patients with inflammatory bowel disease. Dr. Tuske is an Associate Professor of Medicine at the University of Virginia and the Director of the Inflammatory Bowel Disease Program there and the Quality Liaison for the Division of Gastroenterology at UVA. And she currently serves as a member of the ASGE Quality Assurance and DOSB Committee. And so we're really lucky to have her here today. And with that, let's queue you up for your talk. I would like to thank the Course Directors, Dr. Skeswani and Shaka, for inviting me to speak to you today on endoscopy considerations in patients with IBD. I have no disclosures that are relevant to this talk. I am a local site PI on several multi-centered, industry-sponsored clinical trials. During this talk today, I plan to discuss the role of endoscopy in the management of ulcerative colitis and Crohn's disease, review the importance of standardization of language and procedure reports, and when and how to perform surveillance colonoscopy and IBD. Endoscopy is essential in the diagnosis and management of patients with inflammatory bowel disease. Endoscopy is used to make the diagnosis of ulcerative colitis or Crohn's disease in a patient presenting with concerning symptoms, such as bloody diarrhea or abdominal pain. Endoscopy is also used to assess disease activity. It can be used in flares if there is a discordance between patient symptoms and biomarkers, like C-reactive protein and fecal calprotectin. It is also used to assess response to therapy and guide therapy adjustments. In fact, endoscopic remission or mucosal healing is a treatment target in IBD, in addition to clinical remission. Lastly, endoscopy is used for surveillance for colorectal cancer. Now I want to pivot to talk about standardization of reporting language. Ideally, IBD phenotype should be classified according to validated classification systems, and the documentation of endoscopic disease activity should be standardized. The Montreal Classification System for Classifying Disease Extent in Adults with Ulcerative Colitis and Crohn's Disease has been endorsed by both ECHO and the British Society for Gastroenterology. This is actually built-in, but optional, section under the patient profile in my endoscopy reporting system, Probation. No consensus exists for endoscopic disease severity scores. In my practice, I use the simple endoscopic score for Crohn's and the UC Mayo score, both of which are built into my endoscopy reporting system. The endoscopy software that uses standard report templates and dropdown menus can improve reporting by standardizing structure and terminology. While it's advantageous, I think we can all agree that no two inflamed colons are alike, and thus detail is also invaluable in IBD reporting. So I want to make sure that I am also not discouraging you from using descriptive prose, but rather encouraging you to include a standardized scoring system in your procedures so that we can all be speaking the same language. Rett-Gerdt's anastomotic score has an established role in the postoperative evaluation of ileocolonic Crohn's disease. It allows us to identify patients who are high risk for symptomatic recurrence and worse outcomes. This is also built into my endoscopy reporting system, and I use for all of my postoperative endoscopic procedures. In the final portion of my talk, I want to review the role of surveillance colonoscopy and IBD, and when and how to perform a surveillance exam. Patients with ulcerative colitis and Crohn's colitis are at a two to three-fold greater risk of developing colon cancer than the general population. The risk of colon cancer is almost two times higher in IBD colitis, but what factors influence that risk? Well, first there are disease-related factors such as extensive colitis, duration of disease, severity of inflammation, the overall cumulative inflammatory burden, structural alterations as a consequence of chronic inflammation such as pseudopolyps, stricture, or a shortened tubular colon. There are also patient-related factors, including a prior history of dysplasia, family history of colorectal cancer and a first-degree relative, primary sclerosing cholangitis. So patients with PSC and IBD are at increased risk of colorectal cancer and colonic dysplasia. In one case control study, the cumulative absolute risk of colon cancer or dysplasia after 25 years of colitis in patients with PSC and UC was 50% compared to 10% in patients who had UC alone. Despite the lack of randomized controlled trials, surveillance colonoscopy is recommended by multiple societies and is the standard of care with a goal of detecting dysplasia and reducing mortality in those who develop colon cancer. In a large cohort study of IBD patients, the incidence of colorectal cancer was higher in those who did not have a colonoscopy within three to 36 months of the diagnosis compared to those who did have surveillance. The same study also demonstrated improved survival in patients with IBD undergoing colonoscopy compared to those without surveillance. So who should undergo surveillance? Well, patients with ulcerative colitis with disease proximal to the rectum and patients with Crohn's colitis involving at least a third of the colon. When should these patients undergo surveillance? They should begin screening exams eight years after diagnosis and at the time of diagnosis for patients who have concurrent PSC. And how often? So well, surveillance colonoscopy should be performed every one to three years based on the risk factors and finding on prior exam and patients with concurrent PSC should undergo annual surveillance. Fecal DNA testing and CT colonography are not recommended for the screening or surveillance in IBD. High definition colonoscopy is the standard of care. Otherwise, the optimal method for endoscopic surveillance is still debated and may vary based on patient factors. The surveillance for colorectal endoscopic neoplasia detection and management and inflammatory bowel disease, Patients' International Consensus or CINIC Panel recommended chromoendoscopy over high definition white light. The CINIC guidelines did not recommend virtual chromoendoscopy like MBI. The guidelines did recommend surveillance over collectivity for endoscopically resectable dysplasia and recommended surgery for management of endoscopically unresectable lesions. Lastly, the guidelines recommended high definition dichromoendoscopy for all patients with invisible dysplasia. The image on the right shows a lesion photographed with high definition white light and then after methylene blue dye spray. You can see now how the borders are more distinct. The most recent of many guidelines on surveillance are the UC Practice Guidelines for Dysplasia Screening and Surveillance from the American College of Gastroenterology published in 2019. As you can see, they recommend that when using high definition colonoscopes, they suggest white light endoscopy with narrow band imaging or dye spray chromoendoscopy with methylene blue or indigo carmine to identify dysplasia. Guidelines felt it was unclear whether segmental random biopsies are still required during surveillance, colonoscopy in UC, but similar to the CINIC guidelines felt that when dysplasia is not resectable or is multifocal, a patient should be referred for proctocolectomy. This is a busy slide, but the takeaway here is that older studies compared NBI to white light for dysplasia detection and colitis found no benefit when using NBI, which is why NBI is not recommended in the CINIC guidelines. However, the newer studies from 2018 suggest that virtual chromoendoscopy or NBI was as good as either high definition white light colonoscopy or dye chromoendoscopy, which is why it was included in the ECG recommendations. This image here shows the use of dye chromoendoscopy. Methylene blue was used in this instance. It unmasks flat lesions. You can see here in the first image, and then after the blue dye spray application, the neoplastic and non-neoplastic tissue is differentiated based on the staining pit patterns. So dye chromoendoscopy can be performed in the whole colon or targeted for better visualization of a certain lesion. It can be performed using indigo carmine or methylene blue. The dye can be sprayed using the spray catheter or the water jet channel using the auxiliary foot pump. In my practice, I use methylene blue through the water jet channel. I clean the colon on insertion. It must be an excellent prep, so a Boston bowel prep score of nine. I start dye spraying in the cecum, and I perform pan-chromoendoscopy by section. I take targeted biopsies, but if a patient has primary sclerosing cholangitis, a history of previous dysplasia, or a tubular colon, or if I am also performing the exam to document disease activity, I will also take random biopsies in addition. At the end of the procedure, the water bottle and all of the tubing is placed prior to the next procedure. So what is the yield of adding random biopsies in addition to targeted biopsies with chromoendoscopy? With this slide, I wanted to highlight two studies to address that question. The first is a study looking at 1,000 patients with IBD who underwent 1,000 scopes with chromoendoscopy. 140 dysplastic sites were identified in 94 patients. 80% of these were found on targeted biopsies, but 20% were found on random biopsies. Looking at risk factors for development of dysplasia, they found a personal history of dysplasia, tubular appearing colon, and PSC were all noted to be risk factors for finding dysplasia on exam. In the second study, 305 patients with IBD underwent high-definition chromoendoscopy versus high-definition white light endoscopy. Chromoendoscopy had a significantly higher yield of visible dysplastic lesions compared to high-definition white light, but random biopsies found dysplasia in both groups. Again, the risk factors for finding dysplasia, a third of these patients with dysplasia on random biopsies had primary sclerosing cholangitis. So consider taking random in addition to targeted biopsies for patients who have a history of PSC or with a tubular appearing colon or those patients who have a prior history of dysplasia. So how can you incorporate IBD surveillance into your practice? Well, in my practice, we created a separate order for IBD surveillance. So those cases stand apart from other procedures. This allows us to schedule the cases in one-hour blocks. It's also important to ensure that you have trained nursing and tech staff and ensure available equipment. When I first entered practice, I was using the spray catheter, but often there were disruptions in the case when the catheter could not be found or couldn't be set up appropriately. I've since changed to methylene blue in the water that I dispense using the foot pump. There was a national shortage for methylene blue. So in the past, I had to check with the pharmacy in advance of scheduling a chromo case, but now I need to let the nurse know to pull it from the Pyxis in advance. Given these variables and variations, even in how I perform surveillance exams compared to my partners, I think a quick team huddle prior to the procedure is essential. In advance of the case, I try to let the team know what I am planning with biopsies. Will it be targeted, targeted plus random? So the bottles are already ready. All of this has made the incorporation of chromoendoscopy into my practice very easy. This slide shows the recommended terminology for reporting findings on colonoscopic surveillance of patients with IBD as modified from the Paris classification. Describe lesions as polypoid or non-polypoid. Include location. Is the lesion within or outside an area of known colitis? Are the borders distinct or indistinct? And is there the presence of ulceration or other features of submucosal invasion? Think of lesions as resectable or unresectable and consider referral to interventional endoscopist for the removal of any large flat lesions with EMR or ESD rather than referral to surgery for colectomy. Remember that dysplasia when found should be confirmed by a second GI pathologist. And remember that patients with invisible dysplasia on random biopsy should be referred for high definition chromoendoscopy at an expert IBD center. We've already talked about patient and disease-related factors. Now let's talk about dysplasia-related factors. Grade. So high-grade dysplasia imparts a greater risk than low-grade or indefinite dysplasia. Is the lesion visible or invisible? Are the borders distinct or indistinct? And overall, is this lesion endoscopically resectable or not resectable? Also, is the dysplasia unifocal or multifocal? And are we talking about dysplasia on a single exam or is this a patient who has had dysplasia found on serial exams? In ulcerative colitis, if dysplasia is unresectable or multifocal, the patient should be referred for a total proctocolectomy. After total proctocolectomy though, patients are not done with surveillance. In fact, if proctocolectomy was performed for dysplasia, then patients should undergo pouch surveillance one year later and annually thereafter. A complete pouchoscopy exam should include examination of the rectal cuff, the pouch, and the pre-pouch ileum. I will also perform retroflexion in the pouch. The pouchoscopy may be indicated for symptoms to evaluate for cuffitis, pouchitis, or Crohn's disease of the pouch, in addition to surveillance. The algorithm on the right is from Bo Shen and colleagues. They recommended surveillance pouchoscopy every one to three years, beginning 10 years after the initial diagnosis of UC in patients without risk factors. In high-risk patients, such as those with chronic pouchitis or cuffitis, family history of colorectal cancer and a first-degree relative, or PSC, pouchoscopy with biopsy should be done every one to two years. And in patients who have undergone total proctocolectomy because of preoperative neoplasia, they should undergo annual pouchoscopy with a focus on the cuff or the anal transition zone. So in summary, endoscopy is essential in the diagnosis, management, and surveillance of patients with IBD. Utilize standard endoscopic disease severity scores in your procedure notes and standard terminology for describing dysplastic lesions. Patients with UC and Crohn's colitis should undergo surveillance exams of the colon or pouch every one to three years, starting eight years after diagnosis. And I recommend a brief team huddle prior to IBD surveillance exams to allow everyone to get on the same page and ensure available equipment.

endoscopy

inflammatory bowel disease

surveillance

Montreal Classification System

chromoendoscopy