Welcome to ASGE Endo Hangouts for GI Fellows. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event entitled Endoscopic Evaluation and Management of Inflammatory Bowel Disease or IBD. The discussion of this webinar will focus on the role of endoscopic findings in IBD. My name is Redi Akova, 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 within two business days on GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it's my pleasure to hand over the presentation to our two GI Fellow moderators who will help with the incoming questions, Dr. Michelle Rosario and Dr. Naurose Syed. I will now hand the presentation over to them. Hi, my name is Naurose Syed. I am one of the third year fellows here at Penn State Hershey, and I'll be staying on next year as one of the advanced fellows. Hello, I'm Michelle Rosario. I'm also one of the third year fellows here at Penn State in Hershey, and I'll be staying as a fourth year IBD fellow next year. I have the pleasure of introducing Dr. Emmanuel Williams. Dr. Williams is here as faculty at Hershey Medical Center, and she carries the appointment of associate professor of medicine. And she is not only the associate medical director of the Penn State Inflammatory Bowel Disease Center, but she also serves in her capacity as the associate dean of student affairs for the Penn State College of Medicine. And I have the pleasure of introducing Dr. Kofi Clark, who also holds an appointment here as faculty, as professor, he's also part of our IBD and Celiac Center, and is also our division chief of gastroenterology and hepatology here at the Penn State Milton S. Hershey Medical Center. Oh, thank you so much, Norose and Michelle, we're so excited that we're going to have these incredible fellows stay with us next year. And this talk is relevant to both of them. So it works out perfectly. So thank you so much for having us. I have an interest, obviously, in IBD, I've been at Penn State since 2010. And I was one of the formers of our IBD Center. I also have an interest in wellness. And I think I want to thank the ASG for thanking us to for inviting us today. And note that whatever practice you end up going into, joining our national associations is really a fantastic way of getting involved in your field. And also a great way to ward off burnout, you get to work with people who like you have the same interests, same suffering at times, but also same joy in the same field. So I wanted to give a talk or a little bit of a talk, but really, we want to be this as interactive as possible. Tonight on what I would have known, wanted to know as a fellow starting off with IBD patients. So today, we'd like to welcome all questions at any time. So feel free to post those questions, and Rose and Michelle would be looking over that. The learning objectives today, we want to evaluate the role of endoscopy and IBD, and appraise and appropriately report endoscopy findings in IBD, and also distinguish between do's and don'ts in IBD endoscopy. As you know, there's not one modality that makes the diagnosis or follows the course of an IBD patient, but endoscopy is a very important part of that role. It's one of the biggest team members in when we're evaluating our patients. We always look for objective findings of disease and endoscopic evaluation is one of those. So a term invented by Dr. Rosario, who's with us, IBD endoscopy is not the time to do discovery endoscopy. It's not when you go into the room and think, wow, IBD endoscopy looks like a gold statue. And here in the Raiders of the Lost Ark, Indiana Jones might well find snakes or something terrible in there. That can happen to you too in IBD. So it is very, very important, not that it's not important in general endoscopy to prepare, but particularly so for our IBD patients. So it is important to look at the chart review. When did this patient's onset of disease, how long has the disease been going on? What has been the course of the prognosis of this patient? What's the medical history therapy and current therapy? Are they in the midst of a change of medical therapy? Is this someone who's been stable for a long time? What is their surgical history and anatomy? Very important. When you start turning someone on their left and they have an ostomy, we have a little problem when the attendant comes into the room. Indication, what's the disease act? Is it for disease activity? Is it post-op surveillance, dysplasia surveillance? Or some of our patients who have ileal Crohn's at the age of 50 still need a screening colonoscopy. We can't forget that. And then what are their current symptoms? Is this someone who's coming with very active disease? Is this someone in remission? Very important as well. Look at the past endoscopy report and pictures. These are absolutely key to see improvement, to see what the disease looked like before. So you're not operating in a vacuum, which would be problematic. So one of my biggest fears when I was a fellow is I could not understand any of the surgeries that patients in IBD had, which was one of the reasons I dreaded going to IBD clinic. But I finally, I wanted to go into hepatology at first, but I finally was assigned to IBD clinic and I thought it was about time that I learned the anatomy. It is very important to know what the anatomy means and what surgical surgeries meant. It took me a long time to figure that out in fellowship because I didn't dare ask questions, which was a mistake. Ask as many questions as possible. So first anatomy, when you have an ileostomy, you can have an end stoma. So again, that is one orifice there. The patient is usually on their back when we're doing their endoscopy. We don't need a whole lot of anesthesia. They're not going to feel a whole lot when we do this. It's always important to ask if the patient has extra supplies and whether you're going to use one of their supplies or not. Ostomy supplies are very expensive. They're very limited by insurance companies. A patient won't like it if you take one out and throw it in the trash can and they don't have another one. So that's an important thing to ask. A loop stoma may be used for a diversion and it has two orifices and the afferent limb is usually where the stool is coming from, is usually the largest one. It can sometimes be actually very tricky to find the efferent limb. But if you don't know that it is a loop stoma, you may be mistaken in thinking they have an end ileostomy and not examine the other loop, which would be a miss there. For the colon, you can have colostomy. So wherever the hole is in, that's the colon ostomy. In the ascending colon, the transverse colon, the ascending sigmoid, they also can be end colostomies, end loops. So be aware of what that is. And then also if they have an end colostomy, they may have a Hartman's pouch, which is a dead end, which also needs to be evaluated as well, because it is at risk also for dysplasia and colonic polyps. So not to be forgetting that. So that is very basic anatomy. And I know maybe too basic for some of you on this, but I think that it's good to start with the very basics. In ileosacectomies, it gets a little trickier. So end in the end, end to end ileostomy. Here the colon is directly sewn, hand sewn, it takes a lot of time from the colon to the small bowel. This is my dream sequence. Some of our pediatric patients have end to end ileostomies. Some patients who come to us from Pittsburgh have end to end ileostomies, and it's lovely. You're in the colon, and right then you go into the terry cloth of the small bowel, and it's no problem. Sometimes they can get strictured, but it's usually a straight shot, very easy, any scope can get there. End to side, and in our institution, we have some surgeons who do end to side and side to side. So in end to side, they basically make what's basically the equivalent of what's anatomically there already. So they have a colon, and they attach the end of the ileum there. So you basically come to the end of the colon, and you have an orifice, which would be like your bowel, but it is the anastomosis there. Also very easy to navigate, not a problem to get through, can get strictured as well, but that's an easy anatomy. A little bit more difficult can be side to side. And side to side can actually be in two directions. It can be iso or asymmetric, so in one side this way, or both sides the same way. And the problem with this is sometimes the lumen of the small bowel is behind your head when you're coming in. It can be very tricky to find. You may find the dead end of the small bowel, but you might actually have to retroflex to get into the actual limb of the small bowel, and can be fairly tricky. These are the easiest anastomosis to do. They're very quick. You use the stapler in two directions, and the surgery is completed. However, for us endoscopists, it can be a little bit tricky. There's discussion and controversy as in anything, whether one is better than the other. And obviously you can see that even in our institution there's differences, but there's always a risk of small bowel bacteria overgrowth when you have a blind limb. But if you have a reporting system such as the recognized probation system, you'll see that the anastomosis is always an end-to-end. It is extremely rare for me to see an end-to-end anastomosis, but the reporting system thinks that it is. So be aware, even though that's what the reporting system makes you do, know the type of anastomosis and be able to recognize it. It's important for the patient's course. J-pouches are another anatomy issue to be dealt with as well. So you can have a loop ileostomy at first before the J-pouch is actually healed. So we usually don't go through these loop ileostomy, these patients are healed, and we have the J-pouch. And the J-pouch has an afferent and efferent limb, and also important to know there's the tip of the J-pouch, which is the length of the J-pouch, the pouch body, the suture site, and then the cuff and anal transition code. And I have another picture there because it can get a little bit tricky. So note where the anastomosis is, that's the one anastomosis in the J-pouch, which is the ileum to the rectum, the anal transition zone, and where the cuff is. The rectal cuff is the little tiny bit of rectum that is left, which can be problematic and cause copious, but also a place where you can get dysplasia. So looking at the J-pouch, the picture A is at the tip of the J, and if you measure from that tip to the anus, that's the length of the pouch, or that's how I measure it. Picture C is the afferent inlet, which sometimes can get strictured and is misidentified sometimes as anastomosis. The surgeons do not consider the inlet to be an anastomosis, but it can get strictured there. And then at the D-level, that's where we have our rectal anal anastomosis. And then my favorite is the owl's eye, where you have the picture of both. And this is actually, the picture B is upside down. The nose of the owl, or this beak, is pointing to the top, and then there's this two eyes. And I unfortunately, after seeing this owl, can never unsee it. So that is the owl's eye that we look for, and I do retroflex in the pouch to look at the rectal cuff, both in fourth view and in retroflex view. Any questions at this moment yet, Rose or Michelle? No, we don't have any questions yet. Okay. So we're still on anatomy. So before, so you've started, you've looked at the chart of the patient, you haven't even met the patient yet. You've looked at their vascopes, you're familiar with the anatomy, you're ready to go. Well, what's next? Consent. Consent, it's important that, it really is actually important that it's not consent for every patient. And this is something that's not always recognized by all our colleagues, but this is something that I have seen in my practice. I don't know if you have too, Dr. Clark, but many of my patients will say, I had a biking accident and I had a perforation, or I had a perforation 20 years ago during an endoscopy. It is overrepresented in IBD patients that they've had a prior perforation, unfortunately. So in a paper by Dr. Shen, they've looked at the outcomes of endoscopic perforations for patients with and without IBD. So first of all, there is an increased risk of perforation in patients with IBD, particularly if there's need for dilation, the older age of the patient, interesting female gender. But there, more importantly, is when they have a perforation, the complications actually don't seem to be that different from other patients unless they've been on chronic steroids. So again, the devil for all of us in IBD is steroids, but it is also the devil when we're doing endoscopy. So be very, very careful in patients who've been on long-term chronic steroids. First of all, if they do get perforated, they may not have the same visceral sensitivity and you may not realize that they've had a perforation. The second of all is they do have an increased risk of complications after. So it does happen in IBD. It's why we are very careful when there's very severe disease, but it can happen actually when the patients are also in remission. So my colleague, Dr. Tinsley, had a 45-year-old with UC. She had had a perforation during colonoscopy during her teens. She had told the doctor, absolutely, I am not doing a colonoscopy. I got perforated. She wasn't doing well. She really wanted to get a picture because she was a second opinion to him, but she did transfer her care to our center. She had been on many years of steroids. She finally was convinced to get a colonoscopy. And the famous last words was, don't worry, we will not perforate you. So unfortunately, when they were in the CECM, they took what they thought was an ignocuous biopsy, which as you can see, may not have been so innocuous. So that was fixed with Eclipse. And fortunately, the patient just had an overnight observation and was discharged in the morning, has since been very reluctant, as you can imagine, after her second perforation to get another colonoscopy. But this is something that we, I tell specifically to my patient, given your history of inflammatory bowel disease, and then particularly if they've been on steroids, their age, or they have active disease, you are at increased risk of perforation above and beyond the regular risk of perforation. They have to know that. When you have doubt as to when to do endoscopy for IBD, how to do it, or management of IBD patients, don't worry. There are plenty of guidelines to guide you. And I didn't feel that I wanted to go through the indications necessarily as much as what we see endoscopically. So what will you see and what to report? Take many pictures, right? It's when you have children, take as many pictures as possible, but before you know it, they're not as cute as they were when they were toddlers, I'm just saying. They may be beautiful, but maybe not quite as cute. And then indicate the location. So when you're doing, when you're taking lots of pictures in your report, it's important to actually have all of those pictures, but it's also important to report where those pictures were taken. If you need help from a technician to kind of write some things down to help you, that is also important as well. For ulcerative colitis, there are standardized index and two of them that are routinely used for studies. I will report with full disclosure. I try, just as I know Dr. Clark does as well, I try to scope as many patients of mine as I can, because I feel like there's nothing better that replaced this looking at the patient, speaking to the patient before and after the procedure. It's kind of like a very complete clinic visit for me. So I try and scope all my patients. So I, in full disclosure, do not commonly use these index scores. They are available as pull-downs in many of the programs to report endoscopy, but I personally don't always use them. I look compared to the other reports. So Dr. Clark, do you use these index scores often with your UC patients? Yes, Dr. Williams. I do use them for a few reasons, as we all know. Because they are fairly standardized, it provides the opportunity that if there's another endoscopy is when I'm not available, and they can look at those and compare apples to apples. Now clearly when we're scoping people who are on, we've seen in the office, then we have a sense if we're going to be doing the repeated scopes by ourselves. But because they are standardized, yes, I try to use them as much as I can. So I'm not a good student, but that's okay. I'll get there. I'll get there. Thank you. So the Mayo score is actually very simple to use. And while I should use it more often than I do, because it's very helpful when our fellows go back and do research to have that scoring. And also I always use it when I'm part of a study myself. So normal would be no friability, no granularity, intact vascular pattern, that's a very happy colon there. If you have a little bit of erythema, diminished or absent vascular markings, and mild granularity. What I say Mayo one is if you took a little bit of a mild sandpaper and did that very superficial scratch when you fell on AstroTurf, this is like the superficial knee injury that no one cries about, that's mild, right? Moderate marked erythema, no vascular marking, but also bleeds with minimal trauma. So this is the kid who comes crying because they see blood, right? This is the knee injury on the AstroTurf. There's definitely blood there when you just touch, that is moderate. Absence of vascular markings, and usually you see spontaneous bleeding in the lumen. And so I always laugh a little bit about Mayo, because one of our colorectal surgeons, who was a very enthusiastic person, one day tells me, so you're telling me that I should take this patient to the OR because they have a Mayo four? And I was like, well, yes, yes, they're off the chart. So we joked about that for a long time. He was trying to be very, you know, showing that he knew knowledge of the endoscopic scores, but there is no four. So there you go. So again, these are pictures of Mayo, a little bit more so you can see kind of the difference. Where it's a little bit difficult is it's tempting when someone has not done a whole lot of endoscopy to look at everything and think it's really severe. And so I think, you know, paying attention to whether something bleeds and it's actively bleeding or whether it bleeds with touch is a difference that helps me between two and three, and also just kind of how severe the ulcerations are. I find that sometimes when our, some of our surgeons who don't scope as much as we do tend to call things, a lot of things, Mayo two. And so, or even three, when I see them more so as mild. So it is important to be able to remember what these pictures look like. The UC, the other scoring system we don't use as much, but I've used in quite a few studies, which actually is a little bit more complete, has the vascular pattern bleeding and ulcers and counts them and has deep ulcers. And there's a score for the UCES. It's a little bit more difficult because you have to add up numbers. The Mayo is by far the simplest one. So in Crohn's disease, it's even a little bit more complicated, but you basically want to look at the presence of ulcers, the extent of the service involved, whether it's less than 10%, 10 to 30%, more than 30%, the extent of the surface affected, the presence of stenosis and how many segments. So I think more so with Crohn's, it is really important to look at where you see the ulcers, where they seem to be worse. And again, that's very important. Don't forget that an ulcer of colitis, and it's the favorite PIMP questions, and PIMPing does not lead to learning, but someone will ask you, you can see just proctitis or left-sided sigmoid disease and inflammation in the cecum, which is, you know, the cecal patch. It does not mean that they have pancolitis. They can sometimes just get that cecal patch. But that is something people like to ask. Oh my gosh, you see this inflammation in the cecum. Don't you think this patient has Crohn's? And your answer is no, no, no. I learned on the ASGE leap that this was just a cecal patch. That's your answer there. Post-op Crohn's, and this is one that I definitely use, is the Root-Gerx scoring. And so endoscopic remission is no lesions or less than five absence lesions. And why this matters so much is when we do post-op surveillance six months after surgeries after an ileocechectomy, it is very important to know, first of all, if the patient has not been on medical therapy, if they have evidence of recurrence, we would start them on medical therapy. So counting those at this ulcers and five is the magic number. Okay. And so that's where you want to look at how severe the disease is. It's fairly simple. Dr. Miguel Rogero, his son, and I think now is in medical school. But when he was doing his post-op studies, he told me that his son actually helped him. And he realized how Root-Gerx was very simple because his son, who had no medical knowledge at the time, was able to do it reliably and count the ulcers. So Root-Gerx A here is I0, which is no at this ulcers. In the picture B, it's I1, which is fewer or equal than five. So you can see those little white canker sore looking things on B. In C, we have more than five. So this is where counting counts. And I do not count the ulcer at the anastomosis. I count just the ulcers behind. Many, many of our patients will form an ulcer at the anastomosis. It is a sign and a harbinger of recurrence of Crohn's, but I do not count it in my Root-Gerx scoring. D is I3, diffuse aphthous ileitis. So as far as the eye can see, you see aphthous ulcers, and there's definitely more than five. And I4 is diffuse inflammation with large ulcers, nodules, and or strictures. And so that's when it looks like a bear went in there and started scratching the ileum is definitely a Root-Gerx I4. In pouches, it's actually important as well. So often in pouches on the suture lines, there will be ulcers. These are kind of a mild ischemia that occurs with suture lines. Yes, my colorectal surgeons will tell me that when they do these pouches for FAP, they don't often see these ulcers at suture lines, nor at the atherum inlet, but we do see them and they don't necessarily indicate severe pouchitis. Often the patients have no symptoms. So A would be a normal pouch with a little bit of ulceration at that suture line. B is a picture of chronic pouchitis and quite frankly, it often looks like Crohn's disease. And then ischemic pouchitis, which is very well described by Beauchesne, is really when you only see one side of a pouch. So if you look at that picture C, there's completely normal mucosa on one side and very ulcerated on the other side. I have only seen this a handful of times, but the time that I did was a patient who was cachectic at the time of his surgery wearing, I don't know, I think 125 pounds and went on to gain up more than 300 pounds. And you know, it actually stretches the pouch. So and then D is an inflammatory polyp, which we can see in chronic pouchitis and the problem with those inflammatory polyps is actually they can cause quite a bit of anemia for patients. So I do remove them, especially when the patient has anemia. So Dr. Clark, have you seen ischemic pouchitis before? Yes, Dr. Williams. Unfortunately, when we work in the settings that we do, we see the end of the spectrum and there's a referral bias coming through. And as you described very elegantly, Beauchesne has been a big advocate warning all of us to focus on looking for these things. If I could add a couple of lines as well, you summarized the Rutgers score excellently. And for the fellows on the screen and joining us this evening, we typically don't look at those ulcers within five centimeters of the anastomosis, just for the reasons Dr. Williams described. There are a few settings and different scores, which we look at those, but by and large, those are not the ones that we worry about as well. It also helps us to compare future scopes to whether people are responding to the post-operative therapy or not. So someone who has a Rutgers score of I3, you do a follow-up and they are I1 or I0. It tells you exactly what's going on and you can compare those as well as for research purposes as well. I found it to be very, very helpful and a very, very helpful scoring system. So I saw that there was a question on the pouch and I will direct that to you, Dr. Clark. So these inflammatory polyps, do we have to worry of them in terms of any kind of dysplastic? Why would we take them out? Why do we leave them? What do you do in your practice? So once again, thank you, Dr. Williams, for talking about that. One of the problems we have with inflammatory polyps in pouches is that they span a wide spectrum of simple inflammatory polyps all the way to people who are developing Crohn's-like phenomenon or immune-like phenomenon of the pouch after the surgery. We were fortunate to describe a case about three, four years ago in our own institution and go through the differential diagnosis. So what I do is if these people don't have a history of high-risk disease, for instance, chronic disease, they have a history of dysplastic changes and everything else, I do simple biopsies because as we all know, these polyps have a propensity to bleed significantly. So as you described in the beginning, we should be prepared to deal with whatever we are going to remove. Every now and then, we are all surprised and we think, hmm, what was I thinking when I did this? So in my own practice, unless there are previous episodes of dysplastic changes, I do my biopsies focusing on the cuff, particularly if the length of the cuff is very long. And as you know from the studies from Beauchamp, if there are going to be dysplastic changes, usually it's in those patients who have a longer cuff at the end of the pouch. So in my practice, I do the biopsies first. And if I have any concerns, then we speak to our surgeons and then we decide whether these people need a redo of the pouch, they need an endoleostomy, or we can, in collaboration with our advanced endoscopists, plan to resect the ones that are concerning. I don't have an evidence, I don't have, I've never had a patient with any dysplastic changes in these. Most of the time when I've resected them, it's really because of ongoing bleeding and anemia as well. But, you know, all of these growths that do some point, but we don't, I don't have a size and be interested to hear from Beauchamp if he has experience in terms of how big they are and when do we leave them, when do we resect them. I don't think there are clear guidelines at this point on the management of these polyps that I know of. Yes, you described that very well. I was just actually going to go on the bleeding, just like you said as well. And so there's no good reason to resect these polyps simply because of the size, but unless you see dysplastic changes or they are a source of significant bleeding. And even if you see dysplastic changes, it is difficult to tell whether they are real dysplastic changes or associated with the inflammation that you show us in here. So, special situations. C. diff, never ever forget it in IBD. IBD patients who are poorly controlled are incredible risk of C. diff. If a patient tells you, no, no, no, I was tested by C. diff by my doctor. It's literally a, it's literally the sinequanon that they're going to be positive for C. diff when I retest them and convince them to do it. But I have actually found a significant yield. When we are doing a flex sig to evaluate for the disease activity, I get a stool sample from the colon and actually the yield is not lower. If anything, my experience is the yield is actually higher for C. diff. I've talked to ID extensively about this. They feel that this is not necessarily colonization. When we get it from the stool eluant, it's actually a positive. And so that is one thing that I do do when I see a very inflamed colon. Another special situation that I didn't mention is when you have patients who have had colitis for a long time and develop pseudopolyps. So I usually do not remove pseudopolyps because the bigger post polypectomy bleeds I've had was removing pseudopolyps. But sometimes they do grow big enough that they should be removed for anemia purposes. However, pseudopolyps, I have seen an example, and we did see on the IBD Live multicenter group, a patient, a physician who looked at a pseudopolyp looked at that the stock was somehow more cerebriform than the other. And they did have dysplasia at the base of the pseudopolyp. The usual thinking is that pseudopolyps in and of themselves don't turn into anything dysplastic, so it can be left alone. However, they really make screening much more difficult. And so one of the questions Norose and Michelle had was, you know, how do you tell the difference? And so we do have evidence now, and Dr. Clark, you have a paper as well, that white light endoscopy with a good prep is completely equivalent to chromoendoscopy. However, I was lucky enough to train through a Crohn's and Colitis Foundation fellowship at Mount Sinai using chromoendoscopy. And I have felt, I have a couple patients who have developed a lot of tubular adenomas, but also have a lot of pseudopolyps. And I find that targeted chromoendoscopy in those patients really helps me look at the pit pattern. And most recently, I had a patient who has hundreds of pseudopolyps, and I was able to safely remove multiple tubular adenomas and feel pretty confident that they were the tubular adenomas as a part of the forest. So pseudopolyps are also a special situation. Also, fulminant colitis, when someone comes in very ill, febrile, in the hospital, I do think it is incredibly important to get some staging of the disease and also get biopsies for HSV and CMV. I also biopsy for histology. So this is a time that's critical for the patient. It's a high-risk situation. So Dr. Clark, how do you biopsy for HSV and CMV usually? Thanks again for speaking about this. So as we all know, there are different yields if you biopsy from the edge of the ulcer and from the base of the ulcer. There's always the concern about whether you're going to have bleed from the base of these ulcers. Clearly, we are not advocating for taking biopsies if you see a pigmented spot or you see an oozing vessel. But you try to biopsy from the central part of these where you are likely to get a higher yield with some of these viruses as well. And if you see multiple ulcers, that's where you want to get some of these as well. I'd want to throw in the line to think about that, keeping in mind that sometimes the biopsy positive for CMV might indicate something that's an innocent bystander. But when they do occur, the path of the IBD is a little different. And I think Dr. Williams will be talking about that as well. Yeah. So another thing too is sometimes CMV yield is actually higher in the right colon. If this disease is severe, I actually don't force myself to go to the right colon. There are times where the patient is not responding to steroids. We have treated for CMV without going to the right colon because that's the yield is higher. Also note that histology is really important. I mean, it's IBD 101 that you can get granulomas in 30% of Crohn's disease patients, but it can be a dramatic difference to that patient. So there was a young man who was 18 or 19 who came to a colorectal surgeon. He was quite ill. And the colorectal surgeon said, you know, I feel like I see a little skin tag. I'm a little worried this actually might be Crohn's disease. And as you know, in pediatrics, colitis presenting as just colitis is often actually Crohn's colitis rather than ulcerative colitis. So he had, he was astute and asked me to do a biopsy. The biopsy came back absolutely chock full from granulomas. The patient, as you can imagine, did not get a pouch, but was treated for his Crohn's disease and ultimately did very well. So that really can be a change for a surgeon about to do a surgery on these patients. But it is important. And this may be the slightly controversial part of this talk. And this is something from Asher Kornbluh. So my line when I try not to impress on anything, but when you go in, we're really, really hot colitis where everything is male for everything's bleeding. You can't even, you get in there and there's blood everywhere. It looks like literally some animals fought there against each other, a bear against some kind of cheetah and the whole colon is scratched through. You really want to go in as if you're going to, you know, you're going to steal, you're going to borrow it from a bank. You go in, you get the money and you get out of there. So you don't get caught. Right. Asher Kornbluh has put it in a different way, which unfortunately I've never been able to unsee, but it is very helpful because it's tempting sometimes to think, Oh, you know, maybe I'm going to go further, you know, but the colon looks like it's going well. There is nothing more distressing when there's a family of a young person who's first diagnosed that your colonoscopy, your flex sig that you said would be a quick procedure is complicated by a perforation. This is when perforations happen. Dr. Asher Kornbluh refers to this as some young, some teenager having sex under the bleachers. That young man wants to go in, do the deed and come back unscathed. That's kind of the same thing. I cannot unsee this horrible picture, but be know that severe colitis is really not a time to insufflate with a lot of air. It is not a time to try and get to the right colon, to put pressure on the colon or anything like that. These are very, very high risk situation. And it's important that you recognize those. So my summary key points for tonight, please no discovery endoscopy, try and be as work up your patients as much as possible. Your attendings will love you for it, but you will also learn a lot more. If you know more about the patient before you go in, do know why. So what's the indication? What's the chart? What's the past history? Do know what you need to do when, so how to consent the patient and whether or not to take biopsies. And also know what, so what was the past report? What are you going to write down? What's your reporting going to be like? These are important. These are important things to know when you're doing IBD endoscopy. Another thing that I have to say is, I realize that there are times where my endoscopy staff has felt that my patients come in and they dictate what exact vein they want the IV in, and they dictate exactly how they want the pillow and what gown they want and the number of warm blankets. Realize that some of our IBD patients, especially as we are seeing a lot of pediatric IBD have had multiple, you know, multiple tens of dozens and plus of colonoscopies in their lifetime. So I do give them grace. I tell my nursing staff, this is a young person who's had a lot of colonoscopies and recognize that this is something that is not the easiest thing for them to do. It's very important for us. And I think that it's, it does require a little bit of grace sometimes when they sometimes will dictate their care, because it's the one place where they have control. Control is a big issue for patients with IBD. It's hard to not have control. Please don't go blind. That's always a problem for us. Please don't go bold, which is even more problematic. And when in doubt about the anatomy, about how a patient's doing, about their chart, ask. It's so important to ask. I regret during fellowship, not asking enough questions because there were answers all around me. But ask before you proceed so you have more knowledge, you have more opportunities to learn, and more opportunities to ask questions. So those are my summary key points. I think there are some questions. And so Norose and Michelle, I will let it up to you to moderate from that standpoint. So I know this is not a complete review of everything in endoscopy, but I tried to think as hard as I could of things I wished I had known as a fellow. And thanks to our fellows here and Dr. Clark for assisting me in putting these slides together. So thank you. Thank you, Dr. Williams. And thank you, Dr. Clark, for really an insightful and really well put together talk. I feel like I learned a lot even after I've gone through several of these cases with you through the years. So we're going to transition now to the question and answer portion of the event. And I'm going to kick it off with a question that I have of my own and that I've had for a while, but I think this would be a good opportunity to bring it up. And that is that when you endoscopically encounter a native stricture, so a non-anastomotic stricture, what is your thought process? What are some of the things that tell you that this might be appropriate and amenable to endoscopic intervention rather than aborting and saying this is something really that would be best handled by a surgeon? So thank you, Nerose, for having us join you. And thank you, Dr. Williams, for that excellent lead off summary that you just gave us. So let me throw in a couple of quick things before I answer Nerose's question in here. I think I will remember, Dr. Williams's analogy for a very long time. But the summary I would say is that when you're doing endoscopy in patients with IVD who are sick, that's not a time to be a hero. So coming back to what Nerose was just asking us, when do we decide to abort or when do we decide to intervene in strictures? I would urge you to go back to what we all learned. What's the history? Does this individual have symptoms? When we talk about symptoms, are they objective symptoms, bowel abstraction, pain? Are they losing weight? Have they changed their diet to facilitate the ability for food to pass in that area? And typically, when you ask them about things like are you avoiding salads? Are you avoiding corn? Are you avoiding those things? You get a very direct answer. One other useful thing you can gain from them is they will give you a history of they suddenly feel this severe pain. And then just as it started, it goes through, it looks like things are flushed, and they feel better. I would urge all of us to also do some ancillary things before we do that. Look for active disease in that area. Is there an abscess in the area of the stricture? Is there bowel perforation? Is there a fistula? And is there ongoing inflammation? And just like Dr. Williams explained to us, this is not a time to discover things. You get as much information as you can. Endoscopically, you also want to see the size of the stricture, and you would have made some estimation of the length of the stricture, because what we know is that clearly strictures above five centimeters are typically not amenable to long-term benefits from these balloons. And people who have pre-stenotic dilation or people who have thickened walls in that area of the strictures are not likely to respond to balloon dilation. There are two big schools of thought doing some amazing research now at the moment. Florian Reeder from the Cleveland Clinic and Simran from Allegheny Health Network are looking at this. The fascinating thing is that they have opposite ends of the spectrum. One side is gung-ho about using this for everyone, including needle knife and making these things in here. So the specific answer to this is do a pre-endoscopy assessment, looking at the length of the stricture, the presence or absence of symptoms, whether there's active disease in that area. If you are unable to visualize the end of the stricture, either by fluoroscopy or being able to pass your scope through, you want to avoid trying to dilate blindly because you won't be aware of what you're going through. And then finally, once you've made that decision to dilate, make sure you have a good colorectal surgery backup service. And also, in signing the consent with the individual, you've explained to them that your risk of perforation, as we learned this evening from Dr. Williams, is much higher than the average garden variety and what that will mean. Because if you perforate, keep in mind the surgery is no more elective. It is now emergency surgery in these groups of people. One last line from me on this is there's an, I shouldn't say a new tool, but something that's not been adopted as frequently here in the U.S. as has been in Japan and Canada, something we call small bowel contrast ultrasound. So if you do those, you are able to assess the thickness of the wall, and if you can use that as part of your preoperative assessment, I think in the next few years that will become some other things in here. So I apologize for giving you a longer answer than I thought I would, but it goes by doing that thorough assessment to reduce the risk and the challenges that you're going to have, and I hope that's helpful. Yeah, you know, I would say, I would add to that, I think if we did have access to the ultrasound, it would be also very important in terms of the thickness and, you know, what the tissue looked like, a lot of caution in active disease, and remember also that you don't want to miss a malignancy in the setting of a stricture, especially an ulcer of colitis, because when you see one, to me, an ulcer of colitis, you really do have to think about the possibility of malignancy. That being said, even with the dilations, I do dilate these patients, patients that I've known well. While there's data that shows increased perforations with dilates in patients with IBD, these series are usually quite small. So we don't have as much data as we possibly could have, but every patient is different, and just as Dr. Clark said, knowing the history, the indication, and what you're going to achieve with it is important. Awesome. I appreciate the thorough answer. And so now we're going to go through several of the questions that have been posed in the Q&A forum. Do you want to? All right. So we'll transition over to a question. I'm going to combine actually a few that have been posed to us, essentially about kind of just general endoscopic, I guess, techniques. So first part would be, and this will be for you, Dr. Williams, first part is how important is a perianal exam and anal canal exam during endoscopy? And in terms of techniques like CO2 insufflation and the levels for that, and also like underwater immersion techniques in IBD patients, how do you utilize those? So thank you, Michelle. So first of all, I think perianal exams are very, very important. So we do have a subset of patients who I call the underfeelers who won't report anything. So they're doing, they tell you they're doing fine, you get them to endoscopy and you're doing the rectal exam, perianal exam, and there are fistulas everywhere. I have seen this more times than I care to say. And so, and you know, you then ask the patient, my gosh, you have all these fistulas. Well, you know, I knew it was a problem, but I didn't really want to talk about it. It's kind of embarrassing, you know, so that is very important. And also when we start seeing fistulas that look Crohn's like really can change the diagnosis. So I think it's very important. I think, you know, I do do a careful perianal exam. I always take a picture. I will do also a very careful perianal exam also with pouches too, because sometimes you need to dilate the anal stricture as well. But I do think it's incredibly important. This is something sometimes the patients won't report. We're rarely rushed in clinic at times. We don't necessarily undress the patients. We should far more than I do, especially with Crohn's. And I think that is an important component. First you can diagnose Crohn's when you didn't see it. You can also look at the severity of perianal disease, and you can also check on healing as well, because there are patients who will complain a lot, but when you look at their perianal disease, their fistulas are really healing beautifully. So that's very important. I definitely, when I do a flexing or a fulminant type colitis, I never use air, always CO2, and as little as possible. And so again, it's really an in out, take a good look, get out of there as soon as possible. I do use water emulsion, but I actually don't use it specifically in that setting. I don't know about Dr. Clark, but I tend not to use it in that setting only because often the area is very bloody, there's a lot of secretions already, it doesn't necessarily help me. It may be beneficial to the patient, but it doesn't usually help me. And really the goal is to be in there so quickly that very little CO2 will be used. Okay, that's awesome. A couple of the questions that we got in the chat reference a topic that you touched upon regarding CMV biopsies. So in patients who are presenting with a flare in whom all infectious causes have been ruled out through stool studies, and you do an endoscopy for one of the indications being to rule out CMV, how important is it to you to get to the right colon? How much higher are the yields from the right colon? And if you do a flexig and we don't have evidence of CMV, but you're kind of left in a, you know, in this situation where the suspicion still remains on the table, what are your next steps then? Well, I'll answer quickly with my favorite answer that all medical students should be advised to use at all times is it depends. It answers all medical questions. It depends, right? It always depends. But I think that when you have a fulminant, it's not worth it. You're not going to go to the right colon. It's actually no benefit to it. I have not really seen CMV in mild disease personally. And I have actually had a pretty high yield of CMV when I have a high suspicion in biopsies. So personally, I haven't really, well, I know that by data and report, there's a higher yield in the right colon. I have not found necessarily, I mean, perhaps I'm missing a lot of CMV, but I have not necessarily found that. And the issue is CMV presence in IBD, just as Dr. Clark mentioned, can be, we don't sometimes know whether it is an actual infection versus innocent bystander. And so, you know, I personally don't, I don't get to force myself to go to the right colon. Awesome. Thank you, Dr. Williams, if I could add a few things onto that. So we've also learned from multiple studies that there are certain risk factors that should make us run away from trying to force our way onto the right side. One would be female gender, increasing age, people with multiple comorbidities, and then people with strictures as you make your way through, and then the almighty steroids that we want to avoid. So if you stick to the mantra that you're not trying to be a hero in a small attempt to get a biopsy for CMV, I was fortunate enough to be part of a study about 10 years ago, where we looked at about 110 people who were severely immunocompromised, people who had bone marrow transplants, IBD, and everything else. And just like Dr. Williams describes, the actual yield of making your way all the way to the right side to get those biopsies is actually small. So is it worth the risk? I would say no. So if you can get your biopsy safely, yes. But if not, that should not be your driving factor, especially in the setting of individuals these risk factors in trying to get a biopsy and making your way all the way to the right as well. Awesome. Thank you, Dr. Clark. So the next question, switching gears a little bit more about the scoring systems. So we had a question about the Mayo score, and that was, does the extent or length of involvement of the mucosal change impact the Mayo score? Did you want me to start on that, Michelle? Okay. So the Mayo score is telling you about severity of disease. So you can have left-sided colitis, which may be Mayo 3. So you don't necessarily have to have pancolitis to be able to report that. Now keep in mind, though, that the extent of disease itself is another indication of outcomes. So for instance, we know that people with rectal disease or limited left-sided disease are less at risk of developing dysplastic changes down the line. So it's not zero, but it's less than people who have pan-ulcerative colitis. So the specific answer is no. You are describing an activity and severity of disease as Coruscigal, nowadays makes a specific point of separating the two. You want to let the next person who goes in to say that, oops, when Dr. Williams and Dr. Clark were scoping and Dr. Rosario and Dr. Syed, anytime they touched that area, there was a lot of bleeding. That was the Mayo 3. Now that I go in, I can make my way all the way to the right without anything apart from some redness. You know, one point that I did not make is sometimes people ask, what do you biopsy when you're looking at patients? So once a patient's been diagnosed, eight years later, I try and do an assessment no matter what the extent was. I try and do at least within eight years an assessment of the extent of the disease. Sometimes when patients are in excellent control, for example, in anti-TNF, you may not endoscopically see that there's disease, but there may be microscopic disease. And the length of the colon involved determines the interval at which we screen for colon cancer. So a pancolytic as opposed to proctetic would make a difference. And sometimes the anti-TNFs do make us blind to that. So I absolutely do biopsy areas that appear quote unquote normal to the naked eye when I'm trying to assess for the length of the disease. So that's something we didn't touch on during the talk. There's a very good question I saw about what do you do about a terminal ileum quote unquote asymptomatic stricture? So Dr. Clark, what do you do for those terminal ileum? I see valve strictures that we sometimes see in Crohn's. And Dr. Williams, I think you alluded to that about some segment of IBD patients who are under feelers. And then also keep in mind that we talked about this briefly earlier on in the discussion. These are very smart people who've lived with a disease for a very long time. They notice that any time they have corn, peas, carrots that are not boiled over. So what they may be reporting to you as no symptoms may not actually be asymptomatic. Something to think about. And again, in the spirit of looking at the individual in a holistic way, even though they have no symptoms, if they have pre-stenotic dilation of four centimeters, five centimeters, you want to begin to think that you have to intervene. If it looks benign, if it's short, and they are truly asymptomatic without any pre-stenotic dilation or surrounding disease, those are settings where you can attempt a balloon dilation, see how they respond. But if there's any doubt that people are under feelers, they are underreporting their symptoms. So David Binion, when I was a fellow, taught us something that has stuck with me all along. And what he says is that fistulae are the body's way of finding a bypass to downstream strictures and stenosis. So if you leave people to have these things happening for a very long time, eventually they begin to develop all the bad things we don't want them to see. Yeah. The other thing sometimes is, you know, I don't get completely aggressive with them either, but I do dilate enough so I can get to the other side to take biopsies because I'd like to see what, you know, in someone who has small bowel disease, I think that it's important to, I've gone in there to evaluate their small bowel disease. You know, MRIs are dependent on who reads them. And so I think that I sometimes have dilated very gently just to get to the area of where I want to get biopsies. I also am very careful about the patient who says they're completely asymptomatic because just as Dr. Clark says, they're completely asymptomatic if they need mashed potatoes and Wonder Bread. But they're, you know, they're not going to tell you that necessarily there's a lot of things they can't eat. So, you know, sometimes when there is a stricture that's very mild and, you know, I'll leave it, but I'll talk to the patient, mention it to them. If I feel like there's any kind of symptoms, the next time I bring them up, I will be dilating, but I'm cautious with that obviously as well. But we have very good results with dilating those strictures. I saw also a really good question about how we do surveillance colonoscopy patients. And so when the studies looked at this, and at some point I was very interested in chromoendoscopy, so I looked at obviously and reviewed all these studies in terms of what's the yield when we take all these random biopsies. So the reality is that it's incredibly low. So if you're taking millions of biopsies of every quadrant at every centimeter, you're really going to cost the hospital system, the world, and your patient a lot of money. However, I do want to get biopsies to evaluate the extent of the disease. So I will get biopsies for the extent of the disease. When it's for dysplasia surveillance, I think that with high definition scopes, I think we can have a really good look. I do a very, very careful exam. I wash as I go in, especially if I'm doing dysplasia surveillance, and I wash on the way back. I often will use targeted chromo if I want to, but I will take targeted biopsies of anything that appears dysplastic. However, also, if you're taking a polyp on a patient who has IBD in an area where they've had disease before, I do think it's important to remove the polyp and have a separate jar of the base of the polyp or the area surrounding the polyp, because we sometimes, it's very difficult to see a polyp which is purely sporadic as opposed to a polyp which may have spread at the base of it, can be difficult to, it's better now with all these high definition scopes, but it can be sometimes a little bit difficult, but I do not do the hundreds and hundreds and hundreds of biopsies that we used to do. The yield is extremely low for doing that. So I do biopsy for extent. I biopsy targeted regions, and then I make sure that I get the base of a polyp if I'm concerned that there's any potential spread beyond the polyp that I've removed. I also try and tattoo. I think we under tattoo sometimes to go back to an area, because there have been a couple times where I've been worried about an area, and it does come back a dysplastic, and then I remember this flat, but it gets very difficult if you don't have a tattoo. Thanks, Dr. Williams. One quick thing for our members who joined us this evening. Keep in mind that the term random biopsies is probably going to fade away in the next few years. So think of these as non-targeted biopsies and targeted biopsies. And just like Dr. Williams explained, if you see a lesion, those would be the targeted biopsy areas, you tattoo those areas. And what we previously alluded to as random, which we still do sometimes, we call them non-targeted biopsies because you were just sort of biopsying as much as you can. There's probably no big advantage, as Dr. Williams has explained very well. There are a couple of studies that tell us that if you look at a conglomerate of all the random biopsies we used to do in the past, sometimes we pick out areas of dysplastic changes. Now, these are retrospective. They don't tell us whether there was simmering inflammation and everything else, but by and large, look for targeted biopsies and non-targeted biopsies and stay away from the non-targeted if you don't have to do them. And a follow-up question is, what if you find dysplasia on a quote-unquote targeted biopsy? I was going to say I cry, but no, that's not completely true, but that can be problematic. I mean, it's very rare. Honestly, there's only a few instances, I think. And it was often in the setting of bad prep where a truly random biopsy has revealed significant dysplasia. But it is possible. It would be unfortunate for the patient because it would be very difficult, if not impossible. So what I tell patients in that case, and especially if it's multifocal, which once has happened to a patient of mine, is that I would recommend, especially if it's high-grade dysplasia, I would recommend surgery. Often patients are not ready for that. They want you to do another scope. It is absolutely important to tell patients that that will not remove the report, the dysplasia that we already had. If anything, it will confirm it. But if you don't find findings, I still recommend surgery. Sometimes that's what patients need to feel more comfortable. But I think that's an important concept as well. Once you find high-grade dysplasia, you can't unfind it as much as the patient would like you to with repeated procedures. Do you think we have time for one more question? It's 8.59. One minute. All right. So this is a personal question of mine. So, you know, and for you, Dr. Williams, since we work on these transition patients together, you know, how do you approach colon cancer surveillance in our IBD transition patients, you know, especially if they were diagnosed earlier in life, say around five years old or so, you know, they're coming into adulthood, and now you're telling them, oh, now we got to keep scoping them. And now you're telling them, oh, now we got to keep scoping you all the time. How do you approach that? Yeah, of course, you give me the tough one. But, you know, again, I'm going to say it depends because it does depend. It does depend, right? So if I have a young person who had extremely severe disease that was very poorly controlled, so the patient who I had a patient from an Amish family where they did not treat the young woman for many, many years, you know that they've had a huge burden of inflammation. And we know that the burden of inflammation is associated with the risk of dysplasia. So in that patient, once they've had eight years of disease, and I will be very careful with them, obviously, in patients with PSC, and we do see young people with PSC, we definitely do those colonoscopies every year, and a patient with a lot of pseudopoems. Now, where I kind of have changed a little bit because it is difficult for a teenager is you don't want to completely alienate them from care either. So that's sometimes where I veer on my European roots and go towards the British guidelines, that if a patient has had very well-controlled disease, even if it's beyond eight years, we can sometimes extend our intervals, not every two years, but every three to five years, especially if they've been treating with, you know, some of our little children have been treated with anti-TNF starting at age five, and they've been extremely well-controlled. I think in those cases, we need to think about, one, are we going to completely alienate a patient by immediately scoping them and bringing them to the adult unit, which is a very different experience, and two, do we really need as much screening in that case? Now, I do think the duration of the disease, no matter what age you were when you started, and usually children can have a more severe course, I'm still careful, but there have been cases where I've seen patients with very, very mild courses where I have extended the interval, because you need to know that they are going to have colonoscopies until we have a test like the fecal calprotectin to detect dysplasia. They are signing themselves up for a lifetime of colonoscopies. So in that case, I will go a little bit towards the British guidelines of extending those intervals. So really, it does depend. It really depends on the severity of the disease, the duration of their getting treatment versus non-treatment, and where they are at the present time. Thank you, Michelle. There is hope, though, for all of you bright people coming up. So there is something we call field effect. So there are some preliminary studies where you can take samples from the rectum, and in some of these people who have precancerous changes further up a field, there are some initial studies which are not ready for clinical work yet where you can detect field effect in the rectum. So if you have that showing up, then it tells you that those are the people that you can follow up. I recall Randy Brand from the University of Pittsburgh was leading a group to look at that, but I think it's way down the line. So keep the hope alive. We're counting on you and Naroz and people like you to come up and move it along. So thank you. Thank you. Thank you. Thank you again, Dr. Williams, Dr. Clark, Dr. Rosario, Dr. Saez for tonight's excellent presentation in IBD. Before we close out, I just want to let the audience know that our next Endo Henga will take place on Thursday, September 2nd at 7 p.m. Central Daylight Time. We will confirm the topic and open registration in just a few days. Also, to check the quality of this presentation, we have added a very short survey to the networking lounge of the virtual platform. Your experience with these learning events is important to AASG, and we want to make sure we are offering interactive sessions such as this one that fit your educational need. At the conclusion of this webinar, if you could just go to the networking lounge and take the survey, we would greatly appreciate it. And as a final reminder, if AASG 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 make sure to sign up to get all the AASG membership benefits. In closing, again, thank you to our panelists and moderators for this excellent presentation, 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 good night, everyone.

endoscopic evaluation

management

inflammatory bowel disease

IBD

endoscopic findings

scoring systems

C. difficile infections

strictures

colon cancer surveillance

thorough evaluation