Northeast Florida Medicine Journal, Winter 2015

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DCMS online. org Northeast Florida Medicine Vol. 66, No. 4 2015 23
Inflammatory Bowel Disease
Endoscopy in Diagnosis of IBD
One of the most important components in diagnosis
of IBD is the information gathered from endoscopy.
Location and pattern of inflammation, in addition to the
shape, depth and appearance of the ulcerations, are some
of the information gathered during endoscopy that helps
in accurate diagnosis. Endoscopic biopsy, although rarely
definitive in IBD, can help to rule out other disorders.
Normal mucosal biopsies effectively exclude active IBD.
In ulcerative colitis (UC), inflammation almost always
starts proximal to the anal verge and extends proximally
in a continuous, confluent and concentric fashion. In
comparison, Crohn’s Disease (CD) inflammation typically
has a patchy distribution with skipped lesions (areas
of inflammation interposed between normal appearing
mucosa). Rectal sparing has been described in children
presenting with UC prior to treatment.1,2,3 In adults with
UC a normal or patchy inflammation in the rectum is
more likely due to previous topical therapy.4
Mucosal ulcerations in CD can be longitudinal, linear,
or appear as multiple aphthous ulcers.5,6 In contrast,
ulcers in UC tend to be more superficial. Strictures are
exceedingly rare in UC and should raise the possibility of
CD or underlying malignancy. None of the endoscopic
features are specific for UC or CD. Biopsies taken from the
edges of ulcers increase the chance of detecting granulomas,
which are pathognomonic in CD.7
Upper Gastrointestinal endoscopy is mandatory
in pediatric patients with suspected IBD to confirm
the diagnosis of CD.8 In adults, there are no specific
recommendations regarding performance of upper GI
endoscopy at the time of diagnosis. Upper GI endoscopy
may be important in establishing diagnosis of Crohn’s
disease, to assess disease extension and severity, and to aid
in tailoring the therapy.9 Also, CD patients with dyspepsia,
abdominal pain and vomiting would benefit from upper
GI endoscopy.10 Finally, upper GI endoscopy is mandatory
in patients with suspected concomitant coeliac disease.11
Small bowel capsule endoscopy is instrumental in the early
diagnosis of patients with suspected CD in the absence of
involvement of the colon or terminal ileum. Small bowel
capsule endoscopy is the most sensitive diagnostic test
to detect early small bowel lesions and to exclude small
bowel CD, even in patients with negative cross sectional
imaging studies. 12,13 In cases that cross-sectional imaging
studies or small bowel capsule endoscopy are inconclusive,
device-assisted enteroscopy may be performed to confirm
the diagnosis of CD endoscopically and histologically.
Role of Endoscopy in IBD disease activity
Early achievement andmaintenance of mucosal healing is
considered to change the natural course of CD and prevent
fistula and stricture formation.14,15 The same concept seems
to offer a better prognosis compared to symptomatic control
alone in patients with UC.16,17 Endoscopy is considered the
gold-standard for evaluating disease activity and confirming
mucosal healing. Other markers of active inflammation,
such as increased fecal levels of calprotectin and lactoferrin,
are less sensitive for mucosal healing and have been used
as surrogates to monitor disease activity.18
Address correspondence to:
Ali Lankarani, MD
Advanced Therapeutic Endoscopy Center
Borland Groover Clinic
4800 Belfort Road
Jacksonville, FL 32256
Advanced Endoscopy and Inflammatory Bowel Disease:
Beginning of a New Era
By Ali Lankarani, MD
Abstract: Diagnosis of inflammatory bowel disease (IBD) is possible
with the information gathered from a patient’s history, laboratory
and imaging studies, and endoscopic findings. With recent advances
in endoscopic technology and newer endoscopic techniques, the role
of endoscopy has evolved from only a diagnostic tool to an essential
modality for monitoring IBD activity, surveying for complications
associated with longstanding IBD, and as a therapeutic tool. The role
of endoscopy with Crohn’s disease (CD) and ulcerative colitis (UC)
continues to evolve.