Clinical Utility of Mucosal Healing in Patients with Pouchitis

Abstract

Purpose: Mucosal healing as an endpoint has been included in recent clinical trials in IBD, although consensus on the definition of endoscopic mucosal healing has yet to be developed and validated. Clinical utility of mucosal healing in patients with pouchitis has not been investigated. We hypothesized that endoscopic mucosal healing may provide additional diagnostic and prognostic information in patients with pouchitis. Our aim is to assess correlation between endoscopic mucosal healing and inflammation scores on pouch endoscopy and symptoms scores.Table: Correlation between mucosal ulceration scores and the PDAI scoresMethods: Medical records of 43 consecutive patients from our subspecialty Pouchitis Clinic Database were reviewed. Inclusion criteria were patients with ileal pouch-anal anastomosis (IPAA) for IBD and history of pouchitis with antibiotic therapy. Ulcers of the pouch on endoscopy were re-evaluated in a blinded fashion and scored before and after antibiotic treatment. The ulcer score 0 = no ulcers in the pouch, score 1 = ulcers in <50% pouch area, and score 2 = ulcers in >50% pouch area. Modified Pouchitis Disease Activity Index (PDAI,range 0 - 12), PDAI endoscopy score (range 0 - 6), and PDAI symptom scores (range 0 - 6) were used (Sandborn Mayo Clinic Proceeding 1994; Shen Dis Colon Rectum 2003). Thirteen demographic and clinical variables were evaluated. The Spearman correlation coefficients were used. Results: Among 43 patients analyzed, 70% were male. The mean age was 49 ± 13 years, with a mean duration of IBD of 18 ± 11 years, and mean duration of the pouch of 10 ± 6 years. 23 patients had repeated pouchoscopy post treatment for the 2nd time, 10 patients for the 3rd time, and 6 patients for the 4th time. The ulcer score was positively correlated with PDAI endoscopy score in patients evaluated at the baseline before treatment, 1st and 2nd post-treatment pouchoscopy. However, the correlation was not significant for the 3rd and 4th post-treatment pouchoscopy, which might be due to the small sample size. There was consistent positive correlation between mucosal ulceration score and modified PDAI scores from all 5 stages of evaluation. The correlation between ulceration score and PDAI symptom score fell into a wide range. Conclusion: Mucosal healing on pouch endoscopy appeared to be correlated with modified PDAI scores and PDAI endoscopy scores, but not well correlated with PDAI symptom scores. Since all 6 components (edema, granularity, friability, loss of vascular pattern, mucous exudates, and ulceration) of the PDAI endoscopy score are not inherently weighted, mucosal healing or ulcer scores may provide additional information for diagnosis and prognosis of pouchitis and may serve a more objective marker for future clinical trials.