Increased Risk of Endoscopic Disease Progression With Rutgeertsʼ i2a and i2b Recurrence: Implications for Disease Prevention

Abstract

Introduction: It is standard of care to perform ileocolonoscopy within a year of ileo-colonic resection for CD and to guide management decisions based on the Rutgeerts' score (RS). i2 lesions correlate with increased rates of clinical recurrence of CD when compared to i0 or i1. The modified RS subdivides i2 into lesions confined to the anastomosis (i2a) or over 5 aphthous lesions in the neo-terminal ileum (i2b). There is uncertainty if i2a lesions incur an increased risk of disease recurrence. The aim of this study was to compare the endoscopic progression (EP) of i2a and i2b when compared to i0 and i1. Methods: This was a retrospective single center study including CD patients who had an ileocolonoscopy ≤12 months after ileo-colonic resection and who had >1 year of follow up. Demographic, disease and treatment data were collected. Endoscopic recurrence was determined from the endoscopy report and separately rereviewed based on the images obtained. Discrepancies were resolved by a third investigator. Patients with i3 or i4 RS recurrence at baseline were excluded. For patients with RS i0-i2 (including i2a, i2b), endoscopic progression (EP) was pre-defined as progression of the RS in subsequent colonoscopies to i3 or i4. Results: 180 CD patients (median 37.7 years old (range 14-74)) with a median follow up of 52 months (range 12-145) were included in this study. 91% of patients had either stricturing or penetrating disease prior to surgery and 12% of patients in the cohort had repeat surgery or endoscopic dilation during the follow up period. At index colonoscopy, 79 patients (43.8%) had a RS i0, 29 (16 %) i1, 34 (18.8%) i2a, 25 (13.9%) i2b, 9 (5%) i3 and 4 (2.2%) i4. EP was observed in 3 patients (3.4%) with i0, 2 patients (6%) with i1, 6 patients (17.6%) with i2a and 10 patients (40%) with i2b. Odds of EP were significantly higher with i2a and i2b lesions when compared to i0 or i1 (OR=3.64, 95%CI [1.01,12.94] and OR=11.3 95%CI [11.3,38.1] respectively) Fig 1. Patients with i2b had numerically higher rates of EP when compared to i2a, but this did not reach statistical significance (OR=3.1 95%CI [0.9,10]).694 Figure 1. Comparison of endoscopic progression between i2a, i2b and i0+i1Conclusion: This large study of CD patients demonstrated that both i2a and i2b have a significant risk of progression of disease compared to i0 or i1. We recommend escalation of medical therapy in these patients. Prospective trials to validate these findings are needed.