Predicting outcome in severe ulcerative colitis

BACKGROUND

Simple criteria are needed to predict which patients with severe ulcerative colitis will respond poorly to intensive medical treatment and require colectomy.

AIMS

To find out if the early pattern of change in inflammatory markers or other variables could predict the need for surgery and to evaluate the outcome of medical treatment during one year follow up.

PATIENTS

51 consecutive episodes of severe colitis (Truelove and Witts criteria) affecting 49 patients admitted to John Radcliffe Hospital, Oxford.

METHODS

Prospective study monitoring 36 clinical, laboratory, and radiographic variables. All episodes treated with intravenous and rectal hydrocortisone and 14 of 51 with cyclosporine.

RESULTS

Complete response in 21 episodes (< or = 3 stools on day 7, without visible blood), incomplete response in 15 (> 3 stools or visible blood on day 7, but no colectomy), and colectomy on that admission in 15. During the first five days, stool frequency and C reactive protein (CRP) distinguished between outcomes (p < 0.00625, corrected for multiple comparisons) irrespective of whether patients or the number of episodes were analysed. It could be predicted on day 3, that 85% of patients with more than eight stools on that day, or a stool frequency between three and eight together with a CRP > 45 mg/l, would require colectomy. For patients given cyclosporine, four of 14 avoided colectomy but two continued to have symptoms. After admission, complete responders remained in remission for a median nine months and had a 5% chance of colectomy. Incomplete responders had a 60% chance of continuous symptoms and 40% chance of colectomy.

CONCLUSIONS

After three days intensive treatment, patients with frequent stools (> 8/day), or raised CRP (> 45 mg/l) need to be identified, as most will require colectomy on that admission. The role of cyclosporine for treating severe colitis has yet to be defined. After seven days' treatment, patients with > 3 stools/day of visible blood have a 60% chance of continuous symptoms and 40% chance of colectomy in the following months.

Nonsteroidal antiinflammatory drug-induced intestinal inflammation in humans

This study examines the effects of nonsteroidal antiinflammatory drugs on the small intestine in humans. Using an 111In-leukocyte technique in patients with rheumatoid arthritis (n = 90) and osteoarthritis (n = 7), it appears that nonsteroidal antiinflammatory drugs cause small intestinal inflammation in two-thirds of patients on long-term treatment and on discontinuation, the inflammation may persist for up to 16 mo. The prevalence and magnitude of the intestinal inflammation was unrelated to the type and dose of nonsteroidal drugs and previous or concomitant second-line drug treatment. There was a significant inverse correlation (r = -0.29, p less than 0.05) between fecal 111In excretion and hemoglobin levels in patients treated with nonsteroidal antiinflammatory drugs. The kinetics of fecal indium 111 excretion in patients treated with nonsteroidal antiinflammatory drugs was almost identical to that of patients with small bowel Crohn's disease. Eighteen patients on nonsteroidal antiinflammatory drugs underwent a radiologic examination of the small bowel and 3 were found to have asymptomatic ileal disease with ulceration and strictures. Nineteen patients on nonsteroidal antiinflammatory drugs, 20 healthy controls, and 13 patients with Crohn's ileitis underwent a dual radioisotopic ileal function test with tauro 23 (75Se) selena-25-homocholic acid and cobalt 58-labeled cyanocobalamine. On day 4, more than half of the patients with rheumatoid arthritis had evidence of bile acid malabsorption, but the ileal dysfunction was much milder than seen in patients with Crohn's ileitis.

Intravenous cyclosporine versus intravenous corticosteroids as single therapy for severe attacks of ulcerative colitis

BACKGROUND & AIMS

Cyclosporine has been effective in patients with steroid-refractory attacks of ulcerative colitis (UC). We investigated the effects of intravenous (IV) cyclosporine as single IV therapy (without glucocorticosteroids) for severe UC and compared these with the response to glucocorticosteroids.

METHODS

Patients with a severe attack of UC were randomized to treatment with IV cyclosporine, 4 mg x kg(-1) x day(-1), or with methylprednisolone, 40 mg/day, in a randomized, double-blind, controlled trial. After 8 days, patients who had a response received the same medication orally in combination with azathioprine. Patients were followed up clinically, endoscopically, and by scintigraphy. Renal function was assessed using urinary inulin clearances. Endpoints were clinical improvement, discharge from the hospital, and remission up to 12 months after intravenous therapy.

RESULTS

Thirty patients were included. After 8 days, 8 of 15 patients (53%) who received methylprednisolone had a response to therapy vs. 9 of 14 (64%) receiving cyclosporine. In nonresponders, 3 of 7 methylprednisolone patients and 1 of 3 cyclosporine patients improved when both treatments were combined. No serious drug-related toxicity was observed with either treatment. At 12 months, 7 of 9 patients (78%) initially controlled with cyclosporine maintained their remission vs. 3 of 8 (37%) initially treated with methylprednisolone. No clinically significant decrease of renal function was observed.

CONCLUSIONS

Cyclosporine monotherapy is an effective and safe alternative to glucocorticosteroids in patients with severe attacks of UC.

CT evaluation of the colon: inflammatory disease

Computed tomography (CT) is valuable for detection and characterization of many inflammatory conditions of the colon. At CT, a dilated, thickened appendix is suggestive of appendicitis. A 1-4-cm, oval, fatty pericolic lesion with surrounding mesenteric inflammation is diagnostic of epiploic appendagitis. The key to distinguishing diverticulitis from other inflammatory conditions of the colon is the presence of diverticula in the involved segment. In typhlitis, CT demonstrates cecal distention and circumferential thickening of the cecal wall, which may have low attenuation secondary to edema. In radiation colitis, the clinical history is the key to suggesting the diagnosis because the CT findings can be nonspecific. The location of the involved segment and the extent and appearance of wall thickening may help distinguish Crohn disease and ulcerative colitis. In ischemic colitis, CT typically demonstrates circumferential, symmetric wall thickening with fold enlargement. CT findings of graft-versus-host disease include small bowel and colonic wall thickening, which may result in luminal narrowing and separation of bowel loops. In infectious colitis, the site and thickness of colon affected may suggest a specific organism. The amount of wall thickening in pseudomembranous colitis is typically greater than in any other inflammatory disease of the colon except Crohn disease.

Primary sclerosing cholangitis: findings on cholangiography and pancreatography

Cholangiograms of 86 patients with primary sclerosing cholangitis (PSC) were compared with those of 82 patients with primary bile duct carcinoma and 16 with primary biliary cirrhosis. Multifocal strictures involving both intra- and extra-hepatic bile ducts were most common in PSC; they were diffusely distributed, short, and annular, alternating with normal or slightly dilated segments to produce a "beaded" appearance. Very short, band-like strictures occurred in 18 patients; 9 also had diverticulum-like out-pouchings. Fourteen patients had "diverticula" without band strictures. Both findings appear to be specific for PSC. Inflammatory bowel disease was seen in 57 patients (66%), who could not be distinguished cholangiographically from other PSC patients. Of 40 patients with adequate retrograde pancreatograms, 3 had abnormalities of the pancreatic ducts.

Indium 111-granulocyte scanning in the assessment of disease extent and disease activity in inflammatory bowel disease. A comparison with colonoscopy, histology, and fecal indium 111-granulocyte excretion

Indium 111-leukocyte scanning has recently been introduced as a new method for imaging inflammatory bowel disease. The technique has recently been made more specific for acute inflammation by labeling a pure granulocyte fraction rather than the conventional mixed leukocyte preparation. We now report a prospective study comparing 111In-granulocyte scanning with endoscopy, histology, and fecal 111In-granulocyte excretion for the assessment of disease extent and severity in colonic inflammatory bowel disease. In 52 patients with Crohn's disease or ulcerative colitis, disease extent and severity were assessed macroscopically, histologically, or by scanning using a numerical grading system. Excellent correlations were found between both endoscopy and histology and 111In scans [r = 0.90 (endoscopy) and r = 0.90 (histology) for extent; r = 0.86 and r = 0.91 for disease activity]. Severity graded by scanning also showed a close correlation with fecal 111In-granulocyte excretion (r = 0.90). Indium 111-granulocyte scans are a rapid, accurate, noninvasive means of assessing both disease extent and severity of colonic involvement in inflammatory bowel disease.

Diagnostic ionizing radiation exposure in a population-based cohort of patients with inflammatory bowel disease

OBJECTIVE

For diagnosis, assessing disease activity, complications and extraintestinal manifestations, and monitoring response to therapy, patients with inflammatory bowel disease undergo many radiological studies employing ionizing radiation. However, the extent of radiation exposure in these patients is unknown.

METHODS

A population-based inception cohort of 215 patients with inflammatory bowel disease from Olmsted County, Minnesota, diagnosed between 1990 and 2001, was identified. The total effective dose of diagnostic ionizing radiation was estimated for each patient. Linear regression was used to assess the median total effective dose since symptom onset.

RESULTS

The number of patients with Crohn's disease and ulcerative colitis was 103 and 112, with a mean age at diagnosis of 38.6 and 39.4 yr, respectively. Mean follow-up was 8.9 yr for Crohn's disease and 9.0 yr for ulcerative colitis. Median total effective dose for Crohn's disease was 26.6 millisieverts (mSv) (range, 0-279) versus 10.5 mSv (range, 0-251) for ulcerative colitis (P < 0.001). Computed tomography accounted for 51% and 40% of total effective dose, respectively. Patients with Crohn's disease had 2.46 times higher total effective dose than ulcerative colitis patients (P= 0.001), adjusting for duration of disease.

CONCLUSIONS

Annualizing our data, the radiation exposure in the inflammatory bowel disease population was equivalent to the average annual background radiation dose from naturally occurring sources in the U.S. (3.0 mSv). However, a subset of patients had substantially higher doses. The development of imaging management guidelines to minimize radiation dose, dose-reduction techniques in computed tomography, and faster, more robust magnetic resonance techniques are warranted.

Colitis: use of CT findings in differential diagnosis

PURPOSE

To determine whether colitides can be differentiated based on computed tomographic (CT) features.

MATERIALS AND METHODS

The CT scans of 117 patients with documented colitis and colon wall thickening were reviewed. Features evaluated included mural thickness and homogeneity, distribution of bowel involvement, and associated mesenteric and small bowel disease.

RESULTS

The mean colon wall thickness in Crohn colitis (11.0 mm +/- 5.1) was significantly greater than in ulcerative colitis (7.8 mm +/- 1.9) (P < .002). Submucosal fat deposition, not observed in the acute colitides, was present significantly more often in ulcerative (61%) than in Crohn colitis (8%) (P = .0001). Exclusive involvement of the right colon and small bowel was most frequent with Crohn and infectious colitis. Abscess was associated almost exclusively with Crohn colitis (35%) but was seen in one patient with radiation colitis.

CONCLUSION

Although many CT findings in patients with colitis are nonspecific, some features are helpful in suggesting a specific diagnosis.

Cancer risk in extensive ulcerative colitis

Two hundred thirty-four patients with extensive ulcerative colitis from the city of Göteborg, Sweden have been followed up and the cumulative risk of development of cancer of the large bowel was estimated. These patients constitute all persons in this region who developed an extensive ulcerative colitis between 1951 and 1974. All patients were followed up until December 1975. The mean observation time was 8.5 years, median value six years. Fifteen patients developed carcinoma of the large bowel. Five of the 15 patients were still alive in December 1975. The expected number of colorectal carcinomas in a matched reference group was 0.49. The cumulative incidence of carcinoma 25 years after the onset of colitis for the whole group of patients was 34% and for those who developed the disease before 25 years of age it was 43%.

Histology Grade Is Independently Associated With Relapse Risk in Patients With Ulcerative Colitis in Clinical Remission: A Prospective Study

OBJECTIVES

Objective evidence of inflammation has been associated with the risk of relapse in patients with ulcerative colitis (UC) who are in clinical remission. We compared endoscopic and histologic grades for their ability to predict clinical relapse in this patient population.

METHODS

Patients with UC in clinical remission were prospectively enrolled into an observational cohort. Baseline endoscopic scores (Mayo) and histological (Geboes) grades and blood markers were collected. All subjects were followed for 12 months and relapse determined using clinical indices.

RESULTS

A total of 179 subjects were enrolled into the study and followed for 12 months. Clinical relapse occurred in 23%; 5% were hospitalized, and 2% underwent colectomy. In univariate analysis, the baseline Mayo endoscopy score and the Geboes histology grade were significantly associated with the later development of clinical relapse (P<0.001 for both), but only the histology grade remained significant in a multivariate model (P=0.006). The relative risk of clinical relapse was 3.5 (95% CI 1.9-6.4, P<0.0001) in subjects whose baseline Geboes grade was ≥3.1. The area under the curve was 0.73 for the Geboes histology grade to identify subjects at risk of future clinical relapse. Of the patients in clinical, endoscopic, and histological remission at baseline (n=82), only 7% had a clinical relapse over the subsequent 12 months.

CONCLUSIONS

Histology grade has the strongest association with the risk of clinical relapse in patients with UC who are in clinical remission. Consideration should be given to including this end point in evaluating therapy for UC.

The Ulcerative Colitis Endoscopic Index of Severity More Accurately Reflects Clinical Outcomes and Long-term Prognosis than the Mayo Endoscopic Score

BACKGROUND AND AIMS

The Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and the Mayo endoscopic score (Mayo ES) are used to evaluate ulcerative colitis (UC) severity. This study compared UCEIS and the Mayo ES for evaluating UC severity and outcomes in patients undergoing remission induction during routine clinical practice with the aim of predicting medium- to long-term prognosis.

METHODS

Forty-one UC patients who received colonoscopy before and after tacrolimus remission induction therapy were included. An index of clinical activity and endoscopic findings scored by both the UCEIS and the Mayo ES were determined. Changes in UCEIS and Mayo ES before and after induction therapy were compared.

RESULTS

The mean UCEIS improved from 6.2±0.9 to 3.4±2.1 (p < 0.001). Based on the UCEIS, a significant reduction was reached in both the response and the remission groups. In contrast, the Mayo ES did not reflect a significant change in the response group. The discrepancy appeared to be due to ulcers becoming smaller and shallower during the early stages of mucosal healing; the Mayo ES seems to miss these early changes. In other words, whereas the UCEIS indicates improvements when ulcers shrink, the Mayo ES does not distinguish deep ulcers from shallow ulcers and is 3 (severe UC) for both deep and shallow ulcers. Additionally, better UCEIS strata after induction therapy were associated with lower incidences of colectomy (p = 0.0001) or relapse (p = 0.0008).

CONCLUSIONS

The UCEIS accurately reflects clinical outcomes and predicts the medium- to long-term prognosis in UC patients undergoing induction therapy. These findings should support decision-making in clinical practice settings.

Submucosal accumulation of fat in inflammatory bowel disease: CT/pathologic correlation

A prominent submucosal layer of decreased attenuation was demonstrated on CT in three patients with inflammatory bowel disease. On pathologic examination this zone proved to be due to extensive submucosal fat accumulation and not active inflammation. The potential significance of this finding is discussed.

Sarcopenia is a predictive factor for intestinal resection in admitted patients with Crohn's disease

The relationship between skeletal muscle volume and the prognosis of patients with inflammatory bowel disease (IBD) remains undetermined. We conducted a retrospective study of 72 IBD patients who were admitted to the hospital due to disease exacerbation. We enrolled IBD patients who had undergone abdominal computed tomography and assessed the nutritional indices, such as the Onodera's prognostic nutritional index (O-PNI) and the controlling nutritional status (CONUT) index. The L3 skeletal muscle index (SMI), which is the ratio of the cross-sectional area of skeletal muscles at the level of the third lumbar (L3) vertebra to the height squared, was used to identify sarcopenia. Sarcopenia, defined as a low SMI, was observed in 42% of all IBD patients (37% with Crohn's disease (CD) and 48% with ulcerative colitis (UC)). In UC patients, the O-PNI and CONUT values, height, and albumin levels were significantly lower than in CD patients. The SMI strongly correlated with sex, body weight, albumin level, and O-PNI in IBD patients. Multivariate analysis using the Cox regression model demonstrated that the presence of sarcopenia (P = 0.015) and disease type (CD or UC) (P = 0.007) were significant factors predicting intestinal resection. The cumulative operation-free survival rate was significantly lower for sarcopenic patients than in all IBD patients (P = 0.003) and a stratified analysis of CD patients (P = 0.001) using the Kaplan-Meier method and log-rank test. The L3 skeletal muscle area is a prognostic factor for intestinal resection in patients with CD.

Incidence and risk factors for gallstones in patients with inflammatory bowel disease: a large case-control study

The risk for gallstones (GD) in inflammatory bowel diseases and the factors responsible for this complication have not been well established. We studied the incidence of GD in a cohort of Crohn's disease (CD) and ulcerative colitis (UC) patients and investigated the related risk factors. A case-controlled study was carried out. The study population included 634 inflammatory bowel disease (IBD) patients (429 CD, 205 UC) and 634 age-matched, sex-matched, and body mass index (BMI)-matched controls free of GD at enrollment, who were followed for a mean of 7.2 years (range, 5-11 years). The incidence of GD was calculated by dividing the number of events per person-years of follow-up. Multivariate analysis was used to discriminate among the impact of different variables on the risk of developing GD. The incidence rates of GD were 14.35/1,000 persons/year in CD as compared with 7.75 in matched controls (P=0.012) and 7.48/1000 persons/year in UC patients as compared with 6.06 in matched-controls (P=0.38). Ileo-colonic CD location (OR, 2.14), disease duration>15 years (OR, 4.26), >3 clinical recurrences (OR, 8.07), ileal resection>30 cm (OR, 7.03), >3 hospitalizations (OR, 20.7), multiple TPN treatments (OR, 8.07), and long hospital stay (OR, 24.8) were significantly related to GD in CD patients.

CONCLUSION

Only CD patients have a significantly higher risk of developing GD than well-matched hospital controls. Site of disease at diagnosis, lifetime surgery, extent of ileal resections, number of clinical recurrences, TPN, and the frequency and duration of hospitalizations are independently associated with GD.

A comparative radiographic and pathological study of intestinal vaso-architecture in Crohn's disease and in ulcerative colitis

Vascular changes were seen in specimens with lesions of Crohn's disease as well as in ulcerative colitis. In Crohn's disease, the vasculature in the bowel wall was rearranged secondary to thickening of the intestinal coats. An anatomical relationship was often found between the ulcers and the point where arteries break through the muscularis propria. The vasculature was markedly increased in areas with deep ulcers and transmural inflammation, but in areas with only small ulcers and mild inflammatory reaction vascular changes were barely discernible or absent. Occlusive vascular changes were uncommon and not visible in the radiographs. In active ulcerative colitis hypervascularity was more marked than in Crohn's disease, but was confined to the mucosa and adjacent parts of the submucosa. In ;burnt-out' atrophy vascularity was not increased and only minor changes in the submucosal arteries were observed. The observations did not suggest that the vascular alterations are of primary importance for the formation of lesions in either disease.

Indium-111 autologous leucocyte scanning: comparison with radiology for imaging the colon in inflammatory bowel disease

Indium-111 autologous leucocyte scanning was compared with barium enema for assessing the extent of colonic disease in Crohn's colitis and ulcerative colitis. Scanning was shown to be as accurate as conventional radiology in colitis, reliably distinguishing active from inactive disease. The results suggest that 111In-leucocyte scanning is an accurate, non-invasive, alternative technique for imaging the extent of disease in colitis.

Positron emission tomography in the investigation of pediatric inflammatory bowel disease

BACKGROUND

Endoscopic and radiologic studies are frequently required in inflammatory bowel disease (IBD) to determine disease activity, extent of disease, and delineating disease type. Positron emission tomography (PET) using fluorine-18-fluoro-deoxyglucose to identify metabolically active tissues may offer a simple noninvasive alternative to conventional studies in identification and localization of active intestinal inflammation in children with IBD. The aim of this study was to assess the value of PET in identifying active intestinal inflammation compared with conventional endoscopic and radiologic studies, including small bowel follow-through and colonoscopy.

METHODS

Sixty-five children were enrolled in the study. This included 55 children (mean age, 13.3 yr; range, 7-18 yr; 20 girls) with newly diagnosed IBD (37) or symptoms suggestive of recurrent disease (18) and 10 children with recurrent abdominal pain (mean age, 12.7 yr; range, 8-15 yr; 7 girls) who were studied with PET, and the results were compared with small bowel follow-through with pneumocolon and/or colonoscopy. Thirty-eight patients had Crohn's disease (17 ileal, 12 ileocolic, 5 pancolonic, 3 left-sided disease, 1 right-sided disease), and 17 had ulcerative colitis (15 pan-colitis, 2 left-sided colitis). Mean time interval between PET and other studies was 30 +/- 17.6 days.

RESULTS

PET correctly identified active inflammatory disease in 80% of children with IBD (81.5% with Crohn's disease; 76.4% with ulcerative colitis) and correctly showed no evidence of inflammation in children with recurrent abdominal pain. Gluorine-18-fluoro-deoxyglucose accumulated at sites that corresponded with active disease at colonoscopy in 83.8% of patients and with small bowel follow-through with pneumocolon 75.0% of the time.

CONCLUSION

This study suggests that PET offers a noninvasive tool for identifying and localizing active intestinal inflammation in children with IBD. PET may not be able to replace conventional studies; however, it may be useful when conventional studies cannot be performed or fail to be completed.

Low molecular weight heparin as adjuvant therapy in active ulcerative colitis

BACKGROUND

Heparin given intravenously has shown beneficial effects in the treatment of refractory ulcerative colitis in open trials. Low molecular weight heparin (LMWH) offers advantages in the method of administration but have not been evaluated in inflammatory bowel disease conditions.

AIM

To assess the tolerability and safety of subcutaneous self-administered LMWH in outpatients with refractory ulcerative colitis and to evaluate any potential adjuvant therapeutic effect.

PATIENTS AND METHODS

Twelve patients with mild to moderately active ulcerative colitis were included in the trial. The patients had either responded poorly to treatment with conventional therapy, including oral and/or rectal glucocorticosteroids, or had experienced a rapid relapse during or shortly after GCS therapy. Dalteparin sodium 5000 units s.c. injection was administered twice daily for 12 weeks. Patients were monitored for possible adverse events and changes in clinical symptoms, and endoscopic and histological scores were analysed. Leucocyte scanning was performed at inclusion and at the end of the study.

RESULTS

Tolerability and compliance were excellent and no serious adverse events occurred. Eleven patients improved symptomatically and six (50%) attained complete remission after 12 weeks of treatment. Endoscopic, scintigraphic and histological scores were found to be significantly improved.

CONCLUSION

Self-administered LMWH given s.c. may be a safe adjuvant therapy for patients with active, glucocorticosteroids-refractory ulcerative colitis. A controlled trial should be undertaken to confirm the positive effects found in this study.

Inflammatory bowel disease imaging: Current practice and future directions

The purpose of this paper is to evaluate the role of imaging in inflammatory bowel disease (IBD), including detection of extraluminal complications and extraintestinal manifestations of IBD, assessment of disease activity and treatment response, and discrimination of inflammatory from fibrotic strictures. IBD is a chronic idiopathic disease affecting the gastrointestinal tract that is comprised of two separate, but related intestinal disorders; Crohn’s disease and ulcerative colitis. The paper discusses, in detail the pros and cons of the different IBD imaging modalities that need to be considered in order to optimize the imaging and clinical evaluation of patients with IBD. Historically, IBD evaluation of the bowel has included imaging to assess the portions of the small bowel that are inaccessible to optical endoscopic visualization. This traditionally was performed using barium fluoroscopic techniques; however, cross-sectional imaging techniques (computed tomography and magnetic resonance imaging) are being increasingly utilized for IBD evaluation because they can simultaneously assess mural and extramural IBD manifestations. Recent advances in imaging technology, that continue to improve the ability of imaging to noninvasively follow disease activity and treatment response, are also discussed. This review article summarizes the current imaging approach in inflammatory bowel disease as well as the role of emerging imaging modalities.

Fully automated endoscopic disease activity assessment in ulcerative colitis

BACKGROUND AND AIMS

Endoscopy is essential for disease assessment in ulcerative colitis (UC), but subjectivity threatens accuracy and precision. We aimed to pilot a fully automated video analysis system for grading endoscopic disease in UC.

METHODS

A developmental set of high-resolution UC endoscopic videos were assigned Mayo endoscopic scores (MESs) provided by 2 experienced reviewers. Video still-image stacks were annotated for image quality (informativeness) and MES. Models to predict still-image informativeness and disease severity were trained using convolutional neural networks. A template-matching grid search was used to estimate whole-video MESs provided by human reviewers using predicted still-image MES proportions. The automated whole-video MES workflow was tested using unaltered endoscopic videos from a multicenter UC clinical trial.

RESULTS

The developmental high-resolution and testing multicenter clinical trial sets contained 51 and 264 videos, respectively. The still-image informative classifier had excellent performance with a sensitivity of 0.902 and specificity of 0.870. In high-resolution videos, fully automated methods correctly predicted MESs in 78% (41 of 50, κ = 0.84) of videos. In external clinical trial videos, reviewers agreed on MESs in 82.8% (140 of 169) of videos (κ = 0.78). Automated and central reviewer scoring agreement occurred in 57.1% of videos (κ = 0.59), but improved to 69.5% (107 of 169) when accounting for reviewer disagreement. Automated MES grading of clinical trial videos (often low resolution) correctly distinguished remission (MES 0,1) versus active disease (MES 2,3) in 83.7% (221 of 264) of videos.

CONCLUSIONS

These early results support the potential for artificial intelligence to provide endoscopic disease grading in UC that approximates the scoring of experienced reviewers.

Strategies for Detecting Colorectal Cancer in Patients with Inflammatory Bowel Disease: A Cochrane Systematic Review and Meta-Analysis

OBJECTIVES

Patients with longstanding ulcerative colitis (UC) and colonic Crohn's disease (CD) have an increased risk of colorectal cancer (CRC). We assess the effectiveness of endoscopic surveillance in patients with inflammatory bowel disease (IBD) for diagnosing CRC and reducing CRC-related mortality.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched from inception to 19 September 2016. Randomized controlled trials (RCTs), observational cohorts, or case-control studies assessing any form of endoscopic surveillance for early CRC detection were eligible for inclusion; studies without a comparison non-surveillance group were excluded. The primary outcome was rate of CRC detection. Secondary outcomes were rate of early (Duke stage A and B) versus late (Duke stage C & D) CRC detection and rate of CRC-related death. Data were pooled using fixed or random effects models based on the degree of heterogeneity; pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method.

RESULTS

Five observational studies evaluating 7199 IBD patients were included; no RCTs met criteria for inclusion. There are limited new studies evaluating this clinical question (last included study published 2014). There was a significantly higher rate of cancer detection in the non-surveillance group (3.2%, 135/4256) compared to the surveillance group (1.8%, 53/2895) (OR 0.58 (95% CI: 0.42-0.80), p < 0.001). In four pooled studies, there was a significantly lower rate of CRC-associated death in the surveillance group (8.5%, 15/176) compared to the non-surveillance group (22.3%, 79/354) (OR 0.36 (95% CI: 0.19-0.69), p = 0.002). In two pooled studies, there was a significantly higher rate of early-stage CRC detection in the surveillance group (15.5%, 17/110) compared to the non-surveillance group (7.7%, 9/117) (OR 5.40 (95% CI: 1.51-19.30), p = 0.009).

CONCLUSIONS

Colonoscopic surveillance in IBD is associated with a reduction in CRC development and CRC-associated death, as well as increased detection of early-stage CRC.

Indium-111 tagged leucocytes in the diagnosis of inflammatory bowel disease

The distribution of autologous leucocytes labelled with the gamma-ray emitting radioisotope indium-111 was studied in 25 patients with inflammatory bowel disease, 15 with Crohn's disease, and 10 with ulcerative colitis. In all instances the bowel lesion was identified. Radioactivity rapidly accumulated in the lesions over the first 2 h and then passed into the lumen of the bowel within the next 48 h, being redistributed from the liver and spleen. Normally, about 1% of the radioactivity passes into the stools in the 48 h after injection whereas approximately 20% of the administered radioactivity was found in the stools of the patients with inflammatory bowel disease. This noninvasive technique can show the extent of disease in patients too ill for conventional procedures. It can display abscesses and other lesions, and can be performed in outpatients.