Use of colonoscopy in the management of patients with Crohn's disease: Appropriateness and diagnostic yield

IntroductionColonoscopy is a necessary tool in the management of Crohn's disease, but the benefit achieved by the procedure is a matter of debate. In the present study we evaluate the clinical impact of performing colonoscopy in Crohn's disease patients.MethodsConsecutive patients with Crohn's disease undergoing colonoscopy were considered. The following issues were considered: appropriateness of indications; relevant findings able to change the management of the patients; the endoscopist's management decisions based on patient's clinical picture, i.e. increased, maintained or decreased treatment, compared with those selected after performing endoscopy.Results204 patients (116 male/88 female, mean age 41 years) were included. Colonoscopy was judged indicated in 52.9% cases, according to current guidelines. In 54% of patients, endoscopy revealed a significant lesion, and this rate was significantly lower for non-indicated procedures (25.9%, p < 0.0001). The endoscopic findings were in disagreement with symptoms in about 25% of cases, but the impact of the endoscopic findings on the endoscopist's decision was likely to be very small without any differences between appropriate and inappropriate procedures.ConclusionsEndoscopy is a potent tool in the management of Crohn's disease, if correctly used, but in the majority of cases a correct therapeutic decision may be established simply on the basis of clinical picture and non-invasive markers, whilst relevant endoscopic findings have a relatively low impact on the medical treatment.     

Appropriateness of colonoscopy： Diagnostic yield and safety in guidelines

AIM: To evaluate if the guidelines for the appro-priateness of performing colonoscopy by American Society for Gastrointestinal Endoscopy (AGSE) and Italian Society of Digestive Endoscopy (SIED) yield a good diagnostic efficacy and do not present risks of missing important colonic pathologies in an Italian population sample.METHODS: A total of 1017 consecutive patients (560 men and 457 women; mean age 64.4 ± 16 years) referred to an open-access endoscopy unit for colonoscopy from July 2004 to May 2006 were evaluated according to ASGE and SIED guidelines for appropriateness of performing the procedure. Diagnostic yield was defined as the percentage of relevant colonic pathologies of the total number of colonoscopies performed.RESULTS: About 85.2% patients underwent colono-scopy that was considered appropriate based on at least one ASGE or SIED criterion, while it was considered inappropriate for 14.8% of patients. The diagnostic yield of colonoscopy was significantly higher for appropriate colonoscopies (26.94% vs 10.6%, P < 0.001) than for inappropriate colonoscopies (5.3%). There was no missed colorectal cancer following the ASGE/SIED criteria.CONCLUSION: ASGE/SIED guidelines have shown a good diagnostic yield and the rate of missing relevant colonic pathologies seems very low. Unfortunately, the percentage of inappropriate referrals for colonoscopy in an open-access endoscopy system is still high, despite the number of papers published on the issue and the definition of international guidelines. Further steps are required to update and standardize the guidelines to increase their diffusion and to promote educational programs for general practitioners.     

Colon capsule endoscopy versus standard colonoscopy in assessing disease activity of ulcerative colitis: a prospective trial

Background

The aim of our study was to compare colon capsule endoscopy (CCE) with standard colonoscopy (SC) in the assessment of mucosal disease activity and localization of inflammatory colonic mucosa in patients with known ulcerative colitis (UC).

Methods

Thirteen symptomatic patients (8 males, 5 females, mean age 38.5 ± 12.0 years) with known UC (mean duration of colitis: 9.7 ± 8.1 years) and indication for endoscopy due to suspected disease activity were included. All patients underwent CCE (first generation capsule, Given Imaging Ltd., Yokneam, Israel) on day 1 followed by SC on day 2 in a single center non-randomized, non-placebo-controlled diagnostic study (NCT00837304). SC and CCE were video recorded, and analysis was independently performed by 6 experienced endoscopists. The modified Rachmilewitz score was calculated, and Wilcoxon signed-rank test was used for analysis. Difference in recognition of disease activity by the endoscopists was assessed by application of the Kruskal–Wallis test.

Results

Assessment of disease activity revealed a significantly higher Rachmilewitz score of 7.3 ± 2.9 in the SC group compared to 4.8 ± 3.4 in the CCE group. Significantly, more detection of vessel vulnerability, granulated mucosa and mucosal damage was seen by SC. Disease extension was underestimated by CCE compared to SC. Disease activity assessment by means of SC or CCE did not differ statistically between the investigators (p = 0.26 and p = 0.1, respectively). After CCE, the capsule egestion rate was 77 %. The overall acceptance of both procedures was similar.

Conclusion

Considering the significantly different assessment of disease activity and significantly more appropriate assignment of the horizontal spread of inflammation by SC versus CCE, we recommend the preferential use of SC in the assessment of inflammation in UC patients.     

Appropriateness and diagnostic yield of EGD: a prospective study in a large Asian hospital

BACKGROUND: The appropriateness has become an important issue as the use of EGD becomes more widespread. No study of the appropriateness of EGD has been performed in the Asia-Pacific region. This study examined the appropriateness of EGD in a large Asian hospital by using the American Society for Gastrointestinal Endoscopy 2000 guidelines. A secondary aim was to correlate appropriateness with the presence of positive findings at EGD. METHODS: A cross-sectional study was conducted of consecutive diagnostic EGDs performed at a university-affiliated, teaching hospital, which has an open-access endoscopy system for doctors who work in the hospital. The main indication(s) for EGD was recorded and assessed as appropriate or inappropriate by using American Society for Gastrointestinal Endoscopy criteria. EGD findings were recorded and classified as positive or negative. Referrals were categorized as being from endoscopists, primary care physicians, and others. RESULTS: Of 1076 referrals for EGD, 88.3% were deemed appropriate. The group with the highest rate of appropriate referral was endoscopists (90.2%), followed by primary care physicians (89.6%) and "others" (81.9%). The rate of appropriate referrals was significantly higher for endoscopists and primary care physicians compared with "others" (respectively, p=0.001 and p=0.022). The most common appropriate indication was "upper abdominal distress that persists despite an appropriate trial of therapy" (35.4%). The most common inappropriate indication was "dyspepsia in patients aged 45 years or below without adequate empirical medical treatment" (48.4%); 42.2% with an appropriate indication had positive findings compared with only 25.6% of those with inappropriate indications (p=0.006). On multivariate analysis, the following were identified as independent predictive factors for positive findings at EGD: male gender (p=0.005), age over 45 years (p=0.011), smoking (p=0.005), none/primary education (p<0.001), and secondary education (p=0.026). CONCLUSIONS: The proportion of patients referred for open-access EGD with an appropriate indication(s) was high for all doctor groups in a large university-affiliated medical center in Asia. EGDs performed for appropriate indications had a higher yield of positive findings. Independent predictive factors of positive findings were male gender, age over 45 years, lower education level, and referral by an endoscopist.     

Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system

BACKGROUND: Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system. METHODS: Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patient's charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy. RESULTS: 3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies "generally indicated" according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies "generally not indicated" of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy. CONCLUSIONS: Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.     

Sexuality in patients with ulcerative colitis before and after restorative proctocolectomy: a prospective study

BACKGROUND: The purpose of this study was to assess sexuality in patients with ulcerative colitis (UC), before and one year after an ileal-pouch anal anastomosis (IPAA). METHODS: Group I comprised 14 medically treated patients (7 M) and Group II comprised 29 patients (18 M), operated with colectomy and ileostomy, with preservation of the rectum. Patients were interviewed about desire, excitement and general sexual satisfaction before and one year after the IPAA operation. RESULTS: Most of the patients had restarted sexual activity < or = 3 months after surgery. Sexual desire and desire for intercourse had not changed from before the IPAA operation. In Group I, one woman suffered from dyspareunia both before and after the IPAA. In Group II, three women had dyspareunia before the IPAA and four after surgery. Erection and ejaculation were normal in all men before the IPAA operation. After IPAA, one man in Group I and two men in Group II had loss of ejaculation. In Group 1, 10 out of 14 patients were satisfied with their sexual life both before and after the IPAA. In Group II the corresponding figures were 15 out of 28 before and 22 after IPAA surgery. CONCLUSIONS: A third of the patients stated that they were dissatisfied with their sexual life before IPAA. Although a few patients experienced sexual imperfections such as loss of ejaculation and dyspareunia, the majority of patients in both groups considered that the overall general satisfaction with their sexual life had normalized considerably after surgery.     

Sexuality in patients with ulcerative colitis before and after restorative proctocolectomy: a prospective study

Background: The purpose of this study was to assess sexuality in patients with ulcerative colitis (UC), before and one year after an ileal‐pouch anal anastomosis (IPAA). Methods: Group I comprised 14 medically treated patients (7 M) and Group II comprised 29 patients (18 M), operated with colectomy and ileostomy, with preservation of the rectum. Patients were interviewed about desire, excitement and general sexual satisfaction before and one year after the IPAA operation. Results: Most of the patients had restarted sexual activity ≤3 months after surgery. Sexual desire and desire for intercourse had not changed from before the IPAA operation. In Group I, one woman suffered from dyspareunia both before and after the IPAA. In Group II, three women had dyspareunia before the IPAA and four after surgery. Erection and ejaculation were normal in all men before the IPAA operation. After IPAA, one man in Group I and two men in Group II had loss of ejaculation. In Group I, 10 out of 14 patients were satisfied with their sexual life both before and after the IPAA. In Group II the corresponding figures were 15 out of 28 before and 22 after IPAA surgery. Conclusions: A third of the patients stated that they were dissatisfied with their sexual life before IPAA. Although a few patients experienced sexual imperfections such as loss of ejaculation and dyspareunia, the majority of patients in both groups considered that the overall general satisfaction with their sexual life had normalized considerably after surgery.     

The diagnostic yield of colonoscopy in hospitalized patients. An observational multicenter prospective study.

BackgroundColonoscopy demands a considerable amount of resources, and little is known about its diagnostic yield among inpatients.AimsTo assess indications, diagnostic yield and findings of colonoscopy for inpatients, and to identify risk factors for relevant findings and cancer.MethodsMulticentre, prospective, observational study including 12 hospitals. Consecutive adult inpatients undergoing colonoscopy were evaluated from February through November 2019.Results1,302 inpatients underwent colonoscopy. Diagnostic yield for relevant findings and cancer was 586 (45%) and 112 (8.6%), respectively. Adequate colon cleansing was achieved in 896 (68.8%) patients. Split-dose/same-day regimen was adopted in 847 (65%) patients. Factors associated to relevant findings were age ≥70 years (RR 1.32), male gender (RR 1.11), blood loss (RR 1.22) and adequate cleansing (RR 1.63). Age ≥70 years (RR 2.08), no previous colonoscopy (RR 2.69) and split-dose/same-day regimen (RR 1.59) significantly increased cancer detection. Implementing adequate cleansing and split-dose/same-day regimen in all patients would increase the diagnostic yield for any relevant findings and cancer from 43% to 70% and from 6% to 10%, respectively.ConclusionRelevant colorectal diseases and cancer were frequent among inpatients. Factors associated with detection of relevant findings were identified. Adequate colon cleansing and split-dose/same-day regimen significantly increased colonoscopy diagnostic yield.     

Colorectal carcinoma in patients with ulcerative colitis and recent colonoscopy.

Longstanding ulcerative colitis, particularly pancolitis, is associated with an increased risk of colorectal neoplasia. For this reason surveillance colonoscopy at regular intervals has been recommended to identify early cancers or high grade dysplasia. Three cases are described of patients with ulcerative colitis of greater than 10 years duration who presented with colorectal carcinoma within three years of colonoscopy.     

Stress and exacerbation in ulcerative colitis: a prospective study of patients enrolled in remission

OBJECTIVE: We sought to determine whether psychosocial factors influence the course of ulcerative colitis, hypothesizing that high perceived stress among patients with inactive disease will increase the risk of subsequent exacerbation. METHODS: Sixty-two patients with known ulcerative colitis were enrolled into a prospective cohort study while in clinical remission. Their perceived stress, depressive symptoms, and stressful life events were followed, along with potential confounders, for up to 45 months; exacerbation status was monitored for up to 68 months. RESULTS: The 27 patients who experienced an exacerbation were compared with those who remained in remission. Having a score in the upper tertile on the long-term (past 2 yr) baseline Perceived Stress Questionnaire significantly increased the actuarial risk of exacerbation (hazards ratio = 2.8, 95% confidence interval 1.1-7.2). At any given study visit, high long-term stress tripled the risk of exacerbation during the next 8 months (risk for the three tertiles, 8.3%, 16.7%, and 26.2%, p = 0.02). Shorter sleep time, briefer remission, histological activity, and use of nonsteroidal antiinflammatory drugs, antibiotics, or oral contraceptives also increased the medium- and/or long-term risk of exacerbation, but adjustment for these variables did not eliminate the associations with stress. Exacerbation was not associated with stressful life events, depressive symptoms, short-term (past month) perceived stress, smoking, disease extent or duration, or severity of recent course. CONCLUSIONS: Short-term stress does not trigger exacerbation in ulcerative colitis, but long-term perceived stress increases the risk of exacerbation over a period of months to years.     

The yield of diagnostic upper endoscopy: results of a prospective audit

Because of its widespread availability and the generally increasing economic pressure, endoscopy needs critical scrutiny to establish appropriate clinical guidelines. We carried out a prospective evaluation of 200 consecutive upper gastrointestinal (GI) endoscopies to ascertain the frequency of abnormal findings when specific indications were the impetus to endoscopy. Those indications were esophageal complaints, upper GI bleeding, abdominal discomfort, known premalignant disorders and abnormal findings on barium meal. The overall frequency of abnormal findings for all indications was 66%. Abnormal endoscopic findings were most often present when upper GI bleeding or premalignant conditions (88 and 87%, respectively) were reasons for endoscopy. Endoscopic confirmation of lesions seen on barium meal was 64%. Only 37% of patients endoscoped for abdominal discomfort had abnormal findings. Moreover, as symptoms resolved in 70% of such patients within 1 to 9 weeks, the low yield of endoscopy suggests that our current threshold for endoscopy in this setting may be too low. Refinement of the indications for and reassessment of the timing of endoscopy are needed.     

Incidence of ulcerative colitis in Central Greece： A prospective study

AIM: To study the incidence of ulcerative colitis UC in the prefecture of Trikala, Central Greece. METHODS: A prospective and population based epidemiological study of UC from 1990 to the end of 1994 was conducted. Trikala is a semirural prefecture of Central Greece with a population of 138 946 (census 1991). Three gastroenterologists (one hospital based, two private doctors) of the prefecture participated in this study. RESULTS: During the study period, 66 new historically verified cases of UC were recorded. The mean annual incidence of the disease in 1990-1994 was 11.2 per 105 inhabitants (95%CI: 8.7-14.3). There was no difference between men and women (annual incidence: 10.5 and 12.0 per 105 inhabitants respectively), either among urban, semirural or rural populations (annual incidence: 11.7, 17.1 and 9,9 per 105 inhabitants respectively). The majority (56%) of the patients never smoked and a quarter were ex-smokers. About a half of all cases had proctitis. CONCLUSION: UC is common in Central Greece and its incidence is similar to that in North-Western European countries.     

Bowel preparation increases the diagnostic yield of capsule endoscopy: a prospective, randomized, controlled study

BACKGROUND: The aim of this study was to determine the value of small-bowel preparation for patients undergoing capsule endoscopy. METHODS: The study design was prospective, randomized, and controlled. Eighty patients referred for capsule endoscopy were randomized into two equal groups. Patients in Group A (mean age 54.40 [15.65] years) ingested 2 L of a polyethylene glycol/electrolyte solution 16 hours before the test, whereas patients in Group B (mean age 59.85 [14.58] years) prepared for the procedure by taking only clear liquids during the prior day. The primary outcome evaluated was the effect of bowel preparation on the quality of capsule images, as assessed with an objective scoring system in which cleansing was graded as "adequate" or "inadequate" by blinded examiners. A secondary outcome was the effect of bowel preparation on diagnostic yield. For this purpose, the results of capsule endoscopy were classified as positive findings, findings of uncertain significance, and no findings. RESULTS: Cleansing of the small intestine was considered "adequate" in 36 patients in Group A (90%) vs. 24 patients of Group B (60%) (p = 0.004). A diagnosis was established in 26 patients in Group A (65%) compared with 12 patients in Group B (30%) (p = 0.003). CONCLUSIONS: Bowel preparation before capsule endoscopy improves visualization of the small intestine, which may lead to an improvement in diagnostic yield.     

Value of colonoscopy for prediction of prognosis in patients with ulcerative colitis

Ulcerative colitis （UC） is a chronic inflammatory bowel disorder characterized by exacerbations and remissions. Some UC patients remain refractory to conventional medical treatment while, in others, the effectiveness of drugs is limited by side-effects. Recently, cyclosporine and leukocyte removal therapy have been used for refractory UC patients. To predict the efficacy of these therapies is important for appropriate selection of treatment options and for preparation for colectomy. Endoscopy is the cornerstone for diagnosis and evaluation of UC. Endoscopic parameters in patients with severe or refractory UC may predict a clinical response to therapies, such as cyclosporine or leukocyte removal therapy. As for the patients with quiescent UC, relapse of UC is difficult to predict by routine colonoscopy. Even when routine colonoscopy suggests remission and a normal mucosal appearance, microscopic abnormalities may persist and relapse may occur later. To more accurately identify disease activity and to predict exacerbations in UC patients with clinically inactive disease is important for deciding whether medical treatment should be maintained. Magnifying colonoscopy is useful for the evaluation of disease activity and for predicting relapse in patients with UC.     

Diagnostic yield of upper endoscopy in paediatric patients with Crohn's disease and ulcerative colitis. Subanalysis of the HUPIR registry

Background, aimsAccording to Porto Criteria upper gastrointestinal (UGI) endoscopy is recommended in patients with suspected inflammatory bowel disease (IBD). Nevertheless, previous studies revealed frequent involvement of UGI tract even in patients with ulcerative colitis (UC). The aim of the present study was to determine the diagnostic role of esophagogastroduodenoscopy (EGD) and assess the prevalence and different aspects of UGI involvement in children registered in the Hungarian Pediatric IBD Registry (HUPIR) from 1st of January 2007 to 31th of December 2009.MethodsTwenty seven institutes provided prospective follow-up data about newly diagnosed IBD patients to HUPIR. The registry was based on detailed questionnaire (76 parameters) involving anamnestic data, laboratory findings, activity indexes, diagnostic procedures, endoscopic examinations (EGD and ileocolonoscopy), and histological data. Localization and phenotype of disease were based on the Montreal classification criteria.ResultsDuring the 3-year period 420 children were diagnosed with IBD, 265 (63%) of them had Crohn's disease (CD), 130 (31%) UC, and 25 (6%) IBD-unclassified (IBD-U). The mean age at diagnosis was 13.2 years (range: 1.2–18 years). EGD was performed in 237 patients (56%), in most cases in patients suffering from CD. Macroscopic lesions on EGD were noted in 64% of patients with CD and 40% of children with UC. Characteristic lesions for CD (ulcer, erosion, aphthous lesion, and granuloma) were noted in 31% of CD patients, however, EGD helped to establish the final diagnosis in 9% of CD patients (diagnostic yield, 9%).ConclusionsThere was a high frequency of UGI involvement in children with CD and UC. One third of CD patients showed significant lesions at upper endoscopy and one patient out of ten had real diagnostic help from EGD.     

Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis

BACKGROUND AND AIMS: Because of the large number of biopsy specimens, surveillance colonoscopy in ulcerative colitis (UC) is currently time consuming and significant flat lesions still may be missed. In this study we assessed the value of combined chromoscopy and endomicroscopy for the diagnosis of intraepithelial neoplasias in a randomized controlled trial. METHODS: A total of 161 patients with long-term UC in clinical remission were randomized at a 1:1 ratio to undergo conventional colonoscopy or chromoscopy with endomicroscopy. Eight patients were excluded because of insufficient bowel preparation. In the conventional colonoscopic group (n = 73), random biopsy examinations and targeted biopsy examinations were performed. In the endomicroscopy group (n = 80), circumscribed mucosal lesions were identified by chromoscopy and evaluated for targeted biopsy examination by endomicroscopy. The primary outcome analysis was based on the detection of neoplasias. RESULTS: By using chromoscopy with endomicroscopy, 4.75-fold more neoplasias could be detected (P = .005) than with conventional colonoscopy, although 50% fewer biopsy specimens (P = .008) were required. If only circumscribed lesions would have been biopsied in the first group, the total number of biopsy specimens could have been reduced by more than 90%. A total of 5580 confocal endomicroscopic images from 134 circumscribed lesions were compared with histologic results. The presence of neoplastic changes could be predicted by endomicroscopy with high accuracy (sensitivity, 94.7%; specificity, 98.3%; accuracy, 97.8%). CONCLUSIONS: Endomicroscopy based on in vivo histology can determine if UC lesions identified by chromoscopy should undergo biopsy examination, thereby increasing the diagnostic yield and reducing the need for biopsy examinations. Thus, chromoscopy-guided endomicroscopy may lead to significant improvements in the clinical management of UC.