Introduction

The appropriateness of lower gastrointestinal (GI) endoscopy in patients with inflammatory bowel disease (IBD) is a key issue in endoscopic practice, especially given limited healthcare resources, the growing demand for endoscopic procedures, and the increasing prevalence of IBD. While numerous studies have examined the appropriateness of endoscopy, particularly upper GI endoscopic procedures, in general gastrointestinal disorders,^{[1, 2]} there is a relative lack of literature specifically addressing the appropriateness of lower GI endoscopy in patients with IBD.^{[3, 4]}

Aims & Methods

This study aimed to evaluate the appropriateness of lower GI endoscopic examinations in patients with IBD at a tertiary referral center. Secondary objectives were identifying reasons for inappropriateness and assessing the presence of clinically significant pathological findings in inappropriate procedures. This was a prospective, observational, monocentric study including all adult patients affected by IBD who underwent lower GI endoscopy at a tertiary referral center between September 2024 and April 2025, with a confirmed IBD diagnosis for at least six months. Data collected included IBD subtype, endoscopic procedure appropriateness based on the 2023 ECCO Guidelines,^[5] and endoscopic/histological findings.

Results

Among 406 endoscopic procedures, 26 were excluded from the analysis due to inappropriate timing resulting from patients lost to follow-up. Therefore, a total of 380 IBD patients were included (mean age 52.9 ± 15.1 years; 57% male). Among them, 135 (35.5%) had Crohn’s disease (CD), 176 (46.3%) ulcerative colitis (UC), 60 (15.8%) ileal pouch, and 9 (2.4%) unclassified IBD (IBD-U). Lower endoscopic procedures included colonoscopy (256, 67.4%), rectosigmoidoscopy (61, 16.1%), pouchoscopy (60, 15.8%), and trans-stomal ileoscopy (3, 0.8%). Overall, 308 procedures (81.1%) were deemed appropriate. Appropriateness was higher in CD (115/135, 85.2%), in UC (147/176, 83.5%) and IBD-U (8/9, 88.9%), and lower in ileal pouch (38/60, 63.3%). Between the different endoscopic procedures, rectosigmoidoscopy showed the highest appropriateness (56/61, 91.8%), followed by colonoscopy (213/256, 83.2%), pouchoscopy (38/60, 63.3%), and trans-stomal ileoscopy (1/3, 33.3%). Among the 72 inappropriate procedures (18.9%), 23 (31.9%) were performed too early, 20 (27.8%) too late, 27 (37.5%) were unwarranted, and 2 (2.8%) were improper endoscopic procedures. Most early procedures were prescribed by physicians (78.3%), while the remaining (21.7%) were requested by patients. Despite being considered inappropriate, 27 of the 72 examinations (37.5%) revealed endoscopic pathological findings, and 17 (23.6%) led to clinically relevant conclusions (based on both endoscopic and histological findings), including 4 cases of dysplasia. It is noteworthy that, among the inappropriate examinations that led to clinically relevant conclusions, almost 60% were performed either too early or were considered unwarranted, while only the remaining 40% were performed too late.

Conclusion

The appropriateness of lower gastrointestinal endoscopy in patients affected by IBD was found to be nearly 80% in a tertiary referral center. Notably, among the examinations classified as inappropriate, roughly 24% revealed clinically relevant findings based on both endoscopic and histological report. A greater spread and awareness among physicians of the latest international guidelines on IBD management could improve the appropriateness of endoscopic procedure prescriptions, while reducing waiting lists and related healthcare costs.

References

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2. Bohara TP, Laudari U, Thapa A, Rupakheti S, Joshi MR. Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding. JNMA J Nepal Med Assoc. 2018 Jan-Feb;56(209):504-509. PMID: 30058633; PMCID: PMC8997324.
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