Introduction

Endoscopy is still the gold-standard to assess disease activity in Crohn's disease (CD). Its invasiveness, acceptability and cost limit its use in the era of tight control and treat-to-target. Fecal calprotectin and intestinal ultrasound (IUS) are non-invasive alternatives to colonoscopy to assess disease activity. The objective of this study was to evaluate the performance of IUS and fecal calprotectin to assess mucosal healing in CD.

Aims & Methods

All consecutive CD patients who underwent colonoscopy for mucosal healing assessment and IUS and/or calprotectin within 4 weeks between September 2019 and April 2022 were included in a prospective cohort. Bowel wall thickness (BWT) and color doppler signal (CDS) were assessed on each segment. Endoscopic mucosal healing was defined by a CDEIS score < 3.

Results

A total of 153 patients were included, of whom 122 had endoscopic mucosal healing. Eighty-two (53.6%) were female, the median age and disease duration were respectively 36 years (IQR, 28-46) and 10 years (IQR, 4-19). Respectively 56 (56/120, 46.7%) and 93 (93/120, 77.5%) patients presented a BWT < 3 mm and an absence of CDS. The sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of BWT < 3 mm to predict endoscopic mucosal healing were 56%, 88%, 95% and 36% (patients misclassified as endoscopic mucosal healing 2.5%). The association of an absent of CDS with a normal BWT did not modify the performances. For a calprotectin < 250 µg/g , The Se, Sp, PPV and NPV were respectively 91%, 63%, 90% and 67% for (patients misclassified 8%). The association of a calprotectin < 250 µg/g, with a BWT < 3 mm and the absence of CDS increased the specificity and the PPV (Se 58%, Sp 95%, PPV 97%, VPN 43%, patients misclassified 1%).

Conclusion

Ultrasound is an efficient non-invasive tool to identify patients with Crohn's disease who have achieved endoscopic mucosal healing.

Introduction

In the "treat-to-target" era, the development of non-invasive markers to assess endoscopic healing in ulcerative colitis (UC) is essential. Fecal calprotectin (FC) and intestinal ultrasound (IUS) are alternatives to colonoscopy to assess UC activity. The objective of this study was to evaluate the performance of IUS and FC to assess endoscopic mucosal healing in UC patient.

Aims & Methods

All consecutive patients between January 2021 and August 2022 with UC who underwent (1) a complete colonoscopy (2) an intestinal ultrasound and/or (3) a fecal calprotectin (4) within 4 weeks were included in a prospective cohort. Bowel wall thickness (BWT) and color doppler signal (CDS) were assessed on each segment. Endoscopic mucosal healing was defined by a MAYO score of 0-1.

Results

A total of 57 patients were included, 57.9% had endoscopic healing (22/57 MAYO 0 and 11/57 MAYO 1). Thirty-two (56.1%) were female, the median age and disease duration were respectively 43 years (IQR, 30-58) and 29 years (IQR, 18-39). Respectively 16 (16/57, 28.1%) and 41 (41/57, 71.9%) patients had BWT < 3 mm and an absence of Doppler signal. The sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of BWT < 3 mm to predict endoscopic mucosal healing were 37%, 77%, 72% and 44%. The association of the absence of CDS with normal BWT did not modify these performances. The same values for fecal calprotectin < 150 µg/g were respectively 81%, 78%, 84% and 74%. The association of a fecal calprotectin < 150 µg/g, with a BWT < 3mm and the absence of Doppler signal increased the specificity and the PPV (Se 33%, Sp 94%, PPV 89%, VPN 48%). The same values were found for patients classified as MAYO 0 or MAYO 0-1 .

Conclusion

The combination of intestinal ultrasound and fecal calprotectin is effective to identify endoscopic mucosal healing in UC. A stricter definition of ultrasound healing could improve the performance of this tool.

Disclosure

No disclosure with this abstract

Introduction

The STRIDE II guidelines recognize endoscopic healing as one of the main therapeutic targets in Crohn's disease (CD). Nevertheless, transmural healing could reduce the risk of long-term complications. The aim of this study was to assess the risk of long-term complications in CD according to the degree of endoscopic and ultrasound healing.

Aims & Methods

We conducted a prospective study that included all patients with CD in clinical remission who underwent colonoscopy with endoscopic healing (CDEIS <4) and intestinal ultrasound (IUS) within 4 weeks between September 2019 and September 2022. IUS transmural healing was defined by a parietal thickness < 3 mm on all digestive segments (colonic and ileal) without color doppler signal.
The primary endpoint was CD relapse, defined as the need for drug intensification, initiation of corticosteroid therapy, CD-related hospitalization, development of a perianal and luminal fistula or abscess, or the need CD-related bowel surgery. Patients were followed up at least every 6 months for two years.

Results

A total of 93 patients were included, the majority of whom were women (53%) with ileocolonic location (43%). The median disease duration was 12 years (IQR, 4-19) and 71% patients were treated with anti-TNF. Ultrasound transmural healing was observed in 73% (68/93) of patients. After a median follow-up of 22.5 months [IQR, 19.3-23.7] 26% of patients have relapsed. The risk of relapse was significantly higher among patients IUS activity at 6 and 12 months (13% vs. 5% and 24% vs 8 % p = 0.007). In multivariate analysis, the risk of relapse was 3 times higher without IUS transmural healing (HR 3.07 (1.35-9.97); p = 0.007). Among patients with a complete endoscopic healing (CDEIS 0) the relapse rate were also significantly higher among patients with IUS activity compared to those with IUS healing (HR 3.65 (1.06-12.8); p =0.040).

Conclusion

IUS transmural healing was associated with a lower risk of relapse among patients with endoscopic healing and could be considered as a non-invasive therapeutic target in CD.

Introduction

Crohn's disease (CD) is associated with disability by affecting physical and emotional well-being, and by altering social interactions. In the era of treat to target, endoscopic remission has become the therapeutic target to prevent parietal destruction and disability. A deeper remission such as transmural healing would reduce long-term complications related to CD. The impact of transmural healing on disability is currently unknown.

Aims & Methods

We conducted a monocentric cross-sectional study between September 2019 and January 2022. Patients followed for CD in endoscopic remission (CDEIS <4) who underwent within < 4 weeks an intestinal ultrasound (IUS) and a disability assessment by an IBD-disk were consecutively included. Four groups were considered: (A) transmural healing defined by the combination of complete endoscopic healing (CDEIS=0) and ultrasound healing (bowel wall thickness (BWT) less than 3 mm), (B) complete endoscopic healing, (C) ultrasound healing and (D) no healing. Moderate to severe disability was defined as an overall score ≥ 40.

Results

A total of 85 patients were included. Forty-four (51.7%) were female, the median age and disease duration were respectively 38 years (interquartile range [IQR], 33-44) and 12.0 years (IQR, 5-20). There was no difference between the four groups in terms of age, sex, BMI, smoking status, disease location or phenotype or number of biologics failure. The median global IBD-Disk score was 25 (IQR, 9-41) and 24 patients (28.2%) had moderate to severe disability. Transmural healing (group A) was observed in 40 patients (47.1%). Moderate to severe disability was identified in 17.5% (7/40) of patients with transmural healing, 25% (4/16) with endoscopic healing, 44.4% (8/18) with ultrasound healing and 45.4 % (5/11) without healing. In univariate analysis, transmural healing reduced the risk of severe disability (group C vs A OR = 3.77, 95% CI [1.10, 13.45], p = 0.035), group D vs A OR = 3 .75, 95% CI [0.91, 17.12], p=0.063). There was no difference in terms of severe disability between patients with transmural healing and complete endoscopic healing (group B versus A OR = 1.57 95% CI [0.36, 6.23], p = 0.525)

Conclusion

Transmural healing did not provide any benefit in terms of disability compared to complete endoscopic healing. Mucosal healing therefore remains the objective to be achieved in order to reduce the risk of short-term disability.

Introduction

The STRIDE II guidelines recognize endoscopic healing (EH), defined by an SES-CD score ≤2 or a CDEIS score <3, as one of the main therapeutic targets in Crohn's disease (CD). Nevertheless, complete EH could reduce the risk of long-term complications in CD. The aim of this study was to assess the risk of long-term complications in CD according to the degree of EH achieved.

Aims & Methods

We conducted a prospective multicenter study that included all patients with CD undergoing colonoscopy for EH assessment between September 2019 and September 2022 in three centers and were compared outcomes of patients with complete EH (CDEIS = 0) vs partial EH (CDEIS greater than 0 but less than 4). The primary endpoint was therapeutic failure, defined as the need for drug intensification and/or corticosteroid initiation and/or CD-related hospitalization and/or development of a luminal strictures/fistula and/or perianal CD and/or the need for intestinal resection.

Results

A total of 128 patients were included with a median disease duration of 10 (IQR, 4-18) years. Fifty-six (43%) patients had ileocolonic location and 79 (62%) an inflammatory (B1) behavior. Patients had been on treatment for a median of 12 months (8.3-24.3) prior to colonoscopy and 81 (63%) patients had complete EH. After a median follow-up of 22.5 months [IQR, 19.3-23.7], therapeutic failure was observed in 40 patients (31%). The risk of therapeutic failure was significantly higher among patients with partial EH group (25% vs. 43% p = 0.036, HR = 1.90; IC95% = [1.02 - 3.53]; p=0.043). The risk of CD-related hospitalizations (2.5% vs. 17%), p=0.005, HR= 7.09; IC95% = [1.51 – 33.4]; p=0.013) was significantly higher in patients with partial EH. The risk of intestinal resection, steroid initiation and drug intensification among patients with complete and partial EH, were 0% vs. 4.3% (p=0.13), 2.5% vs. 11% (p=0.1) and 22% vs. 36% (p=0.088), respectively.

Conclusion

This prospective multicenter study confirms that complete endoscopic healing is associated with better long-term outcomes than partial endoscopic healing in patients with CD, as well as fewer hospitalizations and an overall decreased risk of treatment failure.

Introduction

At the time of treat to target, endoscopic healing is the goal to achieve in ulcerative colitis (UC). Colonoscopy (CO), rectosigmoidoscopy (RS) or rectoscopy can be performed to assess endoscopic healing. The objective of this study was to compare the performance of rectosigmoidoscopy with colonoscopy to predict endoscopic healing (EH) and histological healing.

Aims & Methods

This is a monocentric, prospective cohort of UC patients. All UC patients with a total colonoscopy were included between January 2021 and January 2023. Endoscopic and histological activity were measured using the MAYO endoscopic scores on each colonic segment and the Nancy Score, respectively. The correlation between RS or rectoscopy alone and CO in terms of endoscopic and histological mucosal healing was assessed using Cohen's kappa coefficient.
The study population was calculated according to the following assumptions: (1) absence of rectosigmoidoscopy lesions if absence of total colonoscopy lesions (0%), (2) 10% of lesions not seen in RS, (3) expected difference of 10% between CT and RS. 80 patients had to be included to demonstrate a significant difference in terms of EH between RS and CT with a bilateral alpha risk of 5% and a power of 81%.

Results

80 patients were included. 34 patients were MAYO 0 in RS and CO, 44 were not healed in RS and CO.. The correlation between the two exams was almost perfect with an index к of 0.949 (p=0) for MAYO 0 (2 patients misclassified), and к of 0.945 (p=0) for MAYO 0-1. The correlation between histological healing in RS and CO was almost perfect (к=0.877, p<0.001). Additionally, the correlation between rectoscopy and CT for the evaluation of mucosal healing MAYO 0 and histological healing was almost perfect (к=0.826 (p < 0.001) and к=0.8 (p < 0.001), respectively.

Conclusion

RS is sufficient in UC to assess both endoscopic mucosal healing (whether defined by a Mayo score of 0 or 1) and histological healing. With a false negative rate < 10%, rectoscopy could be a less invasive exam to assess healing in UC.

Introduction

Ileocolonoscopy and Rutgeerts endoscopic score (RS) remains the gold standard to evaluate post-operative recurrence (POR) in Crohn's disease (CD). Intestinal ultrasound (IUS) is proposed as a non-invasive alternative for the diagnosis of POR, with a sensitivity of 89%, specificity of 86% and area under curve (AUC) of 0.93 (1). Bowel wall thickness (BWT) alone has a high accuracy in the diagnosis of POR and it is proposed that the association of other parameters such as hyperemia, loss of bowel wall stratification, involvement of mesenteric fat (i-fat) or ultrasound scores, increases sensitivity and specificity in the diagnosis of POR (2).

Aims & Methods

The aim of this study is to assess whether IUS parameters and ultrasound scores correlate with endoscopy in the diagnosis of POR. A unicentric retrospective study was performed. There were included patients with CD with both an ileocolonoscopy and intestinal ultrasound performed for the detection of POR, the time between tests was less than 6 months or there was no therapeutic change between tests.
Endoscopic POR was evaluated with Rutgeers score (RS), RS i0 and i1 was considered no POR and RS ≥i2a was POR. The IUS parameters were: BWT, Limberg Score, bowel wall stratification, inflammation of mesenteric fat, Simple US Score, SUS-CD and IBUS-SAS score.

Results

129 patients were included, baseline characteristics are in Table 1. In 108 patients (83.7%) the time between test was <6 months and in 21 (16.3%) >6 months without therapeutic changes. 38 (29.7%) were classified as endoscopic POR (RS i0 – i1) and 90 (69.8%) as POR: 28 (21.2%) i2a, 17 (13.3%) i2b and 45 (35.1%) severe (RS i3 – i4). With IUS, 42 patients (32.6%) were classified as no POR and 87 (67.4%) as POR. The mean BWT by IUS in patients without endoscopic POR was 2.6 mm (SD +/- 1.2) versus 4.8 (SD +/- 1.6) in patients with RS ≥i2a (p 0.001). BWT ≥3 had a sensitivity of 86.6%, specificity 78.9% and AUC of 0.83 in the diagnosis of POR. Hyperemia (Limberg ≥1) was present in 75 patients (84.3%) with RS ≥i2a versus in 8 patients (21.1%) without endoscopic POR (p 0.001). 21 patients (23.9%) of patients with RS ≥i2a presented loss of bowel wall stratification versus 0 (0%) with i0-i1 (p 0.001). I-fat was present in 16 patients (12.4%), all of them RS ≥i2a (p 0.02).
The mean results of IUS scores were: Simple Us score 5.6 (SD +/- 2.9), SUS-CD 2.1 (SD +/- 1.8) and IBUS-SAS 31.6 (SD +/- 23.3). In patients without endoscopic POR the mean result of Simple US Score was 3.0 (SD +/- 2.0) versus 6.7 (SD +/- 2.4) in RS ≥i2a (p>0.05). The mean result of SUS-CD without POR was 0.5 (SD +/ 1.0) versus 2.8 (SD +/- 1.5) in POR (p>0.05). In IBUS-SAS the mean result in RS i0-i1 was 13.4 (SD +/- 10.8) versus 39.2 (SD +/- 22.9) in RS ≥i2a (p>0.05). Simple US Score showed an AUC of 0.85 in the diagnosis of POR (95% CI 0.78 – 0.92), SUS-CD of 0.87 (95% CI 0.81 – 0.93) and IBUS-SAS of 0.85 (95% CI 0.77 – 0.92).

Conclusion

In our experience, IUS parameters such as BWT, Limberg score, loss of wall stratification, i-fat and IUS scores (IBUS-SAS, SUS-CD and Simple US Score), have a high accuracy in the diagnosis of POR.

References

1. Barchi, Alberto et al. “Recent advances in the use of ultrasound in Crohn's disease.” Expert review of medical devices vol. 20,12 (2023): 1119-1129. doi:10.1080/17434440.2023.2283166
2. Yung, Diana E et al. “Capsule Endoscopy, Magnetic Resonance Enterography, and Small Bowel Ultrasound for Evaluation of Postoperative Recurrence in Crohn's Disease: Systematic Review and Meta-Analysis.” Inflammatory bowel diseases vol. 24,1 (2017): 93-100. doi:10.1093/ibd/izx027