Endoscopy for assessment of mucosal healing in ulcerative colitis: time bound or response guided?

Applicability of colon capsule endoscopy for monitoring ulcerative colitis: a systematic review

BACKGROUND

As the target of therapy in Ulcerative colitis (UC) has changed from symptomatic relief to mucosal healing, endoscopic visualization is mandatory. Colon capsule endoscopy (CCE) may serve as a less invasive and more tolerable alternative to standard colonoscopy (SC) for the monitoring of UC.

OBJECTIVES

To evaluate the diagnostic accuracy, adverse events and tolerability for CCE compared to SC.

DESIGN

Systematic review.

DATA SOURCES

A systematic literature search was conducted in PubMed, Embase and Web of Science.

METHODS

Search results were imported into Covidence and screened. Included studies underwent risk of bias assessment using Methodological Index for Non-Randomized Studies (MINORS), and relevant data, including completeness of the procedure, type of bowel preparation and adverse events, was extracted. Pooled estimates of diagnostic accuracy were calculated from the studies providing the necessary data.

RESULTS

Out of 2804 articles, six studies were eligible for inclusion. Three provided the necessary data to calculate pooled estimates of diagnostic accuracy in recognizing mucosal inflammation: pooled sensitivity of 93%, specificity of 68.8%, positive predictive value of 89.4%, and negative predictive value of 78.6%. The adverse events, such as nausea and abdominal distension, were predominantly related to bowel preparation regimens.

CONCLUSION

CCE has the potential for monitoring UC. However, the specificity and NPV must be improved. Bowel preparation regimens must be optimized to improve patient experience and the effectiveness of CCE.

REGISTRATION

Prospero ID CRD42023450210.

Molecular Activity of Inflammation and Epithelial-Mesenchymal Transition in the Microenvironment of Ulcerative Colitis

Background/Aims

: The genetic expression in the active inflammatory regions is increased in ulcerative colitis (UC) with endoscopic activity. The aim of this study was to investigate the molecular activity of inflammation and tissue remodeling markers in endoscopically inflamed and uninflamed regions of UC.

Methods

: Patients with UC (n=47) and controls (n=20) were prospectively enrolled at the Seoul National University Bundang Hospital. Inflamed tissue was obtained at the most active lesion, and uninflamed tissue was collected from approximately 15 cm above the upper end of the active lesion via colonoscopic biopsies. The messenger RNA expression levels of transforming growth factor β (TGF-β), interleukin (IL)-1β, IL-6, IL-17A, E-cadherin, olfactomedin-4 (OLFM4), leucine-rich repeat-containing G protein-coupled receptor 5 (LGR5), vimentin, fibroblast-specific protein-1 (FSP1), and α-smooth muscle actin (SMA) were evaluated. Mucosal healing (MH) was defined according to a Mayo endoscopic score of 0, 1 or non-MH (Mayo endoscopic score of 2 or 3).

Results

: The messenger RNA expressions of TGF-β, IL-1β, OLFM4, FSP1, vimentin, and α-SMA were significantly higher, and that of E-cadherin was significantly lower in inflamed and uninflamed regions of patients with UC than those in controls. In the inflamed regions, patients in the non-MH group had significantly increased genetic expression of TGF-β, FSP1, vimentin, and α-SMA compared to patients in the MH group. Similarly, the non-MH group had significantly higher genetic expression of TGF-β, IL-1β, IL-6, vimentin, and α-SMA than the MH group in the uninflamed regions.

Conclusions

: Endoscopic activity in UC suggests inflammation and tissue remodeling of uninflamed regions similar to inflamed regions (ClinicalTrials.gov, NCT05653011).

Histologic improvement predicts endoscopic remission in patients with ulcerative colitis

Limited research has been performed to determine if histologic improvement serves as a prognosticator for endoscopic remission, a key therapeutic target for ulcerative colitis (UC). The primary aim of the study was to evaluate if histological activity could predict endoscopic remission in UC patients with Mayo endoscopic subscores (MES) of 0 or 1. In addition, we compared the clinical outcomes between histologic improvement group and active group. This research encompassed 492 individuals with UC with MES of 0 or 1, who underwent histological assessment as per the established protocol of Samsung Medical Center between January 2018 and December 2020. Participants were categorized into two cohorts based on the degree of histological activity: those showing histologic improvement and those with ongoing histologic activity. The endoscopic activity was assessed during follow-up, and the primary outcome was endoscopic remission according to histologic activity. Out of the total participants, endoscopic activity was scrutinized in 435 patients during the colonoscopic follow-up and in 146 during the subsequent one. The histologic improvement group at the index colonoscopy was more likely achieve endoscopic remission than the histologic active group. Clinical relapse was more likely in the histologic active group than in the histologic improvement group.

Practical management of mild-to-moderate ulcerative colitis: an international expert consensus

INTRODUCTION

Although there are well-defined guidelines for the management of mild-to-moderate ulcerative colitis (UC), there are still unmet needs. For this reason, we conducted an international expert consensus to standardize the management of patients with mild-to-moderate UC and provide practical guidance to clinicians.

AREAS COVERED

Based on Delphi methodology, 15 statements were approved after two rounds of voting, addressing several aspects of disease management from sequencing to treatment duration, from monitoring to optimization techniques and safety profile.

EXPERT OPINION

Growing knowledge of mild-to-moderate UC has led to the development of new ambitious outcomes such as histological remission and disease clearance. Furthermore, noninvasive tools for patient monitoring such as fecal calprotectin and intestinal ultrasound are now available. Their implementation in clinical practice will allow clinicians to tightly monitor disease activity and promptly adapt treatment, avoiding complications and disease progression and targeting better disease control.

Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023

Ulcerative colitis (UC) is a chronic inflammation of the gastrointestinal tract and is characterized by alternating periods of inflammation and remission. Although UC incidence is lower in Taiwan than in Western countries, its impact remains considerable, demanding updated guidelines for addressing local healthcare challenges and patient needs. The revised guidelines employ international standards and recent research, emphasizing practical implementation within the Taiwanese healthcare system. Since the inception of the guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease has acknowledged the need for ongoing revisions to incorporate emerging therapeutic options and evolving disease management practices. This updated guideline aims to align UC management with local contexts, ensuring comprehensive and context-specific recommendations, thereby raising the standard of care for UC patients in Taiwan. By adapting and optimizing international protocols for local relevance, these efforts seek to enhance health outcomes for patients with UC.

Ischemia-modified albumin: a novel blood marker of endoscopic mucosal healing in inflammatory bowel disease

BACKGROUND/AIMS

The achievement of endoscopic remission is an important therapeutic goal in the treatment of inflammatory bowel diseases (IBD). We aimed to evaluate the role of fecal calprotectin (FCP) and ischemia-modified albumin (IMA) as biomarkers for evaluating IBD disease activity.

METHODS

A total of 48 patients with IBD (20 with ulcerative colitis and 28 with Crohn's disease) were included in this study. FCP and serum C-reactive protein levels, erythrocyte sedimentation rate, and IMA were measured in patients with IBD and compared with endoscopic findings.

RESULTS

Elevated FCP and serum IMA levels were significantly associated with endoscopic non-mucosal healing. The correlation between FCP and IMA was not significant. Analysis of the receiver operating characteristic curve showed that both FCP and IMA had diagnostic value in predicting non-mucosal healing. When the Ln(FCP)+IMA/10 value was calculated using both factors, the predictive value for non-mucosal healing increased; however, no significant difference was observed.

CONCLUSIONS

IMA could be a candidate serum biomarker for predicting endoscopic mucosal healing in IBD.

Comparison of Two Types of 1-L Polyethylene Glycol-ascorbic Acid as Colonoscopic Bowel Preparation: A Prospective Randomized Study

BACKGROUND/AIMS

Recently, 1-L polyethylene glycol-ascorbic acid (PEG-Asc) has been used to reduce the volume of preparation agents in colonoscopy. This clinical trial aimed to compare the efficacy and safety of two types of 1-L PEG-Asc (CleanViewAL^® [Tae Joon Pharmaceutical Company, Seoul, Korea] and Plenvu^® [Norgine, Harefield, United Kingdom]) in average-aged adults.

METHODS

This study was a prospective, randomized, non-inferiority, open-label, phase 4 clinical trial. The primary endpoint was the efficacy evaluated using the Boston bowel preparation scale (BBPS), and the secondary endpoint was clinical safety.

RESULTS

In total, 173 patients were assigned to either the CleanViewAL^® (n=84) or Plenvu^® (n=89) group. Overall cleansing successes of 97.6% (82/84) and 98.8% (88/89) were achieved in the CleanViewAL^® group and in the Plenvu^® group, respectively, showing that CleanViewAL^® has similar bowel cleansing efficacy to Plenvu^® (95% CI, -0.052 to 0.027; p=0.207). The total BBPS score was 8.67±1.00 and 8.70±0.76 in the CleanViewAL^® group and Plenvu^® group, respectively (p=0.869). The most common adverse symptom was nausea, and no adverse symptoms requiring hospitalization were reported in either group. There were no cases of critical hypernatremia and liver dysfunction exceeding the common terminology criteria for adverse events grade I. An overall satisfaction score (scale of 1 to 10) showed no difference between the two groups (p=0.289). However, the CleanViewAL^® group showed a higher taste satisfaction score (scale of 1 to 5) than the Plenvu^® group (CleanViewAL^®: 2.90±0.91, Plenvu^®: 2.60±0.86, p=0.028).

CONCLUSIONS

Both types of 1-L PEG-Asc, CleanViewAL^® and Plenvu^®, are effective and safe bowel cleansing agents in average-aged adults. CleanViewAL^® was preferred in terms of taste satisfaction.