Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Endoscopic Surveillance in Inflammatory Bowel Disease. My name is Michael DeLuttre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to this recording in GILeap as part of your registration. Now it is my pleasure to introduce our moderator, Taylor Ashley Riggs, from Baylor College of Medicine in Houston, Texas. I will now hand over this presentation to her. Hey, everyone, thanks so much for being here with us tonight. I'm Taylor, one of the second year GI Fellows at Baylor College of Medicine in Houston, Texas. Hopefully we'll get some great participation tonight and have a great session on surveillance in inflammatory bowel disease. So like he mentioned throughout the session, we'll have some slides we'll be going through and some case presentations. And if you have any questions during the session, just type them into the Q&A box and we'll intermittently answer them throughout the session, but I'll be keeping track to make sure they get answered. So with that, I'd like to thank Dr. Shukla for being here with us virtually this evening. Dr. Shukla is an associate professor at Baylor College of Medicine and one of the assistant program directors for our fellowship. Her clinical focus is in inflammatory bowel disease, and she's a great clinician educator and mentor for my co-fellows and I at Baylor. So with that, I'll hand it over to her and we can go ahead and get started. Thank you, Taylor. Thank you so much for that kind introduction and thank you all for spending a little bit of your Thursday evening with us. I hope you'll find this session informative and certainly just like everyone else has already said, we want this to be as interactive as you would like for it to be. So please feel free to interrupt. I'm happy to answer any questions you have and we can even chat about any difficult cases that you might've encountered and use some of what I'm talking about here as a launchpad for that. So with that, let me share my screen and we'll get started here. Give me one second to just, okay, great. So again, the topic for tonight's conversation is about endoscopy and IBD surveillance. And so when I was invited to give this talk, which I'm honored to have that invitation, I sort of immediately thought that they wanted me to talk only about dysplasia surveillance. But as I sat with the topic for a little bit longer, I realized that there's so much more that this topic can cover. And so I'll spend a little time in all the areas I think endoscopy is pertinent to. When I think of my own practice as an IBD focused GI clinician, I think mainly of my time in clinic. I don't really think as much about my time in endoscopy, but I think I was selling endoscopy a little bit short in doing that. So here we go. I'll give you a little bit of background. As many of you already know, Crohn's disease and ulcerative colitis, these are chronic conditions with the relapsing and remitting course. Both Crohn's disease and ulcerative colitis are emerging as a global disease with a significant financial burden and a lot of increasing healthcare utilization. We've been seeing rising rates in IBD prevalence over the last 20 plus years. And at this point, we probably have more than 7 million patients affected by one of these conditions worldwide. We're even seeing a change in where we're seeing patients with IBD. We're seeing that historically it used to be more of a Western focused disease, and now we're seeing it move more towards Eastern countries. And we think that has a lot to do with some of the triggers for IBD, including some of the dietary exposures as well. So knowing that it's an increasingly prevalent disease that carries a significant financial burden, it's important to utilize all the tools that we have to really optimize disease control. So while we care a lot about how our patients feel and our priority, of course, is to make them feel better, the symptoms a patient experiences alone cannot help make the diagnosis, nor can they help to accurately evaluate where we stand with a patient's disease activity. And we really have to rely on objective testing to help guide our really important treatment decisions and to help prevent the complications that can occur from uncontrolled disease. And that's where a tool like endoscopy comes in. Endoscopy, as I said, the first thing I thought of was just dysplasia surveillance. But in fact, it's so much more than that. It serves many key roles, including, of course, making the diagnosis of IBD, helping to assess treatment response or what we call mucosal healing, helping to, of course, to conduct dysplasia surveillance, looking at patients who have undergone surgery for management, usually of their Crohn's disease, but also for ulcerative colitis and helping to survey those patients afterward, and also to help treat certain complications of IBD, which is an emerging field in this discipline. So that leads me to the objectives of my talk tonight. I hope you walk away from this with a better understanding of the role of endoscopy in IBD. I'll review some of our current guidelines that exist, and I'll try to give you my two cents on how we can practically utilize endoscopy to help optimize disease control in IBD and improve outcomes overall. So starting off just at the beginning, endoscopy is so important in helping to make a diagnosis of IBD. There is no single test, of course, to diagnose IBD. You might have seen that there's these panels that exist to help look at certain serologic markers. Unfortunately, those are really not super effective in helping to make a diagnosis of IBD. And the diagnosis is based on a combination of clinical endoscopic lab and radiologic findings. But ileocolonoscopy is really one of the most important and key pieces that is needed to confirm a diagnosis of IBD when the symptoms are really indicating that that's what a patient could have. And so without an endoscopy, I think it's really hard to say a patient has IBD. So rarely from these days do I see a patient come in without that and carrying a diagnosis of IBD. But always remember to make sure to do that to help make your diagnosis. So I'll dive in a little bit more about the differences between UC and Crohn's disease and how we make the diagnosis using endoscopy. So with UC, the hallmark trait is that inflammation begins at the anal rectal junction and then spreads proximally. Sometimes you can be a little bit misled when you see things like discontinuous involvement of the inflammation in the colon. But remember that while inflammation tends to be continuous, there can be patchy healing. So if you encounter a patient who has been on some kind of treatment, they may not always have that exact continuous involvement. And so there's some other features as well for you to look at. And this small graphic down here just gives you sort of an idea of like the spectrum of what you might see on endoscopy. So if someone has inactive disease, then they're likely to kind of look like someone without ulcerative colitis. Their mucosa may be pale. They may have normal vasculature or a little bit slightly altered vasculature. But moving down that spectrum, mild disease might appear something like edematous or a little bit of erythema. Maybe the mucosa is a little bit more glistening or we use a term called granularity, which is really manifested by changes in the light reflection during colonoscopy. So instead of light being reflected in like these large patches, granular mucosa tends to reflect it at certain small points of light. So it kind of gives like the sandpaper appearance. So that's something we use to kind of describe the abnormality we see in ulcerative colitis. And then as we move along in moderate disease, we'll see that like coarse appearance become even more pronounced. And we might start to see like erosions, friability, just gentle pressure from the scope might cause some bleeding. And then, of course, severe is where you start to see some of those really like gross mucosal ulceration, spontaneous hemorrhage, even just with like insufflation. And so it can present in a variety of ways. And it's helpful, I think, to see, you know, an image of this. So up here is normal mucosa. You see the vasculature really nicely because it's kind of a pale pink. And then here in this panel, you start to see a little bit of erythema. Maybe you're not appreciating the vasculature as well. And this is where you start to get kind of like that like sandpaper like appearance. It doesn't look quite as smooth as a normal endoscopy would look. And then here in this last one, you're starting to just sort of see it's like, you know, kind of looking like it's got some oozing and you're starting to see some ulceration. It just looks a little bit beefy. And so that's, you know, you can see patients anywhere along that spectrum. Another thing you might appreciate in a patient with ulcerative colitis is pseudopolyps. So pseudopolyps, actually, they are a result of the mucosal hyperplasia that occurs from the repeated episodes of inflammation and ulceration. And over time, as that resolves, you see like these areas of normal tissue that sort of like pop out and appear polyploid. But it's actually it's not adenomatous mucosa. It's just like normal tissue that's kind of undergone like a repeated cycle of inflammation and then control of inflammation. And they're more common in patients with ulcerative colitis. But, you know, you can see them in Crohn's disease, but definitely much more common in ulcerative colitis. And usually you can just tell by the appearance that something looks is a pseudopolyp. It has sort of this elongated appearance. If you were to look under NBI, you wouldn't really see like the typical pit pattern that you associate with adenomas. But if you ever see a polyp and you're not sure, of course, it's always safest to biopsy. But this is just an appearance of like someone with dense pseudopolyposis. The other thing you might see is like sometimes there's some like bridging pseudopolyps where you kind of like see it connect from one side of the lumen to the other. So that's another characteristic finding. Another finding that you might see associated with ulcerative colitis is something called backwash ileitis. And this is a term that we use to refer to inflammation that can occur in the terminal ileum in patients with UC. And, you know, the traditional teaching, of course, is ulcerative colitis is colonic inflammation. But you can sometimes see this this backwash ileitis, which basically is believed to be inflammation that arose from exposure of the ileal mucosa to sequel contents. But it's not, you know, extremely well understood. And in terms of like how often you might see a finding like this, you see, you know, variable rates quoted, but you see something between 10 to 20 percent of time. My experience has been it's probably on the 10 percent side than the 20 percent side. So this is, I think, a really important thing for you to know about if you're not already familiar is the endoscopic scoring systems that we use to describe the severity of someone's ulcerative colitis. The most common one we use is the Mayo endoscopic sub score. It's part of a larger Mayo score that's used to assign UC severity overall. But it's a pretty simple score. We just we we use a number between zero and three to describe what we're seeing and in the colon. And so zero is normal mucosa. A score of one would be some increased erythema, decreased vascular pattern, mild friability. A score of two is where we start to see more of the erythema, really an absent vascular pattern, friability, erosions. And a score of three is where you start seeing like that spontaneous bleeding. You see ulceration. It's pretty severely inflamed appearing tissue. So as I said, that's the most common one that we use. But there are other scoring systems. So another one that you might see from time to time is the ulcerative colitis endoscopic index of severity or the UC EIS. And I have it listed here exactly what the components of that are. But basically you assign a score for each of these descriptors. So vascular pattern, bleeding, erosions and ulcers. And then you total the score and you can come up with a final score. And depending on where you fall, it helps you grade the severity. And sometimes you see this used in some clinical trials, although most are still using the Mayo score. But it's helpful to be familiar with this. So now moving over to Crohn's disease, Crohn's disease as opposed to ulcerative colitis, it tends to be more patchy inflammation. It can occur anywhere technically throughout the GI tract, though most commonly you're going to see the inflammation somewhere in the distal small bowel or ilium or proximal colon or the distal colon as well. And so in order to make a diagnosis of Crohn's disease, ileocolonospy is absolutely necessary. In general, if I'm worried about IBD, I try to make sure that I'm intubating the TI in every patient because you never know what a patient's disease process may evolve and show. One other tool that is wonderful to use is a video capsule endoscopy or wireless capsule endoscopy, which can play a role in helping to diagnose small bowel Crohn's disease. The limitation with VCE is that patients with Crohn's, due to the nature of the transmural inflammation, are prone to forming strictures. And so presence of a small bowel stricture could lead to retention of the capsule, which could either lead to another procedure, like, for example, a balloon-assisted endoscopy to retrieve the capsule, or historically, surgery has been needed to retrieve a retained capsule. But one way you could screen your patient if you feel that capsule is absolutely necessary to help make the diagnosis is you can do what's called a patency capsule, which is basically, it's a material that would eventually, it's made of a material that would eventually dissolve, but it's radio opaque and it has the same size as the pill that we use for the capsule endoscopy, and it can help determine if a capsule would pass. And so you can do that. I have seen that that has been not as widely available in certain offices and sometimes not covered by insurance. So that can be a limiting factor in being able to screen a patient that way. So other distinguishing findings of Crohn's disease, we will appreciate ulcerations, but in Crohn's disease, we might see aftus ulcerations, but we may also see these really deep transmural ulcers, and like, colloquially, we call that, like, bear claw ulcers, almost looks like a bear took its, like, claws and, like, clawed, like, the inside of the colon. Or you might see, like, these serpiginous ulcers that kind of have, like, a snake-like appearance. You can see cobblestoning, which is due to linear ulcers kind of coursing along the colon, sort of dividing up the mucosa in this, like, cobblestone appearance. We already talked about discontinuous lesions or skip lesions, as we call them. One other thing that's sort of a hallmark of Crohn's disease is rectal sparing and then terminal ileum inflammation would typically be seen with Crohn's disease. So when you see those kind of things, you should definitely think Crohn's. And these are some pictures that can kind of convey the difference between ulcerative colitis and Crohn's disease. So if you recall from the pictures I showed you for ulcerative colitis, the inflammation really did appear very, like, superficial and right at the, right at the mucosa versus in this case, you know, you're seeing these deep ulcers right here and here. You're also seeing stricture formation right here. And that's definitely most likely to be with Crohn's disease. These are some aftas ulcerations. So these are some findings that are more typical with Crohn's disease. So in terms of endoscopic scoring for Crohn's disease, I will be honest, I don't really use most of these scores for practical purposes because I think the scoring systems are a little bit complicated. And I think it ends up later on when you're trying to, like, read and decipher them. I still think it doesn't really help you as much as it does to just describe what you're seeing. But that being said, I do think it's important for you to be familiar with these and make your own choice as to whether you like to use it or not. So the one that we probably most commonly see is the SCS-CD or the simple endoscopic score for Crohn's disease. And this is based on the following endoscopic findings, presence of ulcers, amount of ulcerated surface, affected surface in general by inflammation and presence of stenosis. And basically in each segment of the bowel, you assign a score. You kind of look at this chart and you decide what score you're going to assign for this and you total it all up. And then when you get your final score, you give an assignment of your assessment of the disease activity based on what their final score is. Luckily, a lot of endoscopy softwares actually will help you calculate a lot of this. So it's not awful, but it's just sometimes later it populates a lot of text and that's not why I choose not to use it. So one alternative that we have is the CIMA-CD score. And that one is a score that it basically does the same thing where you are giving a grade to each part of the colon, but you're just giving it a score between zero to four, zero being unaffected, four being like the most severe. And then you just total that up. And there are studies that show that that is equivalent to the SCS-CD. So that could be an alternative. And that's something that I like to use a little bit more. So we talked a little bit about diagnosis of IBD and how important using endoscopy is in that regard. But another purpose for using endoscopy in patients with IBD is to assess mucosal healing. If you're not familiar with that term or why we do that, I'd like to start by sharing with you this guide, which we call the STRIDE-2 guidelines. This comes from the International Organization for the Study of Inflammatory Bowel Diseases. And this organization made an initial consensus statement called the STRIDE-1 guidelines and recently updated it for the STRIDE-2 guidelines to give us just a framework for how we need to treat patients with IBD, what our goals and treatment should be. So when we have a patient with active IBD, we choose some kind of therapy for those patients. And once we start them on therapy, our first goal, of course, is that we want these patients to feel better. So in the immediate short term, we want these patients to have a symptomatic response. Once we achieve that goal, then we can press forward. And then our goal is that they actually achieve symptomatic or clinical remission, meaning that they feel how they felt before the inflammation ever set in. They feel normal again. And we also see maybe some objective improvement in things like the CRP. So that's kind of our next goal. If we achieve that goal, then we can continue to move forward and we can then look for a decrease in the fecal calprotectin to an acceptable range. And if you're dealing with a pediatric patient, I'm not sure if there's pediatric fellows on, then the priority would be that you've got a patient back on their normal growth curve. But ultimately, we want our patients to achieve endoscopic healing, have a normalized quality of life. They're able to go to work and function the way they did before they were affected by this disease and have an absence of disability. So that is, I think, the priority for us as a treating physician. But in between, these are also important priorities that we need to achieve. And if at any point you don't achieve that goal, then it's important to sort of take a, go back to the drawing board, take a look at what you're doing and decide how do I change my treatment? Do I put them on a different medication? Do I optimize this medication by dose escalating? Do I look for something else going on with this patient? But you wanna always make sure that you're questioning yourself if you're not achieving these goals. But endoscopic healing is sort of our ultimate goal at this time. At the moment, we don't yet enforce histologic remission or transmural healing as a formal goal, but we do think that maybe in the future that might be where this is heading. So achieving endoscopic healing is the goal of our treatment. And why do we care about that? What's the benefit of that? We have found that mucosal healing is associated with many important outcomes, including a lower risk of clinical relapse, so increased stability of disease. I have patients that come to me and expect that their life is just gonna be a series of ups and downs, that they are just going to live a life full of flares of their disease, but that doesn't actually have to be how it is. And with achievement of mucosal healing, we can guarantee them a lot more stability and fewer hospitalizations, decreased need for surgery or specifically proctocolectomy in ulcerative colitis. And also very importantly, a lower risk of colitis-associated neoplasia. So there's a lot at stake here and confirming mucosal healing is very important. So how do we define that? We define mucosal healing in ulcerative colitis as achieving a Mayo score of zero to one or a UCEIS score of zero to one as well. Or in Crohn's disease, we define endoscopic remission as an SCSCD score of less than four. It's important to know that while zero to one is technically written as an endpoint in many things, including some clinical trials, it still does mean that there could be a little bit of inflammation under the surface. But at the moment, this is how we define these remission goals. So one question I get a lot from patients and I think from people maybe who aren't treating these IBD patients as much is how quickly can I investigate whether I've achieved many of these goals, but specifically endoscopic healing? And so I highlighted that here and I know it might be small, so maybe I'm gonna see if I can just like at least zoom in on that for you guys. So in the left, this column kind of shows you which treatments that we're looking at. And then over here, we can see that the time to endoscopic healing for most of these drugs, and this is in weeks, is at least 15 weeks, sometimes 20 weeks. So typically you're gonna be waiting at least four months, but probably something more like six months before you're gonna assess for mucosal healing, really just to be sure that you've given a medication enough time before you're actually looking into mucosal healing. And this comes from the stride to consensus statement as well. And this diagram I have here is based pretty much on expert opinion. There's not actually like as many studies out there that look at timing to endoscopic healing for each of these drugs. So the way I conduct my practice is that I first ensure that my short-term goals have been met. So I typically like to look for clinical remission at about the three-month mark. And if I've achieved that, then I feel good about what I'm doing and I kind of move forward. And then somewhere between the three to six-month mark after starting a therapy, that's when I check the fecal calprotectin. And then I typically recommend conducting endoscopy to confirm mucosal healing six to nine months after starting therapy. I think that's usually a pretty good timeline for that. And I set patients up for that expectation when I'm starting them on a treatment. I kind of walk them through that this is how we're gonna monitor things and make sure that we've gotten to where we get. Now, if you, at the six to nine-month mark, look at a patient and they haven't achieved mucosal healing, then it's time to consider doing things. And if you haven't already done these things already, for example, checking drug levels, if that's appropriate for them, if that's appropriate for the medication that they're on to see if you can further optimize the current medication that they're on, or start maybe thinking about whether you need to be switching them to another therapy. So this is where I'll spend a little bit more time because I think this is definitely an area where endoscopy is extremely important in our patients with IBD and that's dysplasia surveillance. So patients with IBD are at risk for development of dysplasia and malignancy. And that has to do with the ongoing inflammation that is inside the colon. And so it's our job to detect pre-cancerous lesions and to help manage those for these patients. So there is a clinical practice update that was published in 2021 through the AGA. And I'm gonna spend time going through a lot of the parts of that to help guide you through how you're supposed to monitor for dysplasia and what you're supposed to do in special circumstances when you find it. But to help guide our discussion, I thought we could go through some cases and Taylor can help walk us through those. So I'll move to case one. Yeah, so for the first case, we have a 75-year-old male. I think if you just click the next button, it should kind of start coming up. Yeah, so 75-year-old male, he was diagnosed with left-sided ulcerative colitis in the 1990s. He had previously failed azathioprine and weekly Humira. And when he came to us, he had most recently had an outside hospital colonoscopy done in August of 2021 that showed Mayo 2, left-sided disease, and biopsies taken, non-targeted biopsies, showed possible atypia. So after that, he was switched to vetilizumab in March of 2022. And then that was subsequently increased to four-week dosing. And then he had a repeat colonoscopy done in January 2023. So about 10 months after switching therapies and that showed Mayo 1 disease in the rectum. You can see over on the right side, some of the endoscopic images that were taken after dichromo was done. And the report basically described granularity, which you can kind of see in the top picture, and then loss of vascularity in the rectum, which you can see in this retroflex view here at the bottom. And then biopsies on this colonoscopy showed atypia with indefinite dysplasia. So after this, he continued to undergo surveillance. He had a repeat flex sig done in June of 2023. That showed Mayo 1 disease in the rectum. Dichromo was done during this flex sig and showed an area of what was reported as probable inflammation around 50 centimeters. And you can see that over on the right. Again, with the dichromo, the area that has stained light pink was this area of sort of abnormal mucosa that was described initially as probable inflammation. So this area was biopsied and it came back showing focal low-grade dysplasia and chronic colitis. So after this, he had another flexible sigmoidoscopy. This was an older gentleman. So he just kind of opted for routine surveillance. In September, 2023, had this repeat flexible sigmoidoscopy. Again, showed this area of abnormal mucosa at 50 centimeters. Again, you can see over on the right side kind of this pink staining mucosa that looks a little bit abnormal. Here, it looks even a little bit raised. And biopsies again showed this chronic minimally active colitis, colonic mucosa with ulceration. And this time there was note of highly atypical glands that were at least low-grade dysplasia, but they could not rule out high-grade or severe dysplasia. Additionally, random biopsies throughout the sigmoid colon again showed chronic colitis. And this time there was noted to be focal adenomatous changes that was concerning for additional areas that were indefinite for dysplasia. So ultimately, he ended up undergoing colectomy in February of 2024. And actually after the pathology specimen was assessed, he was found to have a four and a half centimeter mucinous adenocarcinoma in the distal colon. So I thought this was a really interesting case that kind of highlighted the progression of dysplasia through the various stages. And hopefully we can kind of address the next steps during all of these different stages of dysplasia and the timing of repeat procedures. And then also kind of discuss when do you use chromoendoscopy and some additional sort of factors related to diachromo. Yeah, great. I think, yeah, I agree. Thank you for sharing that case. And I think it's a nice launching pad for a lot of different topics that we need to consider when we're thinking about dysplasia surveillance. I'll just start off laying some framework here. Long-standing colitis is the thing that confers an increased risk of colitis-associated colorectal cancer. So when you can control the inflammation, you can really drive down that risk. So this risk really applies to patients who have ulcerative colitis beyond broctitis and Crohn's colitis affecting greater than a third of the colon. As I said, it's long-standing colitis that really increases that risk of the cancer. So it tends to rise eight to 10 years after diagnosis of IBD. Things that even more specifically can be associated with cancer include primary sclerosing cholangitis. That can actually be associated with long-standing subclinical colitis. So the recommendation there, excuse me, is to begin screening immediately upon diagnosis of PSC and conduct screening every year. Patients who have high-grade and low-grade dysplasia are also known to carry a higher risk of concurrent colorectal cancer, which was the case in this patient as well. Other risk factors for IBD-associated colorectal cancer include smoking, which is obviously for any patient that's an increased risk. Family history of colon cancer in a first-degree relative is also its own risk factor as well. Disease extent correlates as well. So for example, there are studies that have shown pancolitis is associated with a much higher risk of developing colon cancer as compared with left-sided colitis or proctitis, as high as a relative risk of 14 versus a relative risk of three in left-sided colitis. So definitely pay attention to disease extent. PSC carries a relative risk of cancer of like five starting at the time of diagnosis, but probably is even higher. So it's definitely important to know and identify these risk factors in a patient so you can risk stratify in your head and how you wanna survey a patient. So that brings me to like, what should we do? How should we survey these patients? So these days, most scopes that we're using are high-definition, white light, endoscopy, which is really actually very good at picking up dysplasia. 90% of dysplastic lesions will be visible with high-definition white light endoscopy, which is compared to 80% on standard definition. So that's already an improvement. Other things that we really want to do to help improve our detection of dysplasia is to really optimize our condition. Clean prep is a huge factor in this. We wanna conduct careful washing and inspection and targeted biopsy of any abnormal lesions as well. So we used to have a little bit of varied terminology when we were describing lesions that we would see during our dysplasia surveillance. We used to say things like adenomatous polyp, adenoma-like polyp, DALM, or flat dysplasia. That's sort of the old terminology. And we've tried, they've, in this AGA clinical practice update, they've tried to simplify that a little bit for us. And now they ask us to describe first, they ask us to sort of differentiate between visible or invisible dysplasia. And under the umbrella of visible dysplasia, we describe what we see as either polypoid or non-polypoid. And then within those categories, we can be a little bit more specific, but it's kind of jives with the Paris classification. And it makes it a little bit easier for us. And invisible dysplasia is just dysplasia that's not seen by the endoscopist, usually within an area of previously inflamed mucosa. Previously inflamed mucosa. But we want to be as specific as we can when we describe these lesions so that, you know, let's say you choose not to remove something. We want our subsequent endoscopist to be able to find and maybe remove these lesions. You talked a little bit about chromoendoscopy, Taylor. And so it's important to know about this. And really everyone should feel comfortable doing this once they just have some sense of what to look for. But there's two options under the umbrella of chromoendoscopy. One is dye-based chromoendoscopy or virtual chromoendoscopy. So dye-based chromoendoscopy, we tend to use either indigo carmine or methylene blue, which methylene blue is the more common dye that we'll use. And this offers a two, even a higher dysplasia detection rate than high definition white light endoscopy. But an alternative to that is virtual chromoendoscopy using tools. If you're using Olympus scope, it's NBI or eye scan on Pentax or Fuji intelligent color on a Fuji scope. But basically these use a special wavelength of light to highlight specific abnormalities that you might see that could help you look for more subtle lesions that may not otherwise be visible. But there's now many studies that exist that say that both techniques perform similarly for dysplasia detection. So you can use whatever you're more comfortable with or whichever you find more convenient. These are some images of lesions that you might appreciate under the diet. These are all dye-based chromoendoscopy, but here in this panel, you can hopefully appreciate this polyp right here. You might see this like slightly more granular mucosa here. Here you have like a potential raised lesion. Here's another one. Here's another one. So, you know, these are things that may be a little bit more subtle. You might not pick up quite as well if you were just looking with white light. And your goal is, you know, if it's clearly polyploid, of course you should just consider removing it. But if you're, you know, not sure the area just looks a little funny, at the minimum, you should be doing a targeted biopsy of anything that looks unusual under this type of enhancement. And here's a picture of something similar, but under NBI. So of course the arrows are making it a little bit more easy to appreciate, but it's a pretty flat lesion. You might miss it on just plain white light, but here under NBI, this lesion here becomes a little bit more obvious to you. And again, you might just consider removing this completely or at the minimum biopsying it. But when chromoendosopy is not available to you, then the recommendation is that you should take non-targeted biopsies. This is what we used to do before we appreciated the role of chromoendosopy, which is to take four biopsies every 10 centimeters in areas that were previously affected by colitis, and even more biopsies from areas of prior dysplasia, or if visibility is poor, then we should take biopsies in that region. So we'll use the next case to kind of help further guide this discussion. So I'll turn it back over to Taylor. Sure, before we go into the next case, can you kind of describe just logistically when you're using NBI or the virtual chromo kind of logistically, like, are you looking at a section with white light and then going back and re-examining with NBI? Yeah, that's a wonderful question. And I'll tell you how I do it. I like to just divide up the colon in my head in sections. So I think it would be what anyone would probably naturally think of just cecum ascending colon transverse descending sigmoid and rectum. But yeah, I do kind of what you said. I'll look at it with white light. I'll make sure I take some good pictures in that area. And then I'll turn on the NBI and basically do the exact same thing in that area. And then once I feel comfortable, and I'll take some biopsies just for disease activity assessment at the minimum, and then I'll kind of move back and do the same thing in the next segment. But I toggle between the two views and kind of in this picture, for example, you see that there's the exact picture of with white light and with NBI, just kind of make sure that I'm doing both in the same area. And then I take some biopsies, like I said, for disease activity assessment. Are there any other questions about that? Nope, that was it. I think we can go on to the second case. Okay, so for this case, we have a 29-year-old female. She has a history of ulcerative pancolitis diagnosed in 2021. She's failed multiple prior medications, including betalizumab, ustekinumab, infliximab. And then most recently was started on upatacitinib in July of 2023. And she's had some clinical improvement on that medication. So then about eight months later, she had a colonoscopy in March, 2024. And that colonoscopy showed pretty dense pseudopolyps and left-sided inflammatory polyps. She also had underlying moderate inflammation and the biopsy showed mild active colitis. There were no dysplasia noted on the biopsies. However, mucosal exam was limited because of the dense pseudopolyposis. and these are some pictures. The first picture is kind of around the hepatic flexure. Next from the sigmoid colon, you can see kind of this pseudopolyps that are extending into the lumen. And then lastly, here we have the rectum. You can see there's a little bit of inflammation with some erythema, and then also you can see kind of the pseudopolyps here. So for this case, you know, one of the discussions points that got brought up was how do we continue surveillance in this patient with really dense pseudopolyps when you can't really examine the mucosa that well. The other factor was she did have a family history of colon cancer in her father at age 51. So, you know, we had kind of discussed if that would play into maybe her risk of colon cancer. And then I think there's one more click here just kind of to discuss her next steps in surveillance. Yeah, so when it comes to dysplasia surveillance and pseudopolyps, it can be a little bit complicated. So once again, just to remind you, pseudopolyps, these are basically normal mucosa within areas of current or usually prior ulceration. They tend to look very like finger-like and the surface architecture tends to be similar to the surrounding mucosa. So it looks kind of very normal when under NBI, but there's just so many of them it's hard to survey. It can mimic an adenoma in appearance, but typically pseudopolyps are not, you know, truly pre-cancer. So what the recommendation here is that all you can do is your best here. You wanna inspect as best you can the flat mucosa between pseudopolyps. It's impossible to expect to remove or sample every pseudopolyp. And it's not recommended to perform chromoendoscopy in areas of pseudopolyposis. And the reason for that is that it might give you this sense of security that I looked with chromo, I didn't see anything, it should be fine. But really you cannot feel confident about that examination. And so you have to have a very frank conversation with your patient about, you know, what are the limitations of your endoscopic exam in the setting of dense pseudopolyposis and do the best you can. In a few slides, I'll kind of give you an idea of how frequently you might survey someone who has more significant pseudopolyposis. And basically we might consider this person a little bit higher risk and consider to survey them a little bit more frequently. And that might just be the best we can do. So I'll hop over to another case then, and that will bring us to another special scenario. Yeah, so this case, we have a 20-year-old male also with ulcerative pancolitis diagnosed in 2019. He has also failed multiple prior therapies, including infliximab, betalizumab, ustekinumab, and tofacitinib. And he ultimately had a proctocolectomy in September of 2021. After this, several years later in October, 2023, he had a pouchoscopy for some ongoing symptoms of diarrhea incontinence. This pouchoscopy showed kephitis as well as some ulcerations and diffuse erythema with ulceration, both in the pouch and the pre-pouch ileum. You can see kind of a view from the pouch over here on the right. It is a little small, but you can see kind of between the six and seven o'clock positions, there's some ulcerations as well as like between the five and six o'clock positions. So this is a picture more of like the rectal cuff. You can, again, see some like erythema and inflammation there. And so after this scope, he was switched to Skyrizzy for Crohn's-like disease of the pouch, given the inflammation that was seen in the pre-pouch ileum. So one of the questions that got brought up here was, should he have continued surveillance of the pouch, not only for disease activity, but for dysplasia? And in what cases do you survey the pouch? Yeah. Great, a great case. And I think there's a couple of things. I'll start by saying, you know, in this patient, you know, with the treatment change, there's an indication to look back in the pouch to evaluate for mucosal healing as we discussed before. But what I'll focus on is generally, what are the recommendations regarding dysplasia surveillance of a J pouch? And the recommendation from that AGA clinical practice update is that you perform pouch surveillance yearly in a high-risk patient. So patients who have a history of prior colorectal cancer, or PSC. You may also consider annual surveillance in patients who have persistent severe pouchitis, or in someone like this who had maybe severe, he had probably more moderate, but anyone with moderate to severe, I think, pre-pouch ileitis to assess treatment response. So that one's a little bit of a different indication. But for everyone else, they sort of leave it open and they tell you to individualize surveillance. And I think it's important to remember that patients these days who have had a J pouch formed still have some rectal cuff left behind. Nowadays, we see patients who have a stapled anastomosis. And so they usually leave about two centimeters of rectal mucosa behind. And so there is a possibility of formation of dysplasia in that area. So the AGA guidelines, like I said, they kind of leave it a little bit open, but then there's other guidelines. For example, the British Society of Gastroenterology, they recommend surveillance every five years if none of the other risk factors I discussed, like PSC, personal history of cancer, or persistent inflammation are present. So I think you could kind of individualize somewhere in there, but I think at the minimum, every five years is probably a good idea with particular attention paid to that rectal cuff. On that note, I think it can be difficult to identify the rectal cuff at times. And I find NBI to be really useful to see the delineation between the transition from the small bowel mucosa to the rectal mucosa. And you really see a darkening in color. Like the small bowel mucosa tends to be like a paler pink, whereas that residual rectal mucosa tends to be a bit darker, almost like a salmon color, if you can find it. So just pay some particular attention as you're withdrawing the scope so you can identify that area and take some biopsies from there. So we've talked about some, oh, go ahead. Yeah, we had a question. And actually it was more about the case. He was asking if the anastomosis was stapled or hand sewn, but just curious if you know this information, and I'm not sure in this case, but does that make a difference on how you survey? Good question. Hand sewn anastomosis is unlikely to have any rectal mucosa left behind, but very few surgeons are doing that these days because you see overall better outcomes with the stapled anastomosis in terms of like quality of the actual anastomosis. And so I think if you want to err on the side of caution, you should probably, and if you don't have any corroborating information in that regard, which most of the time we'll see patients well after this type of surgery or many times we will. So I think you should, it's safe to assume most are going to have a stapled anastomosis. Any other questions there? That was it for now. Thank you. Okay, great. So what do we do when we encounter dysplasia? The rule of thumb needs to be that we should try to remove lesions that appear dysplastic if we feel comfortable that we can remove them. I have had scenarios where there is a polyploid lesion, but whether it's due to fibrosis or something that due to fibrosis from inflammation or something more sinister, I have been unable to remove certain polys, but you should make an attempt to remove what you can because that will open up the opportunity for you to continue endoscopic surveillance in a patient versus pursuing a more significant intervention like colectomy. However, if you find invisible dysplasia, meaning it was not in any kind of raised or polyploid lesion that you could resect, then the next step should be consider a repeat endoscopy with someone who feels very confident in chromoendoscopy and then also take multiple biopsies of the area of concern so that you can really try to get a sense of whether there's any resectable dysplasia there or whether there truly is dysplasia in the area that you're concerned about. And if truly you have unresectable visible or multifocal invisible or high-grade dysplasia, then that'll be a time to pursue colectomy. I realize that there is some difficulty with seeing this, and I don't think that our goal should necessarily be to read every portion of this chart. I really want you to be aware of this resource, though, the AGA clinical practice update on this topic. And to find it, I just typically type into Google like AGA clinical practice update, IBD dysplasia, and it's free and available for patients. But it really walks you through what you should do for various scenarios. Typically, though, if you can feel confident that you have resected a lesion and you have clear borders, then it's very reasonable to continue surveillance in patients. Typically, you might do the next surveillance within three to six months in someone in whom you have high-grade dysplasia and incomplete resection, maybe one year in someone in whom you have low-grade dysplasia, maybe two years in someone who had a smaller lesion with low-grade dysplasia. So that's what you can really consider. And again, if something was unresectable or it's invisible dysplasia, and you're sure about that, you've confirmed that with a pathologist, then it will probably be time to consider surgery in a patient. And certainly, if a patient has multifocal dysplasia, that's another indication for surgery. And then there's some sort of gray-area-type patients who have maybe an area of low-grade dysplasia that nothing else is coming up. You could have a conversation about intensive surveillance in those patients to decide if that may be a way to keep an eye on things. But some of the stuff in the bottom field is sort of a very detailed risk-benefit discussion with the patient. And then I think this is really helpful. Before we had guidelines like this, we sort of committed our patients to colonoscopy every one to two years. Like two years might've been the max that you would give them between colonoscopy. But we realize now that we can do a little bit better of a job to risk stratify our patients. And we can maybe give some of these patients a little bit more time between their colonoscopy. But patients in whom we have persistent inflammation which is a risk factor for colitis-associated cancer, or PSC, or family history of colon cancer in a first-degree relative dense pseudopolyposis, or history of invisible dysplasia, or higher-risk visible dysplasia, they should probably be on the more intensive surveillance side and probably get colonoscopies every year. People in the middle who don't have as strong of a family history of cancer, who may have a history of a lower-risk dysplasia, those people maybe could be every two to three years. And then your patients who have just really checked every box, they have gotten on a treatment, achieved mucosal healing, achieved deep remission over two consecutive colonoscopies, those patients could potentially go longer, even up to five years. So it's helpful to kind of look at this and re-stratify your patients and realize that not everyone needs annual colonoscopy, even though my sense for my patients is that's what they expect, but I think they'd be very happy to get the news that they don't always have to get that. Any questions there before I move on to the next topic? None in the chat right now, but again, if anyone has any questions, feel free to type them into the Q&A box and we can answer them as we go. Awesome, thank you. All right, so then I'll talk about kind of a special scenario, which is post-operative disease surveillance. As you know, patients with Crohn's disease, many are gonna be unable to avoid surgery due to complications of their progressive disease. So we're gonna start off with a case that illustrates one of these patients and then use that as a launch pad to talk a little bit further. Yeah, so this case is a 77-year-old male. He has a history of ileocolonic stricturing Crohn's disease that was diagnosed in 2010. Previous to us seeing him, his history kind of involved this previous small bowel obstruction that required an XLAP and ileocecal resection back in 2010 at the time of his diagnosis. After that, he didn't have really close follow-up. He was off of any therapy. He did have a colonoscopy in 2015, which you can see a picture of on the right that showed pretty deep ulcerations and a stricture at the IC anastomosis site. So after this scope, he was started on infliximab. He initially had a primary response to the medication, subsequently had a secondary loss of response, and so he was switched to Stelara. This was eventually increased to Q4 week dosing based on persistent inflammation that was seen on an MRE. After this, he continued to have some intermittent obstructive symptoms. He would get admitted to the hospital, usually would get a course of steroids and his symptoms would improve. In November of 2023, he had an admission for pneumonia. And at this point, his Stelara was stopped due to the concern that maybe this was contributing to the risk for infection. And then in July of 2024, he was again admitted with a small bowel obstruction, ultimately had an XLAP and resection of his distal ileal stricture and the prior ileocolonic anastomosis. The images on the right are just pictures from his admission CT scan. The top picture, you can kind of see some bowel wall edema and hyper enhancement, and then the bottom, obviously, the dilated small bowel loops. So he had another resection. He had a follow-up in clinic a couple months later in September of 2024, and he was feeling really well in clinical remission. And after discussion with the patient, he really preferred to stay off of therapy. So he's currently off of therapy and we had discussed when his next scope should be after this most recent resection. And then additionally, I was hoping we could discuss kind of what features on a scope would prompt us to initiate therapy. Yeah, great. So this is an important population to think about and map out what you intend to do after surgery. Post ileocecal resection, endoscopic recurrence at or just proximal to the anastomosis can occur in about two thirds of patients. That's not a small number. And so it's a really important consideration to take into account as you decide what you're gonna do after a surgery. It's also important to know that endoscopic recurrence usually precedes clinical recurrence. And so because of that, and because we really want to use that surgery as the fresh start that maybe this patient needs, we recommend ileocolonospi six to 12 months after ileocecal resection. But I'll add on top of that, that it's important to think about your particular patient when you decide what you want to do. There are patients who you should probably consider higher risk. For example, patients who are still actively smoking, patients who had a short time from their diagnosis of their disease to their first surgery. Patients with fistulizing or stricturing disease behavior are a little bit higher risk. Patients who have been refractory to multiple therapies. All of those patients, you might consider putting them on therapy immediately after a surgery to minimize as much as possible the risk of disease recurrence. However, everyone else, it is not unreasonable to consider just waiting for that six to 12 month mark to conduct an ileocolonospi and to decide if a patient has a recurrent disease. And I apologize, this slide got moved from the earlier part of the talk to here. It was about the CMA-CD, which we discussed. But what is more relevant to this case is when we conduct our endoscopy at the six to 12 month mark we assign patients a Rett-Geert score, which is specifically for postoperative Crohn's disease assessment. And it's an evaluation of the neoterminal ileum. And we basically grade the neoterminal ileum, give it a score. And based on what score we give them, we can have some risk stratification of the patient's likelihood of disease recurrence. So we write the score as a lowercase I with a number next to it. So I0 is no lesions. I1 is less than five aftus lesions in the neoterminal ileum. I2 is greater than five anastomotic lesions with passable stenosis or lesions in the area of anastomosis. I3 is diffuse ileitis. And I4 is diffuse ileitis with deep ulceration and or stenosis. And in the next slide, I'll show you some pictures as well. So again, I0 is no lesions at all. And I realize again that it's small. Let me see if I can zoom in here and that might help. But yeah, we see no lesions. This is a very healthy looking anastomosis. Here is these white spots here are aftae, but we just see a couple of them. So we give this patient an I1. Now under the I2 category, we've actually broken it out into I2A, which is lesions confined just to the anastomosis or I2B, which is five aftus lesions with normal mucosa between lesions or areas scattered with larger lesions. I3 is like more diffuse ileitis over inflamed mucosa. And then I4 is diffuse inflammation with large ulcers and or strictures. And so anything I2B and above carries with it a high risk of disease recurrence. And those are patients in whom you want to put them on treatment or further optimize what they're currently on. And this is an algorithm from the AGA again that kind of walks us through what to do in different scenarios. So if we have a patient who has now been surgically induced remission of their Crohn's disease, then we sort of think about what we wanna do next. And if the patient has a low risk of recurrence based on some of those risk factors or lack absence of the risk factors I told you about, then we can consider just observing them and planning for ileocolonoscopy at six to 12 months. But if we have a patient who is a bit higher risk and it probably makes sense to put them on some kind of pharmacological prophylaxis. The best studied evidence is behind anti-TNFs, although there's emerging evidence for all of the advanced therapies and we can probably use any of them if we really want to for one reason or another in terms of the pharmacologic prophylaxis. And then we still conduct that ileocolonospie at six to 12 months. And if we find that there's any evidence of endoscopic recurrence in either type of patient, then either we optimize the current therapy or we switch them to something else. So that's how we consider that. So now the last part of this talk, I'll just consider, I'll go through a couple special cases and more specifically, I'm gonna just cover how we use endoscopy to treat some of the complications related to IBD. So the- Before going into this, we did have one question kind of going back a little bit to the dysplasia surveillance. Can you talk a little bit more about patients with PSC and are you usually doing a colonoscopies for them on a yearly basis or do you ever space it out more than that? No, and if you look here, it really puts them in that one year category and everything that is out there will still continue to reinforce that every year is needed in these patients due to that higher relative risk, almost fivefold risk of colon cancer as compared with someone who doesn't have PSC, but also because they might have had subclinical colitis for longer than you can appreciate, which is the risk of colitis is more of a cumulative thing. So no, the answer would be definitely continue annual surveillance. Okay, great, thanks. And then one more question. Can you clarify the term like prophylaxis or after therapy and just kind of describe what you mean by that? Yeah, it's also a good question. Many times patients who undergo their ileocecal resection for their Crohn's disease, that will be kind of the major focus of their disease and they may have no other disease elsewhere. So by removing that segment, you basically put them into remission and now your goal of treatment is more preventive to prevent disease from coming back in the healthy bowel that remains. So that's what I mean by prophylaxis is that you're kind of starting them on therapy to prevent disease recurrence rather than to treat persistent disease. Now, there are scenarios where a patient gets surgery and they may even have to get like a temporary ostomy due to like severely inflamed tissue and you can't immediately anastomosis. So this is more for applicable to a patient who may have gotten like an isolated ileocecal resection was potentially even able to be put back together pretty quickly and was doing well after that type of surgery. All right, that was all we have for now, thanks. So one of the big IBD related or Crohn's related complications specifically that we can actually make a big impact on is Crohn's strictures. And so we as endoscopists can perform endoscopic balloon dilation of Crohn's strictures. What needs to be taken into account when we decide which strictures we can dilate is that the stricture needs to be confirmed to be non-malignant. In the case of Crohn's disease, strictures are less implicated as malignant than they are with ulcerative colitis. In ulcerative colitis, and if you're really sure about that diagnosis and if a patient has a stricture, you have to have a high suspicion for malignancy until proven otherwise. But if you can be sure that it's a non-malignant stricture, then consider dilation. It is actually okay to perform dilation on strictures that have active inflammation. You want to dilate strictures that are less than five centimeters in length. You do not want to dilate those that have an associated abscess or fistula. You really wanna focus on like a straight stricture where you can even kind of get a glimpse of the lumen, maybe beyond. You don't want to mess with strongly angulated strictures. You will have a higher risk of perforation with that. Stricture dilation is safe for both anastomotic and de novo strictures. Final target diameter of the dilation should be 12 to 15 millimeters. And typically when you do dilate, you wanna hold your balloon for anywhere from 30 seconds to two minutes. I tend to hold for a minute when I do it. This is a picture of a stricture undergoing dilation. And at the end, you see some heme, which is to be expected and kind of lets you know that you've successfully disrupted the mucosa, so don't be afraid when you see that. But here you can really kind of appreciate that the stricture has grown in size and probably allows passage of the endoscope as well. So in terms of- And you do have a question about the stricture. How do you confirm that the length is five centimeters or just confirm the length overall? Do you do MRE? Do you do it based on the scope or how do you usually do that? Most likely, if you need to dilate, you're not gonna be able to confirm on the scope because you're less likely to be able to pass the scope. So you wanna confirm that on imaging first. So MRE, CTE, those are both fine. So success rates. So we define the success by initially symptomatic relief in the short term. And the majority of patients are likely to experience symptomatic relief. Some studies say as high as 60 to 70% of patients will experience symptomatic relief in the short term. And what I'm talking about there is a four to six week period after the endoscopy. What we're also defining as success is whether we prevent or delay the need for surgery. And the rates for this are variable, but we have seen reports that we can defer the need for surgery for several years in these patients. And so I think that shouldn't be ignored or discounted. Some studies do show that 25% of patients will need surgery after three to four years. Others show rates closer to 40 to 50%. So there's definitely a lot of variability, but we can buy our patients some time. If you have tried dilating a patient and you've done it over three or four serial dilations and you're not seeing improvement in symptoms or your ability to pass the endoscope, it might be time to call it and decide to pursue surgery for that patient. But it is worth trying a few times and definitely trying to do it serially so that you can finally get to that 12 to 15 target size. And when you're doing it serially, how long between dilations do you generally wait? Usually like three to four weeks between. If a patient's willing, I sometimes go longer. Like if they experience some symptomatic relief, I might even go like two or three months. So it kind of just depends on like how they're doing with each dilation. But I wouldn't do it sooner, I think, than like three weeks, three or four weeks. Other ways we can treat strictures are with endoscopic stricturotomy or stricturoplasty. So this top panel here is a stricturotomy. So this is like a fibrotic stricture here. And basically with a needle knife, they're breaking up the stricture. And so this is pre on the left and post. You're seeing it's much bigger. Or endoscopic stricturoplasty. And basically, you open up the stricture with a needle knife and then kind of clip back together the sides of the lumen with clips. And so these are done by some really brave, advanced endoscopists who have a special interest in this field. And there's not many of these people doing it, but they are making a big impact. And so this could be an option for patients who have strictures that are refractory to endoscopic balloon dilation. Another set of complications that we can treat, we can perform endoscopic fistulotomy, endoscopic incision and drainage of perianal abscess. And usually this is with assistance from EUS. And even seton placement into perianal fistula. You can have treatment of anastomotic leaks with endoscopic clipping, removal of an obstructive pseudopolyps with polypectomy, or even band ligation of pseudopolyps. Really, I think that if you can dream it, I think it's possible with endoscopy if you have the wherewithal to do it. And we can make a huge impact for our patients with the endoscopic interventions that we can offer. So I think this is a continuing and growing field that we are excited to see where it goes. For those of you that might have an interest in both IBD and interventional endoscopy, this could be a nice way to dovetail those two interests as well. So that brings me to the end, and then I'm happy to take more questions. But I think after this, I hope you have a greater appreciation for what a vital role endoscopy plays in managing patients with IBD. Not only is it needed to make a diagnosis, but it's also used to help confirm response to therapy. It's a key tool in helping to conduct dysplasia surveillance and prevent colorectal cancer in patients. And there's just these new and exciting frontiers in endoscopy that allow us to treat IBD-related complications endoscopically rather than surgically. So I really appreciate your attention. I'm happy to take questions. I'll stop sharing right now. And thanks again for your attention. Yeah, thanks so much, Dr. Shukla. That was a great talk, very comprehensive. I think we'll see as people maybe type in their questions. I can start with one. So I've seen a few like older patients that maybe are approaching the age of 75 when we would typically not be doing their regular screening colonoscopies, but in patients with IBD, is there really an age where you say maybe the risks outweigh the benefits or do you just individualize that decision based on their disease and other comorbidities? Yeah, I think in this case, it's the same type of discussion like it would be for someone undergoing like just age appropriate colon cancer screening. It's very much has to do with their personal wishes probably, but also their medical comorbidities at that time. And so I do have, I have 80 year old patients who are on JAK inhibitors and getting colonoscopy and that's probably not what you would necessarily expect, but there are some people are just in such great health, but it does probably make sense to try to prevent, you know, a colitis associated cancer in that case. I'm curious what your thoughts on the new like quality indicators for colonoscopy, the section about inflammatory bowel disease, if that's changed your practice. I think the main things were just, you know, documenting like Mayo SES score and SES Crohn's disease score. Yeah, yeah, so that I did see that. And I do think it, I mean, I do think it's important. As I said, I find the SES CD to be a little bit more cumbersome to use. So that's why, and I apologize again, it was out of order. I like the SEMA CD a little bit better and I'm happy to bring that up a little bit, but I do think having some standardization is important so that, you know, the purpose of your endoscopy report is not just for you, it's for the next person as well. And so I think it's very helpful to have that. So I agree with doing that. And I realized that like having now worked with fellows for some time that, you know, it's not something that you're, unless you're working with someone who sees a lot of IBD patients, it's not something that you're always taught to do. So I think we should definitely make more of a habit out of that. So let me see, I can share this again. And so you guys can see that, I guess if no one has any other questions, but yeah, this is the SEMA CD score. Again, I know we glossed over it a little bit, but basically you just assign a score between zero, which is remission to four severe disease for each bowel region, either the ileum and the colon. Whatever is the worst number you assign in the colon, you just multiply it by the number of segments involved. And then you add that number to your ileum number and that gets you your final score. So it's just a little bit easier, but I do think some scoring system needs to be included. And there are studies that show that this performs just as well as the SCS CD. There is a question in the chat. After ileocecal resection, do you always use the Rutger's score moving forward in future scopes? Yeah. Yes, I do. You definitely should, whether it's normal or not. I think it's good form to mention it in every colonoscopy that you do, ileo colonoscopy that you do. And always do your best. Sometimes the way patients are put back together, it can be hard to find the neo-terminal ileum, but do the best you can to try to locate it. Sometimes it's even sort of behind you. You might have to sort of a little bit retroflex to find it, but I think it's important to try your best to take a look. There's another question here. So in post-op surveillance, what is the risk for ischemic anastomosis ulceration in this population? And is there a way to distinguish between surgical anastomosis ulceration or ischemia and IBD related ulceration? Off the top of my head, I don't have like the number like in terms of how many patients will develop, but it's a great question. And one that we should remember that like the ulceration that we see just confined to the anastomosis can be driven by ischemia. And I think that's why they really broke out that I2 category into that I2A and I2B, because typically an ischemic etiology will just be confined to the anastomosis. Whereas if it's truly recurrent disease, you're going to see it a little bit more proximally into the neo-terminal ileum. And so I think that's the best way to help kind of differentiate between the two. And if it's just ischemic, you're very likely to be able to leave it alone. That being said, sometimes those still do stricture down and you might have to either revise or dilate that for obstructive symptoms. But that's the best way to differentiate, I think, between the two. One other thing I'll bring your attention to, and I didn't share that here because it was slightly outside the scope of just endoscopy, but know also that we lean hard on endoscopy for our assessment and response to treatment for confirming mucosal healing and even to investigate recurrent symptoms. But we want to just continue to monitor these patients in some way. So there was a clinical practice update that was released about how to use non-invasive testing as well. So in the periods where you're not conducting endoscopy, for example, in a Crohn's patient, if you've confirmed remission in the last three years on endoscopy, you can elect to just use, lean on things like CRP and fecal calprotectin. And so do conduct some monitoring if you're not conducting endoscopy to make sure that you're continuing to objectively monitor these patients and staying on top of inflammation. Especially with Crohn's patients, symptoms are often very subclinical until they're not. And so we want to make sure that we try to catch things before they become a problem. Kind of along those lines, I know we don't really do intestinal ultrasound at our center, but for centers that do, do you think there's a role and if what in sort of surveillance monitoring of disease? Yeah, I mean, intestinal ultrasound is kind of just lining up right there with CRP and calprotectin and really being able to take over some of the times where we want to order cross-sectional imaging or even colonoscopy to help us conduct a disease assessment and just check in on someone if their symptoms are questionable as to the etiology. So I definitely think it's a great tool to have in your armamentarium. Barriers just, I think, include having the training and that's something that's being offered now increasingly across the country, a reimbursement for that type of activity, but hopefully those are things that will improve over time. And then in patients with Crohn's who have maybe primarily like small bowel disease that wouldn't necessarily be entirely surveyed on a colonoscopy, after you switch therapy, are you repeating imaging in that same like six to nine months or what's your sort of practice there? Yeah, typically I'll repeat imaging and I might even forego a colonoscopy if I really feel that there was nothing to be had from that because it's a lot to put a patient through, but yeah, imaging will be my surrogate, hopefully CRP, but as many of you know, about 30% of patients won't have a CRP to follow, so we can't use that, but I'll try not to put them through a colonoscopy if I can avoid it. Yeah, this was really great. Thanks so much. If anyone else has any final questions or comments, discussion points, feel free to type them in, but thanks again, Dr. Shukla, this was great and thanks for all the fellows for logging on. Yeah, thank you to all of you. Thank you, Taylor, for a wonderful job moderating and for helping us with these cases and thanks to everyone who had such wonderful questions and I know this will be posted for reference later and happy to be reached at the end. I've included my email as well if you need anything at all. Thank you both, Dr. Riggs and Dr. Shukla. I appreciate the content and the amazing presentation that was given. Before we close out, I want to let the audience know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of 2024 and also the 2025 events that will be available. Registration is open. Our next Endo Hangout session will be Advanced Endoscopy Fellowship and it'll take place on Thursday, December 5th from 7 to 8.30 p.m. Central Time. Registration is open. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, ASGE training membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and sign up today. In closing, thank you again to our presenters for this excellent webinar and thank you to our audience for making this session interactive. We hope this information has been useful to you and with that, I will conclude our presentation. Have a wonderful evening. Thank you.

Endoscopic Surveillance

Inflammatory Bowel Disease

Crohn's Disease

Ulcerative Colitis

Chromoendoscopy

Primary Sclerosing Cholangitis

STRIDE-2 Guidelines

Mucosal Healing

Ileocolonoscopy

Endoscopic Therapeutic Interventions

Dysplasia Management