have an IBD session, and thanks to Doug Rex, who is our current president, recognizing that IBD has come a long way, and I'm so excited that we offer today an opportunity to learn more about how to do an endoscopy in an IBD patient well. So first, I would like to welcome Miguel Reguero from Cleveland Clinic to the podium, who's going to teach us about assessment of disease activity during the endoscopy in an IBD patient. Great. Well, thank you very much. First of all, as an IBD-ologist, that freaked me out. I'll just tell you right now, sitting next to Frank Ferre, and we're not used to seeing that, so when we see a hole in the bowel, that's not good. But now for something entirely different, we're going to shift gears. As Monica said, this session's going to focus on IBD and disease activity. We do have a video at the end. We do have time for a case discussion as well. So these are my relevant financial disclosures. Now what about IBD in terms of when you see it, you know it? I bet that if I asked each of you, aside from the bottom right, to describe this descriptively without scores, we would probably get several different analyses. And part of the problem we're running into with IBD is we don't have standard language or we don't use standard language enough. And I think what the take-home from this will be are what scores, what endoscopic scores should we be using? Probably in your practices, you have these embedded in your endoscopy systems. And one of the take-homes is going to be we should use these more and more. Well, so what are the purposes of doing endoscopy and IBD? Well, obviously, one of them is to diagnose and to assess disease and to monitor disease over time. Another is obviously therapy, and there are different therapeutic techniques, and you'll hear some of these from other speakers as well. And then obviously another is how can we prevent and screen and, more importantly, survey for dysplasia? And Dr. Frey is going to give a talk entirely on surveillance for dysplasia. What should we not do, and what should we not report, and how should we not report? And unfortunately, I think these are probably how many of the reports come back in IBD. Procedure diagnosis, colon had some inflammation. What does that mean? I have no idea. And the problem is we don't know if it's mild, we don't know if it's in one patch, we don't know if it's in segments, we don't know if there are deep ulcers. Now, this gastroenterologist who will not be named, the biggest input is no imodium. So that was just written on the sheet. But this is all tongue-in-cheek, but at the same time, we shouldn't do this, nor should we do this. So there's a little bit more on this report. You can see a code down here. But there was evidence of colitis in the colon and a biopsy was taken. We need to do better in terms of standardization as far as endoscopic reporting. Why is this important? You see this all the time in your practices. Up to half of the patients who are in clinical remission, when you do a colonoscopy, you find disease and you say, there's a huge disconnect. And if you only followed their symptoms, you would either under or over-treat those patients. The converse is some patients have irritable bowel with many symptoms and you scope them and they have no disease. So I think we need to be better in the way we approach this and come up with an assessment of endoscopic disease that's using more algorithms. We're not going to get into AI, at least I'm not in my talk, but I do think in the future we'll have more machine-based learning as well. We need scoring systems that are reliable, valid, responsive. But probably the most important is if they're not feasible, if you can't do this easily in your practice, you're not going to do it. So these have to be something that practically all of us can do. The take-home is we need to speak the same language. We have lots of endoscopic indices. You come to DDW and if you go to an IBD session, you'll hear about all these different scoring systems and it can be overwhelming. And in research, these are important. But in clinical practice, we need to boil it down to two or three. I think that I put in red here, these are some of the ones that I would consider. You might be using these already. But the SCSCD, and I'll show example at the end, this is, I have to say the name of one because that's what I use. Probation, for example, has these templated. And if they're in there, it takes less than a minute to use the scoring system. And even the SCSCD is easy to use. The Rutgert score, we actually will have a case on that. And the Mayo score for ulcerative colitis. Those three I would uniformly recommend. Why should we do this? Well, again, when you look at these, kind of the table of 12 different photos, the UCEIS is on the left. The Mayo score, which is what I uniformly use, is basically just a four-point score from zero, normal, to three, severe, which includes deep ulcers. When we use these scores in this language, it becomes uniform and understanding. So this is just a close-up of the Mayo score. This is the most common one. Again, I won't show for a raise of hands, but I imagine some of you will use this in your own practices. And I think this is easily transferable amongst physicians. What about Crohn's disease? The CDIS, this is the gold standard. However, it's the most cumbersome. And I would dare say I would probably not even use this in my routine practice. The SCSCD, though, is built in the endoscopic scores. It is much easier than the CDIS. More importantly, it's reliable and reproducible. But I would argue, again, that probably most of us are not using this on a regular basis, even though this does only take about a minute of just clicking boxes along the way. The Rutgeert score for post-op Crohn's, also very easy to use. It's only, like, the Mayo score, four points. When we've done surveys, and actually, now that I'm looking down and seeing Frank, we're actually from an IBD live conference trying to figure out how many of us are using these, even in an IBD practice. And what I think we're going to find is probably only about half at most. There are various appearances on endoscopy in Crohn's. And again, if I were to ask you to describe this little aptis ulcer in the ilium compared to somebody who has deep ulcers on a retroflex exam, we might get different descriptions if we're not using the score. This is just showing you the SCS-CD. I'm not going to go through it in detail. Again, it is using five bowel segments on the score. So essentially, ilium, right colon, transverse colon, left colon, rectum. When I do this on my endoscopy system, basically pulls down a tab. At the very bottom, if it's completely normal, if you click that, it automatically generates a score of zero. And that takes literally three seconds. However, if there are different parameters, depending on the size of ulcers, the amount of ulcerated area, affected surface, these are pretty easy to click off as well. So here's an example, 30% ulcerated, 75% affected. And this is actually just click boxes. This will then generate a score of this segment, which is obviously very different than the segments on the bottom. And the thing I like about this, too, is that it does break it down anatomically. Why is this important? I know you've heard at this meeting, you've heard at other IBD sessions, we now are getting into this treat-to-target approach. And we now know, without reading this whole slide, that if we use these sub-scores, or these scores, to generate how we alter and monitor and change treatment for both Crohn's and ulcerative colitis, we can do a better job. This may not transmit, but this is an example from a probation score. For those that use probation, you're probably familiar with this. But again, it's just clicking on these boxes. You can see the scores that are generated. And this is an example in the bottom right of a Mayo score, which, again, is pretty easy to apply. So this is my summary slide. And this is just saying how we evolve in the role of endoscopy. And at the end, we'll actually have some cases. It would be interesting to see how you would score a post-op Rutgert score, and then also what you would do with the case I'll present. And I know we have some others. So again, endoscopy is more than just making a diagnosis. It's assessing the mucosa. But now we're using this in a treat-to-target outcome, in terms of adjusting therapies, and also using endoscopy to decide if we need to downgrade or upgrade what we're doing. We need simpler scores. And I would submit the Mayo score for ulcerative colitis, the SCSCD score for Crohn's, the Rutgert score. Bo might go a little bit into some of the pouchitis scores, which I think are helpful as well. Many times people ask, are we using histology as an endpoint? My simple answer in clinical practice is no. The only time I use histology in clinical practice is a patient who feels well endoscopically as normal, but still has active disease histologically. One, I'm telling that patient we should not downregulate their treatment, because I worry that that still represents activity. And secondly, when we get into surveillance, there have been some studies that show maybe we should keep a closer eye on those patients, rather than, say, come back in three to four years for your colonoscopy. But what I'm not doing is I'm not switching out of class, using a different medicine, because there's histologic activity. Frank and others have shown us that obviously the power, and especially with our optics and high-definition scopes and some other ways to measure dysplasia, we use these as for surveillance. And then finally, as I mentioned, and you're hearing a lot at this meeting, artificial intelligence is coming. I do think that we will generate. And in IBD, we will use more of these machine-based approaches for endoscopic delivery and assessment of disease. So with that, thank you very much for your attention. And I'll hand it off to Monica to introduce the next speaker. And we'll go from there. So thank you very much.

endoscopy

disease activity

inflammatory bowel disease

Mayo score

SCSCD score