Endoscopy in IBD. F.Hartmann K.Kasper-Kliniken (St.Marienkrankenhaus) Frankfurt/M.

Transcription

1 F.Hartmann K.Kasper-Kliniken (St.Marienkrankenhaus) Frankfurt/M.

2 Indications for endoscopy Diagnosis Management Surveillance

3 Diagnosis Single most valuable tool: ileocolonoscopy Exclusion of other etiologies Distinguishing UC from CD Definition of pattern, extent and activity of inflammation

4 Diagnosis Ulcerative Colitis Characteristic pattern of inflammation Subtotal, total colitis % Left-sided colitis % Proctosigmoiditis % Backwash ileitis - 10 %

5 Diagnosis Ulcerative Colitis Typical mucosal alterations Begin at anorectal junction proximal spread confluent and continuous Erythema, loss of vascular pattern, granular appearance Friable mucosa, erosions, contact bleeding Ulcerations surrounded by inflamed mucosa Normal ileocoecal valve Occasional periappendiceal inflammation

6 Diagnosis Ulcerative Colitis

7 Diagnosis Ulcerative Colitis

8 Diagnosis Ulcerative Colitis Chronic inflammation mucosal atrophy,loss of haustral folds narrowing microcolonic,pseudopolyps

9 Diagnosis Ulcerative Colitis - Biopsy From inflamed and non inflamed mucosa From rectum Patchiness of inflammation after treatment Bernstein CN et al Gastrointest Endsocopy 1995;42: Kim B et al Am J Gastroenterol 1999; 94: endoscopic and histologic patchiness in 23 % of patients

10 Diagnosis Crohn`s Disease Characteristic pattern of inflammation Esophagus, stomach, duodenum 3 5 % Small bowel only % Small and large bowel % Rectum %

11 Diagnosis Crohn`s Disease Skip lesions Colonic disease 50% rectum disease free Aphthous lesions ulcerations Fistula (ileosigmoid) Strictures Biopsies from inflamed and normal mucosa Granulomas 15-36%

12 Crohn`s Disease

13 Crohn`s Colitis

14 Diagnosis Crohn`s Disease capsule Herrerias JM et al Endoscopy 2003;35: Non invasive, no sedation Evaluation of entire small intestine No histology Risk of capsule retention Mow WS et al Clin Gastroenterol Hepatol 2004;2:31-40

15 Capsule Images Aphthous Ulcerations Inflammatory Strictures

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17 Dscn0430.jpg

18 Indeterminate colitis 10 % with indeterminate colitis Pera A et al Gastroenterology 1987;92: % reclassified after 1 2 years (88% of UC, 91% of CD initial diagnosis confirmed) indeterminate colitis: 33% UC, 17% CD Moum B et al Scand J Gastroenterol 1997;32:

19 Assessment of Extent and Severity of Disease Ulcerative Colitis: Extent: histology better than endoscopic appereance progression in mucosal involvement (>50 %) Severity: inactive, mild, moderate, severe

20 Assessment of Extent and Severity of Disease Crohn`s Disease No correlation endoscopic extent/severity clinical severity Modigliani R et al Gastroenterology 1990;98:

21 Assessment of Extent and Severity of Disease postoperative Pouchitis : PDAI Postoperative CD endoscopic evaluation after 6 12 m postop. predictive of early clinical recurrence prophylactic therapy Rutgeerts P et al Gastroenterology 1990; 99:

22 Dysplasia / Colorectal cancer surveillance (no good rct trials!) Colonoscopic surveillance Extensive UC / Crohn`s colitis > 8 y Left-sided UC / patchy Crohn`s colitis > 15 y Family history of CRC PSC and UC Early onset / backwash ileitis Disease severity (Rutter M et al Gastroenterology 2004;126: ) Majority of changes in normal mucosa

23 Prospectively collected data over 30 y from a UC surveillance program for NPL Rutter MD et al Gastroenterology 2006; 130: pat colonoscopies during 5932 patient-years 74 pat. with npl (30 CRC) cum. incidence of CRC: 2.5% at 20y, 7.6% at 30y, 10.8% at 40y 5 y survival rate 73.3% 2/3 with life-threat, npl benefited cancer incidence lower and constant for up to 40 y

24 Chromoendoscopy in UC Kiesslich et al., Gastroenterology 2003

25 Chromoendoscopy in ulcerative colitis N Number of IN Chromo Conv. Colonoscopy N Number of IN Kiesslich et al. Gastroenterology Hurlstone et al. Gastroenterology 2004 Back to back colonoscopy (n=100) Chromo versus conventional colonoscopy 2 IN versus 9 IN (4.5 fold increase) Rutter et al. Gut 2004

26 Endomicroscopy Recent studies indicate that chromoendoscopy can greatly enhance the endoscopic detection of dysplastic lesions in colitic colons. The Committee endorses the incorporation of chromoendoscopy into surveillance colonoscopy for appropriately trained endoscopists. Haifa,

27 Endomicroscopy Confocal endomicroscopy as a novel method to diagnose colitis associated neoplasias in ulcerative colitis 153 patients with long-term UC in clinical remission Randomised at a 1:1 ratio A: Conventional endoscopy with random Bx B: Panchromoendoscopy and Endomicroscopy with targeted Bx Results A: 73 pts.; 31 minutes; 4 Intraepithelial Neoplasias B: 80 pts.; 42 minutes; 19 Intraepithelial Neoplasias Sensitivity: 94.7%; Specificity: 98.3%; Accuracy: 97.8% Haifa, Kiesslich et al., DDW 2005, Plenary Session

28 Endomicroscopy Haifa, Kiesslich et al., DDW 2005, Plenary Session

29 Endoscopic Treatment Bleeding: identification of bleeding site Stricture: TTS balloons Toxic megacolon: colonoscopic decompression

30 PPPPPPPPP stenosierte Anastomose

31 Dilatation mit 18 mm Ballon

32 nach Dilatation

33 Balloon dilation (TTS) in CD Dilation in short fibrotic strictures (< 4cm) diameter: up to 18 mm Long-term success in 50 % (mainly ileocolonic anastomoses) often multiple sessions necessary complications: perforation, sepsis, bleeding no treatment of asymptomatic strictures

34 Major indications: establish diagnosis differentiate UC from CD define extent /severity dysplasia / CRC surveillance diagnose / manage complications Emerging new technologies improve diagnosis and treatment of premalignant mucosal conditions

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