Endoscopic evaluation of patients with inflammatory bowel disease

A Comprehensive Multidisciplinary Approach to Diagnosing Chronic Inflammatory Bowel Diseases: Integration of Clinical, Endoscopic, and Imaging Modalities

Chronic inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, present diagnostic challenges due to their complex and heterogeneous nature. While histology remains fundamental for accurate diagnosis, a multidisciplinary approach incorporating clinical, endoscopic, and imaging modalities is increasingly recognized as essential for comprehensive evaluation. This article delves into the importance of integrating various diagnostic techniques in the assessment of IBD. Colonoscopy and histology, with its ability to directly visualize the intestinal mucosa, play a central role in the diagnostic process. However, histological analysis alone may not suffice, necessitating the inclusion of advanced imaging techniques, such as magnetic resonance enterography (MRE), computed tomography enterography (CTE), and intestinal ultrasound (IUS). These techniques provide valuable insights into the disease's extent, severity, and complications, and should be used in conjunction with biochemical parameters. These modalities complement traditional endoscopic and histological findings, offering a more holistic understanding of the disease process. A multidisciplinary approach that incorporates clinical, endoscopic, histological, serological, and imaging assessments enables clinicians to achieve a more accurate and timely diagnosis of IBD. Moreover, this integrated approach facilitates personalized treatment strategies tailored to individual patient needs, ultimately improving clinical outcomes and quality of life for those affected by chronic inflammatory bowel diseases.

Red/NIR-I-Fluorescence Carbon Dots Based on Rhein with Active Oxygen Scavenging and Colitis Targeting for UC Therapeutics

Ulcerative colitis (UC) is a chronic inflammatory disease with uncontrolled inflammation and demage to the intestinal barrier. Rhein, a bioactive compound in traditional Chinese medicine, has anti-inflammatory and intestinal repair effect. However, their clinical application is limited by their hydrophobicity and poor bioavailability. L-arginine, as a complement to NO, has synergistic and attenuating effects. In this paper, red/NIR-I fluorescent carbon dots based on rhein and doped with L-arginine (RA-CDs), which are synthesized by a hydrothermal process without any organic solvents, are reported. RA-CDs preserve a portion of the functional group of the active precursor, increase rhein solubility, and emit red/NIR-I light for biological imaging. In vitro experiments show that RA-CDs scavenge excessive reactive oxygen species (ROS), protect cells from oxidative stress, and enable the fluorescence imaging of inflamed colons. In a DSS-induced UC mouse model, both delayed and prophylactic treatment with RA-CDs via intraperitoneal and tail vein injections alleviate UC severity by reducing intestinal inflammation and restoring the intestinal barrier. This study highlights a novel strategy for treating and imaging UC with poorly soluble small-molecule drugs.

Diagnosis and management of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic and relapsing immune-mediated disease of the gastrointestinal tract with a gradually increasing global incidence and prevalence. A prolonged course of IBD leads to a decline in patient quality of life and the creation of a substantial economic burden on society. Owing to the lack of specific diagnostic markers, the diagnosis of IBD still needs a gold standard based on a combination of clinical manifestations, imaging, laboratory, and endoscopic results. Accordingly, the current goals of IBD treatment are to alleviate clinical symptoms and reduce recurrence rates. Therefore, it is imperative to develop a standard set of procedures to diagnose and treat IBD. In this review, we summarize prominent and emerging studies, outline classical and contemporary approaches to diagnosing and managing IBD, and integrate multiple guidelines. Furthermore, we propose the possibility of establishing an early and comprehensive diagnostic workflow and personalized management strategy in the future. We aim to enhance the quality and standardization of diagnostic and treatment procedures for IBD.

The Current Status of Molecular Biomarkers for Inflammatory Bowel Disease

Diagnosis and prognosis of inflammatory bowel disease (IBD)-a chronic inflammation that affects the gastrointestinal tract of patients-are challenging, as most clinical symptoms are not specific to IBD, and are often seen in other inflammatory diseases, such as intestinal infections, drug-induced colitis, and monogenic diseases. To date, there is no gold-standard test for monitoring IBD. Endoscopy and imaging are essential diagnostic tools that provide information about the disease's state, location, and severity. However, the invasive nature and high cost of endoscopy make it unsuitable for frequent monitoring of disease activity in IBD patients, and even when it is possible to replace endoscopy with imaging, high cost remains a concern. Laboratory testing of blood or feces has the advantage of being non-invasive, rapid, cost-effective, and standardizable. Although the specificity and accuracy of laboratory testing alone need to be improved, it is increasingly used to monitor disease activity or to diagnose suspected IBD cases in combination with endoscopy and/or imaging. The literature survey indicates a dearth of summarization of biomarkers for IBD testing. This review introduces currently available non-invasive biomarkers of clinical importance in laboratory testing for IBD, and discusses the trends and challenges in the IBD biomarker studies.

A comprehensive review and update on ulcerative colitis. Dis Mon 2019;65:100851. [PMID: 30837080 DOI: 10.1016/j.disamonth.2019.02.004]

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.

Ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease affecting the colon, and its incidence is rising worldwide. The pathogenesis is multifactorial, involving genetic predisposition, epithelial barrier defects, dysregulated immune responses, and environmental factors. Patients with ulcerative colitis have mucosal inflammation starting in the rectum that can extend continuously to proximal segments of the colon. Ulcerative colitis usually presents with bloody diarrhoea and is diagnosed by colonoscopy and histological findings. The aim of management is to induce and then maintain remission, defined as resolution of symptoms and endoscopic healing. Treatments for ulcerative colitis include 5-aminosalicylic acid drugs, steroids, and immunosuppressants. Some patients can require colectomy for medically refractory disease or to treat colonic neoplasia. The therapeutic armamentarium for ulcerative colitis is expanding, and the number of drugs with new targets will rapidly increase in coming years.

Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis

Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Demography and clinical course of ulcerative colitis in Arabs - a study based on the Montreal classification

OBJECTIVE

Ulcerative colitis (UC) is generally considered a disease of the Caucasian populations in developed countries, but its incidence is increasing rapidly in many developing countries, including the Middle East. The objective of this study was to determine the clinical epidemiology of UC in Arabs.

MATERIAL AND METHODS

This cross-sectional medical record-based descriptive study collected sociodemographic and clinical information on 182 Arab patients with UC in Kuwait. Age at diagnosis, extent and severity of disease were determined according to the Montreal classification. results: Among the 182 patients, 91 (50.0%) were males. The median age at diagnosis was 28.5 years. Family history of UC was reported by 26 (14.3%) patients. The extent of the disease was limited to the rectum in 34 (18.7%) patients, left sided in 67 (36.8%) and pan colitis in 81 (44.5%). At the time of inclusion in the study, 127 (69.8%) patients were in clinical remission, 53 (29.1%) had mild-to-moderate disease and 2 (1.1%) had severe colitis. Younger age at diagnosis and non-smoking were associated with more extensive colitis. The majority of patients were treated with mesalamine, steroids and immunomodulators, while biologic therapy and surgery were needed in 5% and 4% of the patients, respectively.

CONCLUSIONS

UC presents more commonly at younger age among Arabs in Kuwait. Extensive disease at presentation is associated with younger age at diagnosis and absence of tobacco smoking. There also appears to be less need for surgery and biologic therapy for the disease in this population.

Comparative study of intestinal tuberculosis and primary small intestinal lymphoma

AIM: To characterize the clinical, radiological, endoscopic and pathological features of intestinal tuberculosis (ITB) and primary small intestinal lymphoma (PSIL).

METHODS: This was a retrospective study from February 2005 to October 2012 of patients with a diagnosis of ITB (n = 41) or PSIL (n = 37). All patients with ITB or PSIL underwent computed tomography (CT) and pathological examination. Thirty-five patients with ITB and 32 patients with PSIL underwent endoscopy. These patients were followed for a further 18 mo to ascertain that the diagnosis had not changed. Clinical, endoscopic, CT and pathological features were compared between ITB and PSIL patients.

RESULTS: Night sweating, fever, pulmonary TB and ascites were discovered significantly more often in ITB than in PSIL patients (P < 0.05), however, abdominal mass, hematochezia and intestinal perforation were found significantly more frequently in PSIL than in ITB patients (P < 0.05). Ring-like and rodent-like ulcers occurred significantly more often in ITB than in PSIL patients (P < 0.05), however, enterorrhagia and raised lesions were significantly more frequent in PSIL than in ITB patients (P < 0.05). The rate of granuloma was significantly higher in ITB than in PSIL patients (87.8% vs 13.5%, χ² = 43.050, P < 0.05), and the incidence of confluent granulomas with caseous necrosis was significantly higher in ITB than in PSIL patients (47.2% vs 0.0%, χ² = 4.034, P < 0.05). Multi-segmental lesions, mural stratification, mural gas sign, and intestinal stricture were more frequent in ITB than in PSIL patients (P < 0.05), however, a single-layer thickening of bowel wall, single segmental lesions, and intussusception were more common in PSIL than in ITB patients (P < 0.05). Necrotic lymph nodes, comb sign and inflammatory mass were more frequent in ITB than in PSIL patients (P < 0.05). The bowel wall enhancement in ITB patients was greater than that in PSIL patients (P < 0.05), while the thickening and lymph node enlargement in PSIL patients were higher than those in ITB patients (P < 0.05).

CONCLUSION: Combined evaluation of clinical, radiological, endoscopic and pathological features is the key to differentiation between ITB and PSIL.

Trends and Factors Affecting Hospitalization Costs in Patients with Inflammatory Bowel Disease: A Two-Center Study over the Past Decade

With the growing number of patients with inflammatory bowel disease (IBD) and hospitalization cases, the overall medical care cost elevates significantly in consequence. A total of 2458 hospitalizations, involving 1401 patients with IBD, were included from two large medical centers. Hospitalization costs and factors impacting cost changes were determined. Patients with IBD and frequency of hospitalizations increased significantly from 2003 to 2011 (P < 0.001). The annual hospitalization cost per patient, cost per hospitalization, and daily cost during hospitalization increased significantly in the past decade (all P < 0.001). However, length of stay decreased significantly (P < 0.001). Infliximab was the most significant factor associated with higher hospitalization cost (OR = 44380.09, P < 0.001). Length of stay (OR = 1.29, P < 0.001), no medical insurance (OR = 1.31, P = 0.017), CD (OR = 3.55, P < 0.001), inflammatory bowel disease unclassified (IBDU) (OR = 4.30, P < 0.0001), poor prognosis (OR = 6.78, P < 0.001), surgery (OR = 3.16, P < 0.001), and endoscopy (OR = 2.44, P < 0.001) were found to be predictors of higher hospitalization costs. Patients with IBD and frequency of hospitalizations increased over the past decade. CD patients displayed a special one peak for age at diagnosis, which was different from UC patients. The increased hospitalization costs of IBD patients may be associated with infliximab, length of stay, medical insurance, subtypes of IBD, prognosis, surgery, and endoscopy.

Serum glycan markers for evaluation of disease activity and prediction of clinical course in patients with ulcerative colitis

BACKGROUND

The aims of this study were to determine the change of whole-serum N-glycan profile in ulcerative colitis (UC) patients and to investigate its clinical utility.

METHODS

We collected serum from 75 UC patients at the time of admission and the same number of age/sex-matched healthy volunteers. Serum glycan profile was measured by comprehensive quantitative high-throughput glycome analysis and was compared with disease activity and prognosis.

RESULTS

Out of 61 glycans detected, 24 were differentially expressed in UC patients. Pathway analysis demonstrated that highly sialylated multi-branched glycans and agalactosyl bi-antennary glycans were elevated in UC patients; in addition, the glycan ratio m/z 2378/1914, which also increased in UC, showed the highest Area under Receiver Operating Characteristic curve (0.923) for the diagnosis of UC. Highly sialylated multi-branched glycans and the glycan ratio m/z 2378/1914 were higher in the patients with total colitis, Clinical Activity Index >10, Mayo endoscopic score 3, or a steroid-refractory status. In particular, the glycan ratio m/z 2378/1914 (above median) was an independent prognostic factor for the need for an operation (hazard ratio, 2.67; 95% confidence interval, 1.04-7.84).

CONCLUSIONS

Whole-serum glycan profiles revealed that the glycan ratio m/z 2378/1914 and highly sialylated multi-branched glycans increase in UC patients, and are correlated with disease activity. The glycan ratio m/z 2378/1914 was an independent predictive factor of the prognosis of UC.

Relative efficacy of different MRI signs in diagnosing active Crohn's disease, compared against a histological gold standard

INTRODUCTION

There has been growing interest in the use of MRI in assessing Crohn's disease because of its lack of ionising radiation. Many MRI signs have been described in the literature, but their relative utility is unknown.

METHODS

The MRIs of the bowel performed at 1.5 Tesla were blindly reviewed on 26 patients with recent histology (surgery and/or colonoscopy and their associated reports) according to a dedicated pro forma. Each patient's bowel was divided into nine segments. Each segment was assessed as to the presence or absence of 15 MRI signs described in the literature: abnormal gadolinium enhancement (both subjective and objective), wall oedema, fat oedema, fat proliferation, nodal enlargement, free fluid, wall nodularity, serosal blurring, mural thickening >4 mm, stricture, multi-segmental disease, fistula, abscess and layered contrast enhancement. The results were compared against a histological gold standard with a six-point scale of disease severity.

RESULTS AND CONCLUSIONS

MRI correctly identified all 15 patients with at least established mucosal disease, and three of eight with only mild mucosal disease. Combining these results, a positive MRI correlated highly with at least early mucosal disease (positive predictive value 95%), while the presence of established mucosal disease was unlikely if MRI was negative (negative predictive value 100%). The MRI signs found to be the most sensitive for detecting active Crohn's disease were those related to the bowel wall, namely, wall thickening, nodularity, contrast enhancement and oedema. The most specific signs were the presence of multi-segmental disease, layered contrast enhancement and complications (fistula and abscess).

Is sigmoidoscopy sufficient for evaluating inflammatory status of ulcerative colitis patients?

BACKGROUND AND AIMS

An adequate range of colonic observations for precise evaluation of inflammation in ulcerative colitis (UC) patients has not been reported.

METHODS

Retrospective analysis of 545 colonoscopic examinations of UC patients was carried out. Severity of mucosal inflammation was evaluated using the Mayo score of endoscopic index at each location (rectum, sigmoid colon, descending colon, and the oral side of the splenic flexure) in each patient. The colonic site with maximum inflammation was determined for each patient.

RESULTS

Of 545 patients, 319 (59%) had maximum inflammation in the rectum, 79 (14%) in the sigmoid colon, 70 (13%) in the descending colon, and 77 (14%) on the oral side of the splenic flexure. Severe inflammatory activity (Mayo 3) was observed more frequently in patients who had maximum activity in the descending colon or the more proximal portion than those who had this in the rectum or sigmoid colon (42% vs 25%, P<0.0001). The first-attack patients were significantly more frequently found in patients with maximum severity in the descending colon or the oral side of splenic flexure than those with maximum severity in the rectum or sigmoid colon (P=0.016). Moreover, among 134 patients with no inflammation in the rectum and sigmoid colon, 54 (40%) had inflamed mucosa in the descending colon or the more proximal portion.

CONCLUSIONS

Sigmoidoscopy is not sufficient for evaluating inflammation in UC patients. In particular, colonoscopy is necessary for first-attack patients and patients who have a discrepancy between rectosigmoid observation and symptoms.

Predictors of clinical and endoscopic findings in differentiating Crohn's disease from intestinal tuberculosis

BACKGROUND

There are many similarities and overlaps in clinical manifestations and ileocolonoscopic features between Crohn's disease (CD) and intestinal tuberculosis (ITB). Differentiation between CD and ITB is of great importance.

AIM

To investigate the values of clinical and endoscopic findings in differential diagnosis between CD and ITB.

METHODS

Clinical and endoscopic features of a cohort of 130 cases of CD and 122 cases of ITB from June 2003 to February 2009 were retrospectively reviewed following predetermined criteria. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve (ROC curve).

RESULTS

The clinical features helpful in differentiating CD from ITB are hematochezia, intestinal surgery, perianal diseases, pulmonary tuberculosis, ascites, and positive of PPD skin test; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 90.3, 76.8, 83.8, 80.7, and 88.0%, respectively. The endoscopic features helpful in differentiating CD from ITB were rectum involved lesions, longitudinal ulcer, cobblestone appearance, fixed-open ileocecal valve, transverse ulcer, and rodent ulcer; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by endoscopic features were 82.9, 82.0, 82.5, 82.9, and 82.0%, respectively.

CONCLUSIONS

It was proposed that a diagnostic algorithm based on available clinical and endoscopic regression equation could improve the current sensitivity, specificity, and accuracy in differentiating between CD from ITB.

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

Novel application of low pH-dependent fluorescent dyes to examine colitis

Background

Endoscopy capable of fluorescence observation provides histological information on gastrointestinal lesions. We explored the novel application of low pH-dependent fluorescent dyes for fluorescence observation of crypt structure and inflammatory cell infiltration in the colon.

Methods

Low pH-dependent fluorescent dyes were applied to the colonic mucosa of normal mice for observation under fluorescence stereomicroscopy system. We also examined mouse models of colitis, which were induced by trinitrobenzenesulfonic acid, dextran sulfate sodium or interleukin-10 deficiency.

Results

Topical application of low pH-dependent fluorescent dyes revealed crypts as ring-shaped fluorescent stains by visualizing the mucin granules of goblet cells. Because of the minimal fluorescence intensity of the low pH-dependent fluorescent dyes in phosphate-buffered saline, it was not necessary to wash the mucosa before the fluorescence observation. 4-Nitro-7-piperazino-2,1,3-benzoxadiazole (NBD-PZ) was quicker to achieve complete staining (three minutes) than LysoSensor Green DND-153 and DND-189 (20 minutes). In each type of colitis, NBD-PZ revealed the destruction of the crypts as the disappearance of the ring-shaped fluorescent stains and the infiltration of inflammatory cells as the aggregation of punctate fluorescent stains through visualization of lysosomes.

Conclusions

Low pH-dependent fluorescent dyes, especially NBD-PZ, are suitable for topical application to the colonic mucosa and have characteristics that allow for the histological examination of colitis.