How To Standardize Endoscopic Interpretations

Endoscopy is an essential tool in the care of patients with inflammatory bowel disease (IBD), but endoscopic reports should be standardized to ensure that all parties are speaking the same language and understand the findings precisely, said David T. Rubin, MD, at the Advances in Inflammatory Bowel Diseases (AIBD) 2020 virtual meeting on December 11.

Dr Rubin is the Joseph B. Kirsner Professor of Medicine and chief of the section of gastroenterology, hepatology, and nutrition at the University of Chicago.

“Everyone here understands the various uses of endoscopy in inflammatory bowel disease,” he said. “But despite the wide use of endoscopy in IBD I think most of us are also familiar with the limitations of the procedure,” such as its invasiveness, expense, variable quality in performance and interpretation, and patient dissatisfaction.

The question of why endoscopic findings in IBD need to be standardized “is almost a rhetorical question. This is important because appearance on endoscopy is part of assessment of activity and severity of disease, and also helps us determine if our interventions are working, or if disease is progressing, despite our efforts to control it,” Dr Rubin stated.

Quality metrics for endoscopy among patients with IBD have been recommended in the past, based on similar metrics for endoscopy performed with non-IBD patients, he explained. These call for appropriate use of endoscopy in the right patients; a uniform approach to disease assessment, including standardized assessment of disease and “with the understanding that it’s just a matter of time before we will be recording all of our endoscopy procedures with full-length video.” Standardized reporting is of course part of a quality measure, he stated, “as well as knowing whether we are adequately preventing outcomes of interest, such as cancer and deaths from cancer, which haven’t really been measured very well in IBD and thankfully are very rare outcomes but surrogates for that, such as dysplasia detection, are very important.” 

A consensus paper published by the BRIDGE group, in which Dr Rubin participated as one of the contributors, suggested that endoscopy reports should include IBD background elements relevant to the procedure, including a description of disease type and extent, “perhaps using the Montreal classification,” he said, and the indication for the procedure. “Be precise. I use terms like ‘to assess extent and severity of disease, or  ‘to assess disease activity,’ or ‘to perform surveillance,’” he explained.         

The report should also include the therapy being used to treat the patient’s IBD at the time of the procedure, “as well as a description of how they’re doing. Are they in clinical remission or are they clinically active? Consider using the Harvey Bradshaw Index or the Simplified Clinical Colitis Activity Index in the descriptor of why you’re doing that procedure.”

The findings and interventions relevant to all endoscopies for IBD include a description of and if possible a photographic documentation of the perianal exam and the anatomic extent of the exam, “including a description of biopsies and where they were obtained; this can be very important when you’re trying to go back and figure out why you have an unusual or unexpected finding,” Dr Rubin said. These reports should also include the physician’s impressions and recommendations, “clearly separating what is factual, which are the findings, and your impressions.”

“Consistency in IBD reports is critical,” he stated. “Be precise in your language. Document both normal AND abnormal areas. It’s especially important when you’re doing an initial colonoscopy with a new patient to put these in separate jars so your pathologist knows what they’re looking at. If you take normal and abnormal samples for biopsy and put them in the same jar, it may look to the pathologist just like patchy disease.”

Dr Rubin emphasized the importance of having a relationship with the pathologist and communicating effectively. “Send them a copy of your report and tell them what you’re looking for.”

The first colonoscopy is the most important, he said. “Remember that the disease may be in evolution, and may not have been treated yet, so documenting everything in that first colonoscopy is really critical. Make sure you’re clearly describing what you’re seeing with the recognition that it may change over time” if disease progresses or responds well to therapy.

He added, “Steve Hanauer actually taught me how to describe the mucosa. First of all is it intact—that is, are there ulcers or erosions? Is it glistening—is there a normal mucosal lining? And third, what is the vascular pattern like?” 

In describing the endoscopic appearance, Dr Rubin stated, “remember we’re distinguishing between clinical activity—how the patient feels; endoscopic activity, or how the colon looks; and histologic activity, or how a pathologist may see it or how we see it if we’re using narrow-band or chromoendoscopy.”

 In his impressions, Dr Rubin said he tries to be very specific, describing his impressions as “endoscopic quiescent Crohn ileocolitis or endoscopic moderately active left-sided ulcerative colitis,” to distinguish the endoscopic and histologic findings. He also recommends noting comparisons to previous endoscopic exams in the report.

To ensure “we’re speaking the same language,” he said, “using the endoscopic severity indices is quite important. There are many different indices, some easier to use than others. An ideal index should include accuracy, sensitivity to detect changes, and inter-and intra-observer reliability. For Crohn disease, the Simplified Endoscopic Score for Crohn Disease satisfies most of these criteria, while the Mayo score or Ulcerative Colitis Endoscopic Index of Severity are satisfactory for ulcerative colitis. These scores should be included on the reports

However, Dr Rubin noted, comparisons of inter-observer agreement on these scores, as well as the Rutgeerts, have shown “these are not as accurate as we would like and we clearly need some better instruments.”

The use of artificial intelligence in scoring “could completely change thing, if we could just flip a switch and get a score; if we remove the observer from the exam,” he said. Until that happens, however, Dr Rubin stressed the importance of carefully documenting every aspect of endoscopy, from using the procedure appropriately for the right patient, adhering to current professional guidelines and society recommendations, using the existing disease severity indices, and being precise in language on the endoscopy report to ensure clear communication with colleagues, pathologists, and patients.

—Rebecca Mashaw

Reference:

Rubin DT. How to standardize endoscopic interpretations in IBD. Talk presented at: Advances in Inflammatory Bowel Diseases 2020; December 10, 2020. Virtual.