Endoscopy in Inflammatory Bowel Disease

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Key points

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    The roles of flexible endoscopy in the setting of inflammatory bowel disease include diagnosis, surveillance, and determination of response to treatment and monitoring for the development of recurrence, dysplasia, or malignancy.

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    Advanced techniques, such as chromoendoscopy and narrow band imaging, can be useful adjuncts when performing endoscopy in patients with inflammatory bowel disease.

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    There are several roles for therapeutic endoscopy in the setting of inflammatory bowel disease, including

Screening/biopsies

The 2 main variants of IBD are ulcerative colitis (UC) and Crohn disease (CD). Prior to endoscopic evaluation, careful perianal examination should be performed in symptomatic patients, noting the presence or absence of anorectal findings that may suggest CD, such as anal skin tags, atypical anal fissures, anal canal ulceration, perianal abscesses or fistulae, or anorectal strictures.3 Although there may be subtle differences in the mucosal appearance of CD and UC, these often are difficult to

Assessment of disease activity

Beyond its role in the initial diagnosis of IBD, endoscopy also plays a crucial role in both determining severity of disease and monitoring response to treatment. The presence of mucosal healing has been associated with improved outcomes, including higher remission rates, decreased use of corticosteroids, decreased hospitalization, and lower risk of developing colorectal cancer (CRC).9, 10 Although mucosal healing is generally recognized as mucosa without ulceration or erosion, definitions of

Dysplasia surveillance

Long-standing IBD is a well-established risk factor for the development of CRC, which is responsible for up to 15% of all deaths in patients with IBD. Additionally, IBD (in particular UC) is the third highest risk factor for CRC, ranking only behind familial polyposis coli and hereditary nonpolyposis CRC. Unlike these familial/genetic syndromes, the cancer risk in IBD is related primarily to chronic mucosal inflammation. IBD-associated CRC does not typically follow the adenoma-carcinoma

Ileoscopy/Proctoscopy After Subtotal Colectomy for Ulcerative Colitis

Since the introduction of tumor necrosis factor inhibitors and other biologic agents, operative rates for IBD have shown a significant decline.39 Up to 30% of UC patients, however, still eventually require surgery for neoplasia or medically refractory disease.40 Definitive surgery for UC involves a total proctocolectomy with either ileal pouch–anal anastomosis (IPAA) or end ileostomy (EI). In patients with severe/fulminant colitis, or those on high-dose corticosteroids, this procedure should be

Therapeutic endoscopy in inflammatory bowel disease

Transmural inflammation is a hallmark of CD and can often result in intestinal strictures, which occur in approximately 25% to 40% of patients with CD and in 10% of those specifically with Crohn colitis.60 Strictures typically are identified either endoscopically or by radiographic studies, which have the added benefit of being able to identify concomitant abscess or fistula.61, 62 The most common location for stricture in CD is the terminal ileum in patients who have not undergone prior

Summary

Flexible endoscopy is an essential tool for the diagnosis, staging, observation, and treatment of IBD. Frequent endoscopic assessment and use of standardized scoring systems allow for monitoring of treatment effect with a goal of achieving and maintaining mucosal healing. Biopsies allow endoscopists to evaluate histologic disease activity and screen for dysplastic changes. New technologies allow for better evaluation of the mucosa to find disease that may not be easily seen by the naked eye.

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    • The authors have nothing to disclose.

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