Does Endoscopic Assessment of Mucosal Healing Affect IBD Management

Diagnosis of ulcerative colitis (UC) or Crohn’s disease (CD) relies on the combination of clinical, laboratory, and endoscopic data, which are needed for diagnosis according to adult and pediatric guidelines. Although the importance of an initial endoscopy is well documented, much less is known about the timing of and indications for follow-up endoscopy, with little stated in adult and pediatric guidelines and in the medical literature. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) published in 2008 questioned the utility of endoscopy in exacerbations of pediatric IBD responding to therapy, citing poorer quality of life and perceived excess risk in the pediatric population [1]. Nevertheless, these questions had little supporting evidence until 2009, when a cross-sectional cohort study based at Baylor University was published, in which 285 endoscopic procedures in 230 children with established IBD performed for gastrointestinal bleeding, abdominal pain, weight loss, and diarrhea were evaluated. The authors reported that 42 % of procedures led to documented management changes such as a change of medication regimen, hospital admission, and surgical consultation [2]. Patients with CD (as compared to UC) and patients with mucosal injury (as compared to mucosal healing) were more likely to experience a management change with the initiation of medical therapy; of note, patient symptoms and laboratory values were not associated with a change in management. The authors concluded that endoscopic mucosal evaluation provided important independent data for the evaluation and management of pediatric IBD, particularly in CD. In the adult population, the value of repeated endoscopy is even less well studied. An early randomized clinical trial published by the GETAID group provided no data to support the value of colonoscopy in deciding the length of steroid treatment in colonic CD [3]. Of 136 patients in clinical remission for persistent disease, 96 with mucosal lesions were randomized to start a taper or continue prednisone at the same dose for 5 weeks before tapering. While the prolongation of prednisolone therapy improved endoscopic scores in that subgroup, the success of steroid weaning was almost identical between groups. Yet, in a parallel French study of 85 patients who underwent colonoscopy, 46 had severe and 39 had moderate endoscopic colitis, with response to medical therapy mostly observed in the latter group. [4]. In 2006, the ASGE reiterated an important finding from the literature: Subjective symptoms are not reliable indicators of disease severity, whereas endoscopy is an objective tool [5]. The technical review underlying the guidelines suggested that endoscopy may be helpful in predicting the need for intensified medical therapy or for surgical intervention. Nonetheless, no guidance is provided in the summary guidelines from the organization. The European Crohn’s and Colitis Organisation (ECCO) guidelines support the need for repeat endoscopy if the diagnosis remains in doubt, but do not support routine endoscopy for patients in clinical remission unless it is likely to change management [6]. ECCO guides that endoscopic assessment is indicated in cases of relapse, refractoriness, new symptoms, or when surgery is being considered. Nevertheless, no investigator has attempted to determine whether the findings reported in the 2009 pediatric study are applicable in adults until recently. In this issue of Digestive Diseases & Sciences, Kim et al. [7] attempted to replicate the Baylor pediatric study in an K. Keyashian (&) Oregon Health & Science University, Portland, OR, USA e-mail: keyashia@ohsu.edu