Northeast Florida Medicine Journal, Winter 2015

Vol. 66, No. 4 2015

Northeast Florida Medicine

DCMS online

. org

Inflammatory Bowel Disease

Multiple reproducible endoscopic scoring systems to

measure the disease activity have been developed and

validated. The most well-known scoring systems to

determine the disease activity in CD are the Crohn’s Disease

Endoscopic Index of Severity (CDEIS)

and the Simple

Endoscopic Score for Crohn’s Disease (SES-CD).

The

Ulcerative Colitis Endoscopic Index of Severity (UCEIS)

and the Ulcerative Colitis Colonoscopic Index of Severity

(UCCIS)

are two of the widely used scoring systems for

UC. Usefulness of implementing such endoscopic scoring

systems in routine clinical setting has yet to be determined.

Therapeutic Endoscopy in IBD

Typical CD begins with a mucosal inflammatory pattern

that over time develops into strictures or fistulas. The

Vienna Classification describes three distinct groups of CD:

inflammatory, stricturing and penetrating.

Stricturing

disease is predominant in the terminal ileumand ileocolonic

anastomosis or in the ileal pouch.

Strictures are believed to

be either inflammatory or fibrotic.

Inflammatory strictures

have the option of being treated by medical therapy.

The most common reason for surgery in CD is intestinal

strictures. Surgical resection and stricturoplasty are the

traditional means of treatment for patients that fail to

respond to medical treatment.

27,28

There is increasing

evidence for endoscopic treatments as safe and effective

alternatives to surgery in these patients.

A systemic review summarized the results of key studies

of endoscopic balloon dilatation in CD.

Overall,

technical success was achieved in 86 percent of patients.

The complication rates were mainly less than 5 percent.

Endoscopic dilatation was successful in avoiding surgery at

the end of the follow-up in 67 percent of patients who were

included in this review. If the patients who had failed for

technical reasons were excluded, the success rate measured

by avoidance of surgery was up to 78 percent.

Re-dilatations may be required in up to 20 percent of

patients at one year and up to 50 percent of patients by

five years.

31,32,33,34

These are comparable to the stricture

recurrence rate of 45 percent at five years following surgical

stricturoplasty.

Device-assisted enteroscopy anddilatationof

deep small bowel strictures

36,37,38,39

and dilation of ileal pouch

strictures are reported to be successful in expert hands.

Rectal pain anddischarge canbe due to rectal inflammation

or a sign of perianal fistula in a patient with rectal CD.

Approximately 25 percent of all patients with CD develop a

perianal fistula.

41,42

Identification of fistulae is difficult with

digital rectal examination alone, or even with examination

under anesthesia. Endoscopic ultrasonography (EUS) has

been used in CD patients with rectal involvement to help

with the detection of fistulae. EUS is more accurate than CT

(82 percent versus 24 percent)

or pelvic MRI (82 percent

versus 50 percent)

to discover perianal fistulae.

Primary Sclerosing Cholangitis (PSC) is a chronic,

cholestatic liver disease characterized by inflammation and

fibrosis of both intrahepatic and extrahepatic bile duct and

leads to the formation of bile duct strictures. PSC is strongly

associatedwith inflammatory bowel disease, mainlyUC, and

is often complicatedby development of cholangiocarcinoma.

Endoscopic retrograde cholangiography (ERC) assisted

dilation and stent placement has been proven to be a safe and

efficacious mode of treating primary sclerosing cholangitis-

associated strictures. ERC can help with improvement of

symptoms and cholestasis with a low rate of complications.

The risk of cholangiocarcinoma after 10 years and 20 years

of PSC is 9 percent and 19 percent respectively.

Bile

duct brushings, EUS-assisted fine needle aspiration and

cholangioscopy are commonly used for tissue acquisition

and diagnosis of PSC-associated cholangiocarcinoma.

46,47

Endoscopic mucosal resection (EMR) is an endoscopic

technique developed for removal of sessile or flat neoplasms

confined to the superficial layers (mucosa and submucosa)

of the GI tract. EMR is typically used for removal of

lesions smaller than 2 cm or piecemeal removal of larger

lesions. In one study, EMR was used to remove 79 flat

lesions with a recurrence rate of 2.4 percent at three

months. No additional lesions were detected in a four-

year follow-up period.

IBD and Colorectal Neoplasia Surveillance

The risk of CRC in IBD is increased with the duration

and extent of disease. UC patients have a higher risk of

developing colorectal cancer (CRC) than the general

population. In the largest report of surveillance colonoscopy

in patients with extensive UC, the cumulative incidence of

CRC increased from 2.5 percent at 20 years to 10.8 percent

at 40 years.

A meta-analysis that included multiple large

population-based studies reported the incidence of CRC to

2 percent at 10 years, 8 percent at 20 years, and 18 percent

at 30 years of disease activity in UC patients.

Patients with terminal ileum Crohn’s have the same risk

of CRC as the general population, but those with colonic

Crohn’s have a relative risk (RR) of 5.6 (95 percent CI 2.1–

12.2). The CRC risk appears to correlate with the extent and