GuidelineThe role of endoscopy in inflammatory bowel disease
Section snippets
Colonoscopy with ileoscopy
Colonoscopy with ileoscopy allows direct visualization and biopsy of the mucosa of the rectum, colon, and terminal ileum. Prospective studies have demonstrated that colonoscopy with ileoscopy is a safe procedure with a low rate of adverse events in patients with IBD.3 Relative contraindications to performing endoscopic procedures in patients with IBD include severe colitis and toxic megacolon. Unless contraindicated, a full colonoscopy with intubation of the terminal ileum should always be
Flexible sigmoidoscopy
Flexible sigmoidoscopy may provide useful information in patients with IBD; however, it is important to recognize that flexible sigmoidoscopy is inadequate to evaluate isolated proximal colitides. Flexible sigmoidoscopy should be performed preferentially when colonoscopy is considered high risk (eg, fulminant colitis).8 It also may be helpful to define disease activity in patients with established UC and in the evaluation for superimposed colitides (eg, cytomegalovirus, Clostridium difficile
EGD
EGD can be useful in the evaluation of patients with CD and IBD-U. Upper GI tract involvement (proximal to the ligament of Treitz) occurs in up to 16% of patients with CD76, 77 and can involve the esophagus, stomach,78 and duodenum.39, 78, 79, 80 Endoscopic findings of upper GI CD include erythema, aphthous lesions, ulcerations, strictures, and fistula openings.76, 81 Gastritis without aphthae is not indicative of CD and can be seen in patients with UC.17 Histologic findings consistent with CD
Capsule endoscopy
The performance of capsule endoscopy (CE) allows direct and minimally invasive visualization of the small-bowel mucosa and has a high diagnostic yield in patients with suspected or established CD.91 It may be particularly useful in identifying superficial lesions not detected by traditional endoscopy and radiography. Findings on CE consistent with CD include erythema, villous atrophy, erosions, ulcerations, and strictures.92 Data from retrospective studies, case series, and prospective studies
Enteroscopy
Enteroscopy has a limited role in the initial evaluation of patients with known or suspected IBD because of the high diagnostic yields of less-invasive modalities such as CE and radiologic small-bowel imaging. In patients with abnormalities seen on other imaging studies that are within reach, enteroscopy allows endoscopic and histologic evaluation and the potential for therapeutic interventions such as hemostasis, stricture dilation, or foreign body retrieval.92, 117, 118 Endoscopic strategies
EUS
EUS has been used to assess disease activity of colitis127, 128 and to differentiate CD from UC.127 EUS also has an established role in diagnosing patients with CD-related perianal disease, especially perianal fistulae and abscesses.129, 130, 131 Studies comparing tests for classifying fistula anatomy demonstrated an accuracy of 91% with EUS, 87% with magnetic resonance imaging (MRI), 91% with examination with the patient under anesthesia, and 100% by using a combination of any 2 methods.132
Classification and scoring systems
Ideally, IBD phenotypes should be classified according to validated classification systems, and documentation of endoscopic disease activity should be standardized. The Montreal classification system for classifying disease extent in adults with both UC and CD (Table 2) has been endorsed by both the ECCO and British Society of Gastroenterology (BSG).8, 16, 26 No consensus exists for endoscopic disease severity scores. Commonly used endoscopic scoring systems are available for review in the
Ileal pouch endoscopy
Ileal pouch anal anastomosis has become the surgical treatment of choice for patients with UC who require colectomy and has been associated with improved health-related quality of life.145, 146 The normal anatomy of a J-pouch has been described as having the endoscopic appearance of owl’s eyes, with one “eye” leading to the afferent limb and the other to the tip of the J-pouch, with a long sharp “beak” of mucosa between the two.147 Immediate postoperative and long-term adverse events of
Colorectal cancer screening and surveillance
Individuals with long-standing UC and extensive CD colitis are at increased risk for development of dysplasia and colorectal cancer (CRC) and should undergo colonoscopic screening and surveillance.8, 158, 159, 160, 161 The risk of CRC increases with longer duration and extent of severe colitis, family history of CRC, young age at disease onset, personal history of primary sclerosing cholangitis, personal history of dysplasia, or, in the case of UC, stricturing disease. Patients with UC who have
Stricture evaluation and dilation
In patients with CD, strictures typically are found in the terminal ileum and colon as well as at the site of ileocolonic surgical anastomosis.244, 245 Endoscopy allows assessment of the stricture, biopsy to exclude possible malignancy, and therapy in select cases. In the setting of UC, a colon stricture should be considered malignant until proven otherwise, and surgery should be considered, especially if a stricture cannot be thoroughly examined and biopsy specimens cannot be obtained.246, 247
Summary
- 1.
We recommend colonoscopy with ileoscopy for the initial evaluation of IBD and for differentiating IBD subtypes. (⊕⊕⊕⊕)
- 2.
We recommend mucosal biopsy specimens from multiple sites during the initial endoscopic evaluation of IBD. (⊕⊕⊕⊕)
- 3.
We recommend flexible sigmoidoscopy in patients with IBD when colonoscopy is contraindicated and to evaluate for other inflammatory etiologies before escalating therapies in patients with refractory disease. (⊕⊕⊕⊕○)
- 4.
We recommend that EGD be performed in pediatric
Disclosures
K. Chathadi is a speaker for Boston Scientific. R. Fanelli is the owner and director of New Wave Surgical and is an advisor to Via Surgical. J. Hwang is a speaker for Novartis and a consultant to US Endoscopy and received a research grant, equipment support, and a loan from Olympus. M. Khashab is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.
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This document was developed by the ASGE Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.