Florian Rieder, MD, on the IBD Endoscopic Toolbox

To ensure the highest level of care for patients with inflammatory bowel disease (IBD), a gastroenterologist needs to know how to write a good colonoscopy report, the indications for use of dilation in stricturing Crohn disease (CD), and the value and safety of small bowel endoscopy for CD, said Florian Rieder, MD, at the March 5 Advances in Inflammatory Bowel Diseases (AIBD) virtual regional meeting.

Dr Rieder is vice chair of the department of gastroenterology, hepatology and nutrition at Cleveland Clinic and is an expert in intestinal fibrosis.

He presented an example of a poor colonoscopy report, for a 32-year-old man diagnosed with CD 13 years earlier who had undergone 2 bowel resections and been treated with infliximab Q8. The report stated only the finding of “some inflammation” and “evidence of colitis; biopsy taken.”

The Crohn Disease Index of Severity (CDEIS), developed in 1989, can guide the endoscopist on the details needed to develop a good colonoscopy report, Dr Rieder said. The CDEIS identifies 9 mucosal lesions, from pseudopolyp to ulcerated stenosis, across 5 segments from the ileum to the rectum.

The Simple Endoscope Score for Crohn Disease (SES-CD) is indeed simpler and easier to use, rating 4 variables per segment from 0 to 3. “The reliability of the SES is very robust, except in stenosis,” Dr Rieder stated; previous studies have suggested that the SES could replace CDEIS.

“If you strive to be a top performer for IBD endoscopy and you want to up your game, use the SES-CD,” he said.

A significant number of patients with CD will require surgery. For assessing the risk of postoperative recurrence of CD, the Rutgeerts score is the primary tool, Dr Rieder said. It determines the number and distribution of ulcers and rates the risk of postoperative recurrence.

For ulcerative colitis (UC), the Mayo endoscopic score is the tool of choice. “It’s overall a bit easier to score than Crohn’s,” Dr Rieder said of UC, ranging from 0 to 3. “My rule of thumb is if there is erythema or edema, it’s a Mayo score of 1; with an erosion but no ulcer, the score is 2; whenever there are ulcerations or spontaneous bleeding, it’s a 3.”

Dr Rieder explained that for strictures in CD, endoscopic balloon dilation is a valuable tool. The indications for using this approach are symptomatic ileocolonic or colonic strictures. “Isolated anastamotic strictures are preferred,” he said, “and upper GI strictures can be dilated if technically feasible. The presence of ulcerated or inflamed stenosis is not a contraindication for endoscopic balloon dilation.”

He stressed that prior to any procedure with a balloon endoscopy, “you want to get cross sectional imaging to exclude penetrating complications” and to assess the length and angulation of the stricture.

Stricture length is the major predictor of success, Dr Rieder noted. “If you have a short stricture, shorter than 5 cm, this is associated with surgery-free outcomes.” Each 1 cm increase in length of strictures increases the risk of surgery by 8%. However, he added, active disease is not associated with increased risk.

He also addressed the topic of injection of corticosteroids in stricture sites after endoscopic dilation. Trials have indicated that corticosteroids are detrimental in adult patients but may be beneficial among pediatric practices. “The jury is still out,” Dr Rieder said. “I personally do not use this practice.”

When do you dilate and when do you send the patient to surgery? The factors that favor a surgical approach include cases in which the dilation is technically difficult at the site; the presence of long or multiple strictures; early recurrence after previous dilation; the presence of abscess, fistula, or phlegmon; dysplasia/malignancy; and longstanding or significant prestenotic dilation.”

“Proceed with caution” in the case of colonic strictures, he said, due to the higher risk of malignancy in these cases, which most often occurs among patients with long duration of disease and symptomatic large bowel obstruction.

Dr Rieder also addressed the safety and value of small bowel endoscopy among patients with CD, performed with capsule or balloon-assisted endoscopy.

One possible indication for capsule endoscopy is suspected isolated small-bowel CD, he explained. “In fact, the diagnostic yield of capsule endoscopy is reported to be higher compared to CT enterography, particularly in mild small bowel Crohn’s disease.” It may also be superior to magnetic resonance enterography (MRE) in early CD and for proximal small bowel lesions. “But the true value of capsule endoscopy in suspected small bowel Crohn’s disease is its very negative predictive value.”

The limitations of capsule endoscopy include the inability to obtain tissue; high sensitivity but specificity is low; and about 14% of healthy individuals show some ulcers or erosions capsule endoscopy.

Dr Rieder pointed out that C-reactive protein and fecal calprotectin are poorly correlated with small bowel inflammation. Capsule endoscopy provides an option for assessment in known isolated small bowel CD, where there is a suspicion of active disease despite normal colonoscopy. Capsule endoscopy can also be useful in monitoring a treat to target strategy for mucosal healing in isolated small bowel CD and in predicting a flare in cases of quiescent CD.

Balloon-assisted enteroscopy in CD “allows deep intubation of the small bowel,” Dr Rieder said. This can be done antegrade or retrograde, allows for tissue sampling and control of bleeding, and is necessary to move ahead with endoscopic intervention.

The technical success of balloon dilation for small bowel strictures is more than 90%, while clinical efficacy is 82%. The rate of complication per dilation is 1.8% over more than 1000 dilations in the deep small bowel, according to one systematic review, “which is quite comparable to ileocolonic dilation,” he stated.

--Rebecca Mashaw

Rieder F. The IBD endoscopic toolbox. Presented at: Advances in Inflammatory Bowel Diseases regional meeting. March 5, 2022. Virtual