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Ellrichmann M, Schulte B, Conrad CC, Schoch S, Bethge J, Seeger M, Huber R, Goeb M, Arlt A, Nikolaus S, Röcken C, Schreiber S. Contrast enhanced endoscopic ultrasound detects early therapy response following anti-TNF-therapy in patients with ulcerative colitis. J Crohns Colitis 2024:jjae034. [PMID: 38457414 DOI: 10.1093/ecco-jcc/jjae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIM Though colonoscopy plays a crucial role in assessing active ulcerative colitis (aUC), its scope is limited to the mucosal surface. Endoscopic ultrasound (EUS) coupled with contrast-enhancement (dCEUS) can precisely quantify bowel wall thickness and microvascular circulation, potentially enabling the quantitative evaluation of inflammation.We conducted a prospective, longitudinal study to assess therapy response using dCEUS in aUC patients undergoing treatment with adalimumab (ADA) or infliximab (IFX). METHODS 30 ADA- and 15 IFX-treated aUC patients were examined at baseline and at 2, 6, 14 weeks of therapy and 48 weeks of follow-up. Bowel wall thickness (BWT) was measured by EUS in the rectum. Vascularity was quantified by dCEUS using Rise Time (RT) and Time To Peak (TTP). Therapy response was defined after 14 weeks using the Mayo Score. RESULTS Patients with aUC displayed a mean BWT of 3.9±0.9 mm. In case of response to ADA/IFX a significant reduction in BWT was observed after 2 weeks (p=0.04), whereas non-responders displayed no significant changes. The TTP was notably accelerated at baseline and significantly normalised by week 2 in responders (p=0.001), while non-responders exhibited no significant alterations (p=0.9). At week 2, the endoscopic Mayo score did not exhibit any changes, thus failing to predict treatment responses. CONCLUSION dCEUS enables the early detection of therapy response in patients with aUC, which serves as a predictive marker for long term clinical success. Therefore, dCEUS serves as a diagnostic tool for assessing the probability of future therapy success.
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Affiliation(s)
- Mark Ellrichmann
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Berenice Schulte
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Claudio C Conrad
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stephan Schoch
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Johannes Bethge
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Marcus Seeger
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Robert Huber
- Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
| | - Madita Goeb
- Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
| | - Alexander Arlt
- Department of Internal Medicine, Israelitic Hospital Hamburg, Hamburg, Germany
| | - Susanna Nikolaus
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christoph Röcken
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stefan Schreiber
- Interdisciplinary Endoscopy, Medical Department I, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Rimondi A, Gottlieb K, Despott EJ, Iacucci M, Murino A, Tontini GE. Can artificial intelligence replace endoscopists when assessing mucosal healing in ulcerative colitis? A systematic review and diagnostic test accuracy meta-analysis. Dig Liver Dis 2023:S1590-8658(23)01023-X. [PMID: 38057218 DOI: 10.1016/j.dld.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUNDS AND AIMS Mucosal healing (MH) in inflammatory bowel diseases (IBD) is an important landmark for clinical decision making. Artificial intelligence systems (AI) that automatically deliver the grade of endoscopic inflammation may solve moderate interobserver agreement and the need of central reading in clinical trials. METHODS We performed a systematic review of EMBASE and MEDLINE databases up to 01/12/2022 following PRISMA and the Joanna Briggs Institute methodologies to answer the following question: "Can AI replace endoscopists when assessing MH in IBD?". The research was restricted to ulcerative colitis (UC), and a diagnostic odds ratio (DOR) meta-analysis was performed. Risk of bias was evaluated with QUADAS-2 tool. RESULTS A total of 21 / 739 records were selected for full text evaluation, and 12 were included in the meta-analysis. Deep learning algorithms based on convolutional neural networks architecture achieved a satisfactory performance in evaluating MH on UC, with sensitivity, specificity, DOR and SROC of respectively 0.91(CI95 %:0.86-0.95);0.89(CI95 %:0.84-0.93);92.42(CI95 %:54.22-157.53) and 0.957 when evaluating fixed images (n = 8) and 0.86(CI95 %:0.75-0.93);0.91(CI95 %:0.87-0.94);70.86(CI95 %:24.63-203.86) and 0.941 when evaluating videos (n = 6). Moderate-high levels of heterogeneity were noted, limiting the quality of the evidence. CONCLUSIONS AI systems showed high potential in detecting MH in UC with optimal diagnostic performance, although moderate-high heterogeneity of the data was noted. Standardised and shared AI training may reduce heterogeneity between systems.
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Affiliation(s)
- Alessandro Rimondi
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, United Kingdom.
| | | | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, United Kingdom
| | - Marietta Iacucci
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, Hampstead, London, United Kingdom; Department of Gastroenterology, Cleveland Clinic London, London, United Kingdom
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Gastroenterology and Endoscopy unit, Milan, Italy
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3
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Dekker E, Nass KJ, Iacucci M, Murino A, Sabino J, Bugajski M, Carretero C, Cortas G, Despott EJ, East JE, Kaminski MF, Karstensen JG, Keuchel M, Löwenberg M, Monged A, Nardone OM, Neumann H, Omar MM, Pellisé M, Peyrin-Biroulet L, Rutter MD, Bisschops R. Performance measures for colonoscopy in inflammatory bowel disease patients: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54:904-915. [PMID: 35913069 DOI: 10.1055/a-1874-0946] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) presents a short list of performance measures for colonoscopy in inflammatory bowel disease (IBD) patients. Current performance measures for colonoscopy mainly focus on detecting (pre)malignant lesions. However, these performance measures are not relevant for all colonoscopy indications in IBD patients. Therefore, our aim was to provide endoscopy services across Europe and other interested countries with a tool for quality monitoring and improvement in IBD colonoscopy. Eight key performance measures and one minor performance measure were recommended for measurement and evaluation in daily endoscopy practice.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Karlijn J Nass
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Alberto Murino
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, UK
| | - João Sabino
- Department of Gastroenterology and Hepatology, University Hospital Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Marek Bugajski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Cristina Carretero
- Department of Gastroenterology, University of Navarre Clinic, Healthcare Research Institute of Navarre, Pamplona, Spain
| | - George Cortas
- University of Balamand Faculty of Medicine, St. George Hospital University Medical Center, Beirut, Lebanon
| | - Edward J Despott
- Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London Institute for Liver and Digestive Health, London, UK
| | - James E East
- Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Division of Gastroenterology and Hepatology, Mayo Clinic Healthcare, London, UK
| | - Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Keuchel
- Clinic for Internal Medicine, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ashraf Monged
- Endoscopy Unit, Royal College of Surgeons of Ireland Hospitals Group, Dublin, Ireland
| | - Olga M Nardone
- Institute of Translational Medicine and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Gastroenterology, Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany
| | - Mahmoud M Omar
- Department of Internal Medicine, Digestive Diseases and Endoscopy, New Mowasat Hospital, Salmiya, Kuwait
| | - Maria Pellisé
- Gastroenterology Department, Endoscopy Unit, ICMDiM, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Catalonia, Spain
| | | | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Cleveland, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, TARGID, KU Leuven, Leuven, Belgium
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Kim KO. Endoscopic activity in inflammatory bowel disease: clinical significance and application in practice. Clin Endosc 2022; 55:480-488. [PMID: 35898147 PMCID: PMC9329646 DOI: 10.5946/ce.2022.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
Endoscopy is vital for diagnosing, assessing treatment response, and monitoring surveillance in patients with inflammatory bowel disease (IBD). With the growing importance of mucosal healing as a treatment target, the assessment of disease activity by endoscopy has been accepted as the standard of care for IBD. There are many endoscopic activity indices for facilitating standardized reporting of the gastrointestinal mucosal appearance in IBD, and each index has its strengths and weaknesses. Although most endoscopic indices do not have a clear-cut validated definition, endoscopic remission or mucosal healing is associated with favorable outcomes, such as a decreased risk of relapse. Therefore, experts suggest utilizing endoscopic indices for monitoring disease activity and optimizing treatment to achieve remission. However, the regular monitoring of endoscopic activity is limited in practice owing to several factors, such as the complexity of the procedure, time consumption, inter-observer variability, and lack of a clear-cut, validated definition of endoscopic response or remission. Although experts have recently suggested consensus-based definitions, further studies are needed to define the values that can predict long-term outcomes.
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Affiliation(s)
- Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Zhuang H, Bao A, Tan Y, Wang H, Xie Q, Qiu M, Xiong W, Liao F. Application and prospect of artificial intelligence in digestive endoscopy. Expert Rev Gastroenterol Hepatol 2022; 16:21-31. [PMID: 34937459 DOI: 10.1080/17474124.2022.2020646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION With the progress of science and technology, artificial intelligence represented by deep learning has gradually begun to be applied in the medical field. Artificial intelligence has been applied to benign gastrointestinal lesions, tumors, early cancer, inflammatory bowel disease, gallbladder, pancreas, and other diseases. This review summarizes the latest research results on artificial intelligence in digestive endoscopy and discusses the prospect of artificial intelligence in digestive system diseases. AREAS COVERED We retrieved relevant documents on artificial intelligence in digestive tract diseases from PubMed and Medline. This review elaborates on the knowledge of computer-aided diagnosis in digestive endoscopy. EXPERT OPINION Artificial intelligence significantly improves diagnostic accuracy, reduces physicians' workload, and provides a shred of evidence for clinical diagnosis and treatment. Shortly, artificial intelligence will have high application value in the field of medicine.
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Affiliation(s)
- Huangming Zhuang
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Anyu Bao
- Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yulin Tan
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Hanyu Wang
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Qingfang Xie
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Meiqi Qiu
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Wanli Xiong
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Fei Liao
- Gastroenterology Department, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
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Tontini GE, Rimondi A, Vernero M, Neumann H, Vecchi M, Bezzio C, Cavallaro F. Artificial intelligence in gastrointestinal endoscopy for inflammatory bowel disease: a systematic review and new horizons. Therap Adv Gastroenterol 2021; 14:17562848211017730. [PMID: 34178115 PMCID: PMC8202249 DOI: 10.1177/17562848211017730] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/26/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Since the advent of artificial intelligence (AI) in clinical studies, luminal gastrointestinal endoscopy has made great progress, especially in the detection and characterization of neoplastic and preneoplastic lesions. Several studies have recently shown the potential of AI-driven endoscopy for the investigation of inflammatory bowel disease (IBD). This systematic review provides an overview of the current position and future potential of AI in IBD endoscopy. METHODS A systematic search was carried out in PubMed and Scopus up to 2 December 2020 using the following search terms: artificial intelligence, machine learning, computer-aided, inflammatory bowel disease, ulcerative colitis (UC), Crohn's disease (CD). All studies on human digestive endoscopy were included. A qualitative analysis and a narrative description were performed for each selected record according to the Joanna Briggs Institute methodologies and the PRISMA statement. RESULTS Of 398 identified records, 18 were ultimately included. Two-thirds of these (12/18) were published in 2020 and most were cross-sectional studies (15/18). No relevant bias at the study level was reported, although the risk of publication bias across studies cannot be ruled out at this early stage. Eleven records dealt with UC, five with CD and two with both. Most of the AI systems involved convolutional neural network, random forest and deep neural network architecture. Most studies focused on capsule endoscopy readings in CD (n = 5) and on the AI-assisted assessment of mucosal activity in UC (n = 10) for automated endoscopic scoring or real-time prediction of histological disease. DISCUSSION AI-assisted endoscopy in IBD is a rapidly evolving research field with promising technical results and additional benefits when tested in an experimental clinical scenario. External validation studies being conducted in large and prospective cohorts in real-life clinical scenarios will help confirm the added value of AI in assessing UC mucosal activity and in CD capsule reading. PLAIN LANGUAGE SUMMARY Artificial intelligence for inflammatory bowel disease endoscopy Artificial intelligence (AI) is a promising technology in many areas of medicine. In recent years, AI-assisted endoscopy has been introduced into several research fields, including inflammatory bowel disease (IBD) endoscopy, with promising applications that have the potential to revolutionize clinical practice and gastrointestinal endoscopy.We have performed the first systematic review of AI and its application in the field of IBD and endoscopy.A formal process of paper selection and analysis resulted in the assessment of 18 records. Most of these (12/18) were published in 2020 and were cross-sectional studies (15/18). No relevant biases were reported. All studies showed positive results concerning the novel technology evaluated, so the risk of publication bias cannot be ruled out at this early stage.Eleven records dealt with UC, five with CD and two with both. Most studies focused on capsule endoscopy reading in CD patients (n = 5) and on AI-assisted assessment of mucosal activity in UC patients (n = 10) for automated endoscopic scoring and real-time prediction of histological disease.We found that AI-assisted endoscopy in IBD is a rapidly growing research field. All studies indicated promising technical results. When tested in an experimental clinical scenario, AI-assisted endoscopy showed it could potentially improve the management of patients with IBD.Confirmatory evidence from real-life clinical scenarios should be obtained to verify the added value of AI-assisted IBD endoscopy in assessing UC mucosal activity and in CD capsule reading.
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Affiliation(s)
- Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandro Rimondi
- Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Vernero
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Milan, Italy
| | - Helmut Neumann
- Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz, Germany
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Milan, Italy
| | - Flaminia Cavallaro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Shaoul R, Day AS. An Overview of Tools to Score Severity in Pediatric Inflammatory Bowel Disease. Front Pediatr 2021; 9:615216. [PMID: 33912519 PMCID: PMC8075054 DOI: 10.3389/fped.2021.615216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/15/2021] [Indexed: 01/07/2023] Open
Abstract
Background and Aims: The management of IBD entails the use of various treatments (nutrition, medications, and surgery) in order to induce and maintain remission. The assessment of IBD disease activity is based on a combination of symptoms, clinical findings, imaging, and endoscopic procedures. As in any disease, reliable assessment of disease activity or severity is required in order to plan relevant follow-up, decide on appropriate investigations, determine the best treatment option and subsequently assess response to treatment. It is important for proper documentation, follow-up, assessment of response to treatment and communication, especially in patients with IBD, to talk the same language by using validated and widely used scores for disease activity, endoscopic and radiologic activity, and patient reported outcomes both for clinical practice and research. This review aims to highlight key tools available for the assessment of disease activity or severity in individuals (especially children) with IBD. Methods: A literature search was performed using MEDLINE, Pubmed, and the Cochrane Library with the last search date of August 2020. Tools evaluating disease severity across various aspects (clinical, endoscopic, and radiological) were identified and discussed. Those tools validated and specific for children with IBD were included were available. Results: Over time a number of scoring systems have been developed to quantify clinical, endoscopic and imaging assessments in individuals with IBD. While some are exclusively for children or adults, others appear to have relevance to all age groups. In addition, some tools developed in adult populations are utilized in children, but have not expressly been validated in this age group. Conclusions: Although some available scoring tools are appropriate for children with IBD, others require consideration. The development and use of pediatric-specific tools is relevant and appropriate to optimal care of children and adolescents with IBD.
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Affiliation(s)
- Ron Shaoul
- Pediatric Gastroenterology & Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
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Tontini GE, Neumann H. Artificial intelligence: Thinking outside the box. Best Pract Res Clin Gastroenterol 2020; 52-53:101720. [PMID: 34172247 DOI: 10.1016/j.bpg.2020.101720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 01/31/2023]
Abstract
Artificial intelligence (AI) for luminal gastrointestinal endoscopy is rapidly evolving. To date, most applications have focused on colon polyp detection and characterization. However, the potential of AI to revolutionize our current practice in endoscopy is much more broadly positioned. In this review article, the Authors provide new ideas on how AI might help endoscopists in the future to rediscover endoscopy practice.
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Affiliation(s)
- Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Helmut Neumann
- Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz, Germany.
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Correlation of Patient-Reported Outcome (PRO-2) with Endoscopic and Histological Features in Ulcerative Colitis and Crohn's Disease Patients. Gastroenterol Res Pract 2020; 2020:2065383. [PMID: 32328091 PMCID: PMC7154964 DOI: 10.1155/2020/2065383] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/01/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022] Open
Abstract
Methods A cross-sectional study was conducted in consecutive newly diagnosed patients with inflammatory bowel disease in a tertiary care referral center. The initial evaluation included patient-reported outcome for stool frequency subscore and rectal bleeding. Endoscopic activity was determined using the Mayo scoring system for ulcerative colitis and the Simple Endoscopic Score for Crohn's disease. Histopathological activity was assessed using a validated numeric scoring system. Results We included 159 patients (63 Crohn's disease with colonic involvement and 96 with ulcerative colitis). We found significant correlation between the Mayo endoscopic subscoring system and histology activity in ulcerative colitis, while no correlation was found in patients with Crohn's disease. Patient-reported outcome showed inverse correlation with endoscopic and histological activity in Crohn's disease (rs = −0.67; rs = −0.72), while positive correlation was found in ulcerative colitis (rs = 0.84; rs = 0.75). Interpretation and Conclusions. Patient-reported outcome is a practical and noninvasive tool for assessment of disease activity in ulcerative colitis patients but not in Crohn's disease.
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Abstract
OBJECTIVES In 2015, the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) program proposed shifting the therapeutic focus on ulcerative colitis (UC) toward altering the natural history of the disease course by regularly monitoring objective measurements of disease activity and tailoring treatment accordingly. The therapeutic paradigm shift was well received in the research community and is often cited. However, new evidence on optimal UC treatment targets continues to accumulate since the time of the STRIDE guidelines. This systematic review summarizes the evidence accrued since the STRIDE UC recommendations, discusses the barriers for adoption of treat-to-target approaches in clinical practice in UC, and suggests directions for future research. METHODS We systematically reviewed MEDLINE for studies from the time of the STRIDE systematic review up to March 31, 2018, that assessed the potential treatment targets identified by the STRIDE recommendations. RESULTS Each potential treatment target literature search returned > 200 articles, which were then reviewed by 2 independent investigators for relevant studies. Selected studies of clinical factors, patient-reported outcomes, endoscopy, histology, imaging, and biomarkers and implications on treatment targets are summarized. CONCLUSIONS It appears that the relative weight given to different therapeutic targets in the development and improvement of UC treatments could be optimized, with an increased emphasis on endoscopic and histological targets over clinical or symptomatic targets. For this evolution to occur, however, new research has to demonstrate that the treat-to-target approach will deliver on the promise of better long-term outcomes compared with current approaches.
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Tontini GE, Mudter J, Vieth M, Günther C, Milani V, Atreya R, Rath T, Nägel A, Hatem G, Sturniolo GC, Vecchi M, Neurath MF, Galle PR, Buda A, Neumann H. Prediction of clinical outcomes in Crohn's disease by using confocal laser endomicroscopy: results from a prospective multicenter study. Gastrointest Endosc 2018; 87:1505-1514.e3. [PMID: 29108979 DOI: 10.1016/j.gie.2017.10.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/19/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Assessment of prognostic factors in patients with Crohn's disease (CD) is of pivotal importance for early intervention and "treat-to-target" strategies. Confocal laser endomicroscopy (CLE) enables on-demand in vivo characterization of mucosal inflammatory and architectural changes during endoscopy. We prospectively assessed the value of CLE for prediction of clinical outcome parameters in CD. METHODS Consecutive patients with CD undergoing colonoscopy were included in a multicenter study. Confocal imaging focused on 2 highly reproducible histologic hallmarks of active colonic inflammation: focal cryptitis and crypt architectural abnormality. We evaluated whether CLE, CD endoscopic index of severity (CDEIS), serum C-reactive protein (CRP), and CD activity index (CDAI) were associated with the risk of medical treatment escalation, transmural adverse events, and CD-related hospitalization or surgery during a 4-year follow-up. RESULTS Among 49 patients (53% men, median age, 39 years), baseline CRP was ≥5 mg/L in 47%, CDEIS ≥3 in 75%, and CDAI >150 in 51%. Focal cryptitis and crypt architectural abnormality were observed in 63% (CLE+ group). CLE+ patients showed an increased incidence of medical treatment escalation (P < .001; relative risk [RR] = 3.27) and transmural lesions (P = .025; RR = 1.70), whereas patients with CRP ≥5 mg/L had increased CD-related hospitalization and surgery (P = .020, RR = 2.71) at 1-year follow-up. No further association with prognostic clinical outcomes was found over the 1-year follow-up as well as for CDEIS and CDAI at any time. CONCLUSIONS CLE reveals CD-related features of mucosal inflammation and allows for early prediction of relevant clinical outcomes. Further studies should now address whether this promising prognostic tool could refine the timing of treatment strategies in patients with CD.
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Affiliation(s)
- Gian Eugenio Tontini
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany; Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Jonas Mudter
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Claudia Günther
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Raja Atreya
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Timo Rath
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Nägel
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Giorgia Hatem
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Giacomo Carlo Sturniolo
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Maurizio Vecchi
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Markus F Neurath
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Peter R Galle
- First Medical Department, University Medical Center Mainz, Mainz, Germany
| | - Andrea Buda
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy; Gastroenterology and Digestive Endoscopy Unit, Ospedale di Feltre, Feltre, Italy
| | - Helmut Neumann
- Department of Medicine I, University of Erlangen-Nürnberg, Erlangen, Germany; First Medical Department, University Medical Center Mainz, Mainz, Germany
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12
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Varkey J, Stotzer PO, Simrén M, Herlenius G, Oltean M. The endoscopic surveillance of the transplanted small intestine: a single center experience and a proposal for a grading score. Scand J Gastroenterol 2018; 53:134-139. [PMID: 29233031 DOI: 10.1080/00365521.2017.1411523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Microscopic examination of endoscopic biopsies forms the basis of acute cellular rejection (ACR) monitoring after intestinal transplantation (ITx). The endoscopy findings during acute rejection (AR) are known but a grading system for its severity is lacking. We designed and implemented a five-stage grading score based on acknowledged endoscopic features of AR, to allow a faster preliminary diagnosis of AR and intra- and interpatient comparisons. METHODS Two investigators reviewed and graded the endoscopy reports after 28 ITx using a novel score and correlated the results with pathology findings. RESULTS We reviewed 512 ileoscopies: 370 examinations (74%) were normal (G0), 59 had mild alterations (erythema, edematous villi-G1) and 36 showed moderate changes (erosions, blunted villi-G2); 17 ileoscopies revealed advanced changes (ulcerations, villus loss-G3). In 18 endoscopies the changes were severe (mucosal loss-G4). Inter-reviewer agreement was very good (kappa = 0.81). Biopsies from 86 endoscopy sessions (17%) indicated ACR with 63 cases having moderate or severe ACR. For mild ACR the sensitivity of the score was 29% and the specificity was 86% whereas the positive (PPV) and negative predictive values (NPVs) were 14% and 93% respectively. During advanced ACR the sensitivity and specificity were 92% and 86%, respectively whereas the PPV and NPV were 49% and 98% respectively. CONCLUSIONS Endoscopy alone has a limited ability to reliably diagnose intestinal ACR. We suggest a novel grading score summarizing ACR findings and allowing comparisons between intestinal graft endoscopies.
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Affiliation(s)
- Jonas Varkey
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Per-Ove Stotzer
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Magnus Simrén
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,b Center for Functional Gastrointestinal and Motility Disorders , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Gustaf Herlenius
- c Transplant Institute , Sahlgrenska University Hospital , Gothenburg , Sweden.,d Department of Surgery, Institute for Clinical Sciences , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Mihai Oltean
- c Transplant Institute , Sahlgrenska University Hospital , Gothenburg , Sweden.,d Department of Surgery, Institute for Clinical Sciences , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
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13
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Bálint A, Farkas K, Szepes Z, Nagy F, Szűcs M, Tiszlavicz L, Bor R, Milassin Á, Rutka M, Fábián A, Molnár T. How disease extent can be included in the endoscopic activity index of ulcerative colitis: the panMayo score, a promising scoring system. BMC Gastroenterol 2018; 18:7. [PMID: 29310593 PMCID: PMC5759871 DOI: 10.1186/s12876-017-0725-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/12/2017] [Indexed: 12/31/2022] Open
Abstract
Background Colonoscopy plays crucial role in the establishment of the diagnosis, management and follow-up of ulcerative colitis (UC). None of the currently widely used endoscopic scores consider disease extent, and therefore do not correlate with the real severity of UC. Our aim was to assess the accuracy of a new score, the Pancolonic Modified Mayo Score that can reflect not only the severity, but the extent of active UC. Methods One hundred and four UC patients were enrolled in this prospective study. The Endoscopic Mayo Scores of the involved area of the five colorectal segments were added; furthermore, the sum was multiplied by 3 in case of eMayo ≥2 (range 0 [normal] to 45 [most severe]) to obtain the Pancolonic Modified Mayo Score (panMayo) in order to clearly distinguish the active and inactive disease. We analysed the correlation of panMayo Score with eMayo and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and complicated disease outcome. We compared the endoscopic indices with serum and faecal inflammatory parameters and Riley Score. Results The panMayo Score correlated with eMayo and UCEIS. Every endoscopic score showed correlation with Riley Score, CRP, haemoglobin, haematocrit, serum iron, faecal MMP-9 and calprotectin and also predicted a complicated disease outcome. Only panMayo score correlated exclusively with the extent of UC. Conclusions We suggest that this new score gives additional information about disease extent besides disease activity with a strong correlation with laboratory parameters of inflammation and with the other widely used endoscopic indices.
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Affiliation(s)
- Anita Bálint
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Klaudia Farkas
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Ferenc Nagy
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Mónika Szűcs
- Department of Medical Physics and Informatics, University of Szeged, Korányi fasor 9, Szeged, 6720, Hungary
| | - László Tiszlavicz
- Department of Pathology, University of Szeged, Állomás u. 2, Szeged, 6725, Hungary
| | - Renáta Bor
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Ágnes Milassin
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Mariann Rutka
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Anna Fábián
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary
| | - Tamás Molnár
- First Department of Medicine, University of Szeged, H6720, Korányi fasor 8-10, Szeged, 6720, Hungary.
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Wędrychowicz A, Tomasik P, Zając A, Fyderek K. Prognostic value of assessment of stool and serum IL-1β, IL-1ra and IL-6 concentrations in children with active and inactive ulcerative colitis. Arch Med Sci 2018; 14:107-114. [PMID: 29379540 PMCID: PMC5778426 DOI: 10.5114/aoms.2017.68696] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/05/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Interleukin-1β (IL-1β), interleukin-1 receptor antagonist (IL-1ra) and interleukin-6 (IL-6) contribute to the pathogenesis of ulcerative colitis (UC). The aim of our study was to evaluate the serum and stool IL-1β, IL-1ra and IL-6 concentrations as potential prognostic factors in children with UC. MATERIAL AND METHODS Thirty-eight children with UC (20 active, 18 inactive) and 14 healthy controls were prospectively included in the study. IL-1β, IL-1ra and IL-6 concentrations were measured in serum and stool supernatants at inclusion to the study using ELISA immunoassays. The children were followed up over 5 years, and at each follow-up clinical disease activity, quantity and severity of relapses, nutritional status, endoscopic and histopathologic activity, disease complications and the treatment regimen were evaluated. RESULTS In children with active and inactive UC who had relapsed during a 5-year follow-up period compared to the non-relapse groups we found significantly increased serum IL-1β (1.34 vs. 0.98 pg/ml, p < 0.05, and 1.02 vs. 0.68 pg/ml, p < 0.01, respectively,) and IL-1ra (718.0 vs. 453.2 pg/ml, p < 0.05, and 567.4 vs. 365.1 pg/ml, p < 0.01, respectively). Additionally, in children who had experienced complications during a 5-year follow-up period we observed significantly increased serum and stool IL-1β (p < 0.05) and serum IL-1ra (p < 0.01) compared to the group without complications. CONCLUSIONS We concluded that serum IL-1β and IL-1ra and to a lesser extend stool IL-1β concentrations may be useful prognostic factors in children with active and inactive UC over a short-term follow-up period, which may help to identify children that require more aggressive therapy due to an increased risk of relapse or complications resulting from UC.
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Affiliation(s)
- Andrzej Wędrychowicz
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Krakow, Poland
| | - Przemysław Tomasik
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Zając
- Department of Pediatric Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Fyderek
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Krakow, Poland
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15
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Iacucci M, Daperno M, Lazarev M, Arsenascu R, Tontini GE, Akinola O, Gui XS, Villanacci V, Goetz M, Lowerison M, Lethebe BC, Vecchi M, Neumann H, Ghosh S, Bisschops R, Kiesslich R. Development and reliability of the new endoscopic virtual chromoendoscopy score: the PICaSSO (Paddington International Virtual ChromoendoScopy ScOre) in ulcerative colitis. Gastrointest Endosc 2017; 86:1118-1127.e5. [PMID: 28322774 DOI: 10.1016/j.gie.2017.03.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 03/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic inflammation and healing are important therapeutic endpoints in ulcerative colitis (UC). We developed and validated a new electronic virtual chromoendoscopy (EVC) score that could reflect the full spectrum of mucosal and vascular changes including mucosal healing in UC. METHODS Eight participants reviewed a 60-minute training module outlining 3 different i-SCAN modes demonstrating the entire spectrum of inflammatory mucosal and vascular changes in UC. Performance characteristics in endoscopic scoring and predicting the histologic inflammation with EVC (i-SCAN) by using 20 video clips before (pre-test) and after (post-test) were evaluated. Exploratory univariate factor analysis was performed on Paddington International Virtual Chromoendoscopy Score (PICaSSO) covariates for mucosal and vascular score separately. Subsequently, a proportional odds logistic regression model for the prediction of histologic scores was analyzed. RESULTS The interobserver agreement for Mayo endoscopic score in the pre-test (κ = .85; 95% CI, .78-.90) and the post-test (κ = .85; 95% CI, .77-.90) evaluation were very good. This was also true for the Ulcerative Colitis Endoscopic Index of Severity in the pre-test and post-test score interobserver agreement (κ = .86; 95% CI, .77-.92; and κ = .84; 95% CI, .75-.91, respectively). The interobserver agreement of the PICaSSO endoscopic score was very good in the pre-test and post-test evaluations (κ = .92; 95% CI, .87-.96; and κ = .89; 95% CI, .84-.94, respectively). The accuracy of the overall PICaSSO in assessing histologic abnormalities and inflammation by Harpaz score was 57% (95% CI, 48%-65%), by Robarts Histological Index 72% (95% CI, 64%-79%), and by the extent, chronicity, activity, plus system (full spectrum of histologic changes) 83% (95% CI, 76%-88%). CONCLUSIONS The EVC score "PICaSSO" showed very good interobserver agreement. The new EVC score may be used to define the endoscopic findings of mucosal and vascular healing in UC and reflected the full spectrum of histologic changes.
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Affiliation(s)
- Marietta Iacucci
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Division of Gastroenterology, Biomedical Research Centre and Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Marco Daperno
- Division of Gastroenterology, University of Torino, Torino, Italy
| | - Mark Lazarev
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Razvan Arsenascu
- Division of Gastroenterology, Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | - Gian Eugenio Tontini
- Department of Biomedical Sciences for the Health Division of Gastroenterology IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Oluseyi Akinola
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Xianyong Sean Gui
- Department of Pathology, University of Calgary, Calgary, Alberta, Canada
| | | | - Martin Goetz
- Division of Gastroenterology, University Klinikum, Tubingen, Germany
| | - Mark Lowerison
- Department of Community Health Sciences, Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brendan Cord Lethebe
- Department of Community Health Sciences, Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maurizio Vecchi
- Department of Biomedical Sciences for the Health Division of Gastroenterology IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Helmut Neumann
- Interventional Endoscopy Center, I. Medizinische Klinik und Poliklinik, University Hospital, Mainz, Germany
| | - Subrata Ghosh
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Division of Gastroenterology, Biomedical Research Centre and Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Ralf Kiesslich
- Division of Gastroenterology, Director of Internal Medicine II, HSK Hospital, Wiesbaden, Germany
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16
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Tontini GE, Rath T, Pastorelli L, Vecchi M, Neumann H. Surveillance strategies for colitis-associated cancer: state of the art and future perspectives. Expert Rev Gastroenterol Hepatol 2017; 11:427-437. [PMID: 28276810 DOI: 10.1080/17474124.2017.1297705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Colitis-associated cancer (CAC) represents a concrete risk of morbidity and mortality in patients with long lasting inflammatory bowel diseases. Surveillance colonoscopy is a rapidly evolving research field with profound changes from the traditional approach based on scheduled controls and random biopsy protocols. Areas covered: A literature search was performed using PubMed/Embase to review the latest evidence supporting the need for surveillance colonoscopy. By focusing on the most promising recent advances in this field, we provide a state-of-the-art overview of the current gold standards for the diagnosis and management of colitis-associated dysplasia. Expert commentary: Evidence-based and emerging data have questioned the efficacy and effectiveness of both standard surveillance colonoscopy and random biopsy protocols. The latest guidelines endorse early initiation of surveillance programs, risk-profiling assessment of colonoscopy intervals and standardized use of advanced imaging modalities to detect early dysplasia. Current trends clearly reveal increased attention to direct visualization and endoscopic management of visible dysplastic lesions, even in patients with longstanding colitis. Emerging technological advances in gastrointestinal endoscopy are expected to change the endoscopic surveillance protocols in the near future.
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Affiliation(s)
- Gian Eugenio Tontini
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy
| | - Timo Rath
- b Department of Medicine I , University of Erlangen-Nuremberg , Erlangen , Germany
| | - Luca Pastorelli
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy.,c Department of Biomedical Sciences for Health , University of Milan , Milano , Italy
| | - Maurizio Vecchi
- a Gastroenterology and Digestive Endoscopy Unit , IRCCS Policlinico San Donato , San Donato Milanese , Italy.,c Department of Biomedical Sciences for Health , University of Milan , Milano , Italy
| | - Helmut Neumann
- b Department of Medicine I , University of Erlangen-Nuremberg , Erlangen , Germany
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Tontini GE, Pastorelli L, Ishaq S, Neumann H. Advances in endoscopic imaging in ulcerative colitis. Expert Rev Gastroenterol Hepatol 2016; 9:1393-405. [PMID: 26365308 DOI: 10.1586/17474124.2015.1087848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Modern strategies for the treatment of ulcerative colitis require more accurate tools for gastrointestinal imaging to better assess mucosal disease activity and long-term prognostic clinical outcomes. Recent advances in gastrointestinal luminal endoscopy are radically changing the role of endoscopy in every-day clinical practice and research trials. Advanced endoscopic imaging techniques including high-definition endoscopes, optical magnification endoscopy, and various chromoendoscopy techniques have remarkably improved endoscopic assessment of ulcerative colitis. More recently, optical biopsy techniques with either endocytoscopy or confocal laser endomicroscopy have shown great potential in predicting several histological changes in real time during ongoing endoscopy. Here, we review current applications of advanced endoscopic imaging techniques in ulcerative colitis and present the most promising upcoming headways in this field.
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Affiliation(s)
- Gian Eugenio Tontini
- a 1 Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Luca Pastorelli
- a 1 Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy.,b 2 Department of Biomedical Sciences for Health, University of Milan, Milano, Italy
| | - Sauid Ishaq
- c 3 Department of Gastroenterology, Dudley Group Hospitals, Birmingham City University, Birmingham, UK.,d 4 Department of Medicine, St. George's University, Grenada, West Indies
| | - Helmut Neumann
- e 5 Department of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany
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Christensen B, Rubin DT. Understanding Endoscopic Disease Activity in IBD: How to Incorporate It into Practice. Curr Gastroenterol Rep 2016; 18:5. [PMID: 26759147 DOI: 10.1007/s11894-015-0477-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Endoscopic assessment of disease activity is an essential part of clinical practice in inflammatory bowel disease (IBD) and is used for diagnosis, prognosis, monitoring for dysplasia and increasingly for the evaluation of mucosal or endoscopic response to therapy. Recently, mucosal or endoscopic healing has emerged as a key goal of therapy as it has been found that patients who achieve endoscopic remission have improved outcomes compared to those who do not, and this may be independent of their clinical disease activity. However, there is currently no validated definition of mucosal healing and there are numerous endoscopic scoring systems proposed to define endoscopic activity and response to therapy in both ulcerative colitis and Crohn's disease. This article will discuss the most common endoscopic scores used to measure endoscopic disease activity in IBD, the pros and cons of each of these scoring systems and proposed definitions for endoscopic response or remission that exist for each. In addition, the role of endoscopy in prognosticating the disease course is discussed and how endoscopy can be utilized as part of a "treat-to-target" treatment strategy where endoscopy results direct decisions regarding medical strategies in clinical practice is highlighted.
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Affiliation(s)
- Britt Christensen
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Ave., MC4076, Room M410, Chicago, IL, 60637, USA
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, Australia
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 S. Maryland Ave., MC4076, Room M410, Chicago, IL, 60637, USA.
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Voting for image scoring and assessment (VISA)--theory and application of a 2 + 1 reader algorithm to improve accuracy of imaging endpoints in clinical trials. BMC Med Imaging 2015; 15:6. [PMID: 25880066 PMCID: PMC4349725 DOI: 10.1186/s12880-015-0049-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 02/12/2015] [Indexed: 12/22/2022] Open
Abstract
Independent central reading or off-site reading of imaging endpoints is increasingly used in clinical trials. Clinician-reported outcomes, such as endoscopic disease activity scores, have been shown to be subject to bias and random error. Central reading attempts to limit bias and improve accuracy of the assessment, two factors that are critical to trial success. Whether one central reader is sufficient and how to best integrate the input of more than one central reader into one output measure, is currently not known. In this concept paper we develop the theoretical foundations of a reading algorithm that can achieve both objectives without jeopardizing operational efficiency We examine the role of expert versus competent reader, frame scoring of imaging as a classification task, and propose a voting algorithm (VISA: Voting for Image Scoring and Assessment) as the most appropriate solution which could also be used to operationally define imaging gold standards. We propose two image readers plus an optional third reader in cases of disagreement (2 + 1) for ordinary scoring tasks. We argue that it is critical in trials with endoscopically determined endpoints to include the score determined by the site reader, at least in endoscopy clinical trials. Juries with more than 3 readers could define a reference standard that would allow a transition from measuring reader agreement to measuring reader accuracy. We support VISA by applying concepts from engineering (triple-modular redundancy) and voting theory (Condorcet’s jury theorem) and illustrate our points with examples from inflammatory bowel disease trials, specifically, the endoscopy component of the Mayo Clinic Score of ulcerative colitis disease activity. Detailed flow-diagrams (pseudo-code) are provided that can inform program design. The VISA “2 + 1” reading algorithm, based on voting, can translate individual reader scores into a final score in a fashion that is both mathematically sound (by avoiding averaging of ordinal data) and in a manner that is consistent with the scoring task at hand (based on decisions about the presence or absence of features, a subjective classification task). While the VISA 2 + 1 algorithm is currently being used in clinical trials, empirical data of its performance have not yet been reported.
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Tontini GE, Vecchi M, Pastorelli L, Neurath MF, Neumann H. Differential diagnosis in inflammatory bowel disease colitis: State of the art and future perspectives. World J Gastroenterol 2015; 21:21-46. [PMID: 25574078 PMCID: PMC4284336 DOI: 10.3748/wjg.v21.i1.21] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/31/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023] Open
Abstract
Distinction between Crohn’s disease of the colon-rectum and ulcerative colitis or inflammatory bowel disease (IBD) type unclassified can be of pivotal importance for a tailored clinical management, as each entity often involves specific therapeutic strategies and prognosis. Nonetheless, no gold standard is available and the uncertainty of diagnosis may frequently lead to misclassification or repeated examinations. Hence, we have performed a literature search to address the problem of differential diagnosis in IBD colitis, revised current and emerging diagnostic tools and refined disease classification strategies. Nowadays, the differential diagnosis is an untangled issue, and the proper diagnosis cannot be reached in up to 10% of patients presenting with IBD colitis. This topic is receiving emerging attention, as medical therapies, surgical approaches and leading prognostic outcomes require more and more disease-specific strategies in IBD patients. The optimization of standard diagnostic approaches based on clinical features, biomarkers, radiology, endoscopy and histopathology appears to provide only marginal benefits. Conversely, emerging diagnostic techniques in the field of gastrointestinal endoscopy, molecular pathology, genetics, epigenetics, metabolomics and proteomics have already shown promising results. Novel advanced endoscopic imaging techniques and biomarkers can shed new light for the differential diagnosis of IBD, better reflecting diverse disease behaviors based on specific pathogenic pathways.
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21
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Neumann H, Kudo SE, Kiesslich R, Neurath MF. Advanced colonoscopic imaging using endocytoscopy. Dig Endosc 2015; 27:232-8. [PMID: 25311804 DOI: 10.1111/den.12395] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/06/2014] [Indexed: 12/14/2022]
Abstract
Optical biopsy techniques were recently introduced to luminal gastrointestinal endoscopy. These include confocal laser endomicroscopy, spectroscopic imaging techniques and endocytoscopy. Optical biopsy techniques allow on demand in vivo histology during ongoing endoscopy, thereby potentially accelerating clinical diagnosis and specific therapy. In the present review, we focus on endocytoscopy as one of the rapidly emerging optical biopsy techniques. We provide technical details of currently available endocytoscopy systems and give tips on their use in clinical practice. We also summarize applications of endocytoscopy for colorectal pathologies.
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Affiliation(s)
- Helmut Neumann
- Department of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany; Ludwig Demling Endoscopy Center of Excellence, University Hospital Erlangen, Erlangen, Germany
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