Endoscopic Mucosal Appearance Research Articles

Progress of ulcerative colitis patients during the COVID-19 pandemic.

We have previously demonstrated that the first wave of the coronavirus disease 2019 (COVID-19) pandemic caused exacerbations in ulcerative colitis (UC) patients, probably through psychological and physical stress. However, successive waves of the COVID-19 pandemic continuously followed the first. The effects of this chronic stress on the disease condition in UC patients are of interest. To clarify the effect of chronic stress from COVID-19 on disease condition in patients aggravated after the first wave. Our previous study investigated 289 consecutive UC outpatients treated in one center during March and April 2020, the period of the first wave of the COVID-19 pandemic. In this study, an identical group of 289 UC patients was evaluated using UC-disease activity index (UC-DAI), endoscopic mucosal appearance score, and Matts pathological grade scoring. Of the 289 UC patients included in the study in 2020, 10 patients dropped out as of 2021 and another 11 patients dropped out as of 2022, making three groups for 2020, 2021 and 2022. No significant differences in characteristics were found among the three groups. UC-DAI scores had aggravated during the period of the first wave of the COVID-19 pandemic, but significantly recovered in 2021 and remained stable in 2022. Matts grade scores significantly recovered in 2021 from those in 2020 and remained stable in 2022. Disease activity of UC patients recovered in 2021 and remained stable in 2022, aggravated by the stress of the first wave of COVID-19 in 2020 despite persistence of the pandemic.

An expert consensus to standardise the assessment of histological disease activity in Crohn's disease clinical trials.

Targeting histological remission or response in Crohn's disease (CD) is not recommended in clinical practice guidelines or as an outcome in clinical trials due to uncertainties regarding index validity and prognostic relevance. To conduct a modified RAND/University of California Los Angeles appropriateness process with the goal of producing a framework to standardise histological assessment of CD activity in clinical trials. A total of 115 statements generated from literature review and expert opinion were rated on a scale of 1-9 by a panel of 11 histopathologists and 6 gastroenterologists. Statements were classified as inappropriate, uncertain or appropriate based upon the median panel rating and degree of disagreement. The panellists considered it important to measure histological activity in clinical trials to determine efficacy and that absence of neutrophilic inflammation is an appropriate histological target. They were uncertain whether the Global Histological Activity Score was an appropriate instrument for measuring histological activity. The Geboes Score and Robarts Histopathology Index were considered appropriate. Two biopsies from five segments should be biopsied, and the colon and the ileum should be analysed separately for all indices. Endoscopic mucosal appearance should guide biopsy procurement site with biopsies taken from the ulcer edge, or the most macroscopically inflamed area in the absence of ulcers. We evaluated the appropriateness of items for assessing histological disease activity in CD clinical trials. These items will be used to develop a novel histological index.

Correlation between canine inflammatory bowel disease activity indices after stem cell therapy

DISPARITY between the magnitude of the clinical response, the endoscopic mucosal appearance and the histological reduction of gastrointestinal inflammation after conventional therapy in dogs with inflammatory bowel disease (IBD) is...

Pediatric UC Drug Development

Pediatric UC Drug Development

Combined oral and rectal mesalazine for the treatment of mild-to-moderately active ulcerative colitis: Rapid symptom resolution and improvements in quality of life

Background and aimsMesalazine (5-aminosalicylic acid) is the standard first-line therapy for mild-to-moderate ulcerative colitis. In the PINCE study, remission rates were significantly greater with combined oral/enema vs. oral/placebo treatment at 8weeks (64% vs. 43%, respectively; p=0.030). In this analysis, we explored early response, mucosal healing rates, cessation of rectal bleeding, and quality of life in PINCE. MethodsPatients with extensive mild-to-moderately active ulcerative colitis received 8weeks of oral mesalazine 4g/day, plus 4weeks of daily active (1g mesalazine) or placebo enema. Early response was assessed using the abbreviated ulcerative colitis disease activity index. Mucosal healing was assessed by disease activity index endoscopic mucosal appearance score. Cessation of bleeding (patient diaries), quality of life (EQ-5D), and patient acceptability (questionnaire) were also assessed. ResultsCombined mesalazine oral/enema treatment achieved a significantly higher rate of improvement in abbreviated ulcerative colitis disease activity index (score decrease≥2) within 2weeks, compared with oral-only treatment (p=0.032). Bleeding ceased significantly more quickly with combination vs. oral therapy (p=0.003). More patients showed mucosal healing (disease activity index endoscopic mucosal appearance score 0/1) with combination vs. oral therapy, which was significantly different between groups at week 4 (p=0.052). Both groups showed quality of life improvements, with a significant benefit for combination vs. oral therapy at week 4 in multiple domains. Most patients reported finding the treatment acceptable. ConclusionsRapid cessation of symptoms was seen with combination therapy, which is particularly important to patients and may improve quality of life.

Recognition of Microscopic Colitis at Colonoscopy

Microscopic colitis is a common condition in Canada and is characterized by watery diarrhea with normal endoscopic mucosal appearance using conventional white-light endoscopy. Two types of microscopic colitis are recognized by histological appearance: lymphocytic colitis and collagenous colitis. Recent studies suggest that 10% to 30% of older patients who present with diarrhea and demonstrate normal mucosal appearance at endoscopy have microscopic colitis (1). Increasingly, however, with high-definition endoscopy assisted by postprocessing of images by filter techniques in combination with chromoendoscopy, subtle abnormalities of the mucosa are apparent in patients with microscopic colitis. iScan (Pentax, Japan) is a newly developed postprocessing light filter that enhances details of the mucosal surface, mucosal patterns (i-Scan p designated iScan 1) and vessel architecture (i-Scan v designated iScan 2). i-Scan is a technique designed for differentiating neoplastic from non-neoplastic lesions in the colon. This new digital modality can characterize mucosal patterns of the gastrointestinal mucosa in detail. Subtle abnormalities can, therefore, be recognized as either neoplastic or inflammatory. Hoffman et al (2) have tested the efficacy of high-definition endoscopy alone in comparison with i-Scan or chromoendoscopy with methylene blue (0.1%) in screening for colorectal cancer. They demonstrated that both i-Scan and chromoendoscopy identified more lesions compared with high-definition endoscopy alone. i-Scan was also able to predict neoplasia as precisely as chromoendoscopy, with an accuracy of 89% to 97%. Case Presentation A 50-year-old woman with persistent undiagnosed chronic watery diarrhea underwent colonoscopy, with random biopsies that were negative. Another colonoscopy was performed with iScan + chromoendoscopy with 0.2% indigo carmine to enhance mucosal surfaces and patterns, and to target biopsies in the colon. iScan 1 and iScan 2 showed irregularity of the colonic mucosal pattern, although the mucosa appeared normal with white-light endoscopy. iScan + chromoendoscopy with indigo carmine characterized, in detail, the mucosal pattern as nodularmosaic with a small honeycomb pit-pattern appearance (Figure 1). Such an appearance is characteristic of microscopic colitis. Targeted

Clinical evaluation of push-type enteroscopy.

Endoscopic exploration of the small bowel is potentially of prime importance in studying gastrointestinal bleeding of obscure origin, diarrhea and malabsorption, neoplasia, and other clinical conditions, but the method is still problematic because of the limited efficacy of sonde-type enteroscopes. This study evaluates the diagnostic yield of two push-type enteroscopes fitted with tip deflection and a biopsy channel. Seventy-two consecutive patients underwent enteroscopy using either an Olympus SIF-10 LY fiberscope or an Olympus SIF-100 video enteroscope. The depth of insertion was always checked by fluoroscopy, and ranged 30-120 cm beyond the ligament of Treitz. Angiodysplasia was identified as the source in eight of 20 patients referred for gastrointestinal bleeding of obscure origin, and electrocoagulation was successfully performed in one case. A jejunal polyp was the cause of obscure bleeding in one patient. Radiological evidence of neoplasia/lymphoma located in the third portion of the duodenum or in the upper jejunum was ruled out in 10 of 12 patients. A normal jejunal appearance was found in two patients with lymphoma, subsequently confirmed by a normal enteroclysis. Duodenal or jejunal polyps were removed in seven of nine patients with familial polyposis. Endoscopic and histological alterations were found in nine of 24 patients with diarrhea or malabsorption. In addition, jejunal histology supplied the diagnosis in five patients with a normal endoscopic mucosal appearance. Only 18% of patients described slight, transient pain, and there were no complications. The tolerance and diagnostic efficacy were the same with both instruments. Even though push-type enteroscope exploration is restricted to the jejunum, the instruments are safe and efficacious in clinical practice, and permit indepth study of small bowel anatomy and pathology.

Stress-induced gastroduodenal lesions and total parenteral nutrition in critically ill patients: frequency, complications, and the value of prophylactic treatment. A prospective, randomized study.

The objective of this study was to assess the frequency, complications, and value of prophylactic treatment of stress‐induced gastroduodenal lesions in critically ill patients requiring total parenteral nutrition (TPN) and prolonged mechanical ventilation. Multidisciplinary intensive care unit (ICU) patients were prospectively randomized to treatment with TPN alone, TPN with sucralfate, or TPN with ranitidine. Ninety‐seven patients were evaluated. Prospectively randomized patients with expected mechanical ventilation for a minimum of 6 days who were metabolically stressed, hemodynamically stable, had normal hepatic and renal function, and required TPN were included. Exclusion criteria were history of gastroduodenal ulcer in the past 12 months before admission, previous operations of the upper gastrointestinal tract, diagnosis of active gastrointestinal hemorrhage, renal or hepatic failure, and administration of antacids, H2‐receptor blocking agents, and sucralfate 48 hours before entering the study. Patients were removed from the study if they were weaned from mechanical ventilation before the sixth day (n = 10), had suffered an episode of acute gastrointestinal hemorrhage (n = 5), developed stress‐induced gastroduodenal ulcers (n = 2), had chronic duodenal ulcers (n = 2), had gastric cancer (n = 1), or could tolerate enteral feedings (n = 1). Ninety‐seven patients were evaluated. Seventy‐three patients completed the study (53 men and 20 women), and the mean age was 38 ± 16 years. To stratify the severity of illness, the APACHE II score and the catabolic index score were obtained on admission to the study. Gastroduodenal mucosal damage was determined by endoscopy performed on day 3 after admission to the ICU and every 7 days thereafter. Endoscopic mucosal appearance was classified using a modification of the Pleura and Johnson1 classification: (1) normal mucosa or erythema, (2) nonhemorrhagic erosions/petechial changes, (3) stress gastroduodenal ulcers without bleeding, and (4) stress gastroduodenal ulcers with endoscopic signs of bleeding.Thirty patients received TPN alone. Twenty‐four patients received TPN and sucralfate (1 g by nasogastric tube every 4 hours) and 19 patients received TPN and ranitidine (50 mg IV every 6 hours). The three groups were matched for severity of illness (APACHE II score) and demographic characteristics. Patients were monitored for clinical evidence of acute upper gastrointestinal hemorrhage and underwent urgent endoscopy if symptoms or signs of gastrointestinal hemorrhage developed. Coagulation studies, hemodynamic status, and active intervention measures were recorded. Endoscopic examinations (n = 101) were performed in 64 patients (9 patients did not undergo endoscopy). Evidence of gastroduodenal mucosal abnormalities (categories 2, 3, or 4) was noted in 19 of 64 patients (overall occurrence rate of 29.6%). The overall frequency for stress ulcerations was 15.6% and 6.2% for stress‐induced hemorrhage. There were no deaths due to stress‐induced hemorrhage. The results demonstrate no statistically significant differences in the frequency of stress‐induced lesions and stress‐induced hemorrhage among the three groups of patients. The authors concluded that prophylaxis with sucralfate or ranitidine in patients receiving TPN offers no additional advantage in a group of ventilated ICU patients receiving TPN in terms of risk for developing stress‐induced gastroduodenal ulcerations and hemorrhage.

Histopathological observations in chronic maxillary sinusitis

Biopsy samples from the maxillary sinus mucosa of patients with purulent, non-purulent and recurrent sinusitis were studied histologically and compared with those from a maxillary sinus of patients with no previous history of sinus disease on the side of sampling. Basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear inflammatory cell infiltration and subepithelial oedema were observed in all groups irrespective of the appearance of the effusion. Although the inflammatory variables in selected areas of the mucosa seemed to show an increase in severity with the increasingly severe forms of sinusitis, neither the endoscopic mucosal appearance nor the nature of the sinus effusion corresponded to any specific histological pattern.