptors Friability Spontaneous bleeding

15 Cochrane Review: Endoscopic Scoring Indices for Evaluation of Disease Activity in Ulcerative Colitis Mosli M, Samaan M, Nelson S, et al.

16 5892 records identified 21 records from other sources 2996 records after duplicates removed 2996 records screened 2996 records excluded 27 full text articles assessed 13 records excluded with reasons 14 reports of 9 scoring systems included 9 validated or partially validated indices out of 33 indices

17 Scoring index Validity Reliability Responsiveness Feasibility Content validity Criterion validity Construct validity Inter Intra TR IC 1 Frøslie Endoscopic + +??????? Score 2 Baron Score ?? +?? 3 Mayo Endoscopic +? + + +???? Sub-Score 4 Jeroen Score +?? +?? +?? 5 Endoscopic Activity +? +?????? Index (EAI) 6 Ulcerative Colitis Colonoscopic Index of Severity (UCCIS) 7 Modified 6-point +? + +????? Activity Index ???? +? + + +?? +? 8 Ulcerative Colitis Endoscopic Index of Severity (UCEIS) 9 Matt s Grade +? + + +???? + positive rating? no information or unclear rating - negative rating Inter = interrater Intra = intrarater TR = test-retest IC = internal consistency

18 Cochrane Review: Endoscopic Scoring Indices for Evaluation of Disease Activity in Crohn s Disease Khanna R, Feagan BG, D Haens G

19 4327 records identified 7 records from other sources 3039 records after duplicates removed 3039 records screened 2984 records excluded 55 full text articles assessed 10 records excluded with reasons 45 reports of 2 scoring systems included 2 validated or partially validated indices out of 2 indices

20 Scoring Index Validity Reliability Responsiveness Feasibility Content validity Criterion validity Construct validity Inter Intra TR IC 1 CDEIS 2 SES-CD ?? +?? ?? +? * Rutgeerts Score (post-operative recurrence) not included in this systematic review + positive rating? no information or unclear rating - negative rating Inter = inter-rater Intra = intra-rater TR = test-retest IC = internal consistency

21 Scoring Systems CDEIS SES-CD

22 Sources of Disagreement Lesions between segments/ anastomosis Anal lesions Superficial ulcers Stenosis

23 Conclusions

24 Case 2: Endoscopy 72 year old female Bloody diarrhea 5 times daily Colonoscopy showed mild ulcerative pancolitis Achieved remission on oral 5-ASA 2.4g/day Increasing symptoms for 3 months No benefit from 5-ASA 4.8 g/day and 4 g enemas nightly Colonoscopy showed severe colitis Partial response to prednisone

25 Case 2: Endoscopy Treated with vedolizumab + MTX and achieved clinical remission Colonoscopy showed improvement but not complete mucosal healing Mayo Score: 2