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drugs (NSAIDs)3 can cause mucosal changes mimicking IBD, these agents should be avoided before initial
colonoscopy.
Patients with other colitides can have similar clinical presentations and similar endoscopic features to the patients
with IBD. These colitides include infectious colitis, druginduced colitis, ischemic colitis, and radiation colitis. The
value of endoscopy alone in distinguishing IBD from nonIBD colitides is limited.4 However, the acquisition of the detailed information from index colonoscopy is important for
the differential diagnosis of CD and UC because, once therapy is started, it may obscure discriminating features of CD
from UC such as segmental colitis (patchiness) and rectal
sparing.5,6 In a study of 39 patients with treated UC, 44%
of patients had endoscopic patchiness and 13% had endoscopic rectal sparing; 33% had histologic evidence of patchiness and 15% had histologic sparing.6 At the time of
colonoscopy, attention should be paid to the anal and
perianal area because abnormalities are commonly seen
in the setting of CD. The most useful endoscopic features
(particularly the initial or index endoscopy) used to differentiate CD from UC are segmental colitis (ie, patchiness),
rectal sparing, involvement of the terminal ileum, and
anal or perianal disease. Other endoscopic features suggestive of CD include aphthous ulcers, discrete ulcers, serpiginous ulcers, and cobblestoning of mucosa. However, none
of the endoscopic features is specific for CD or UC.
Ileoscopy is important to distinguish true CD ileitis
from backwash ileitis, which occurs in up to 10% of cases
of active pancolitis in UC.7 Features that favor CD ileitis include discrete ulcers or strictures of the terminal ileum or
ileocecal valve.7-9
UC may progress proximally over time.10 The finding of
inflammatory changes around the appendiceal orifice (cecal patch or periappendiceal patch) in the setting of UC
with an otherwise normal right colon should not be confused with CD.11,12 The clinical implication of cecal patch
is not clear, although a recent controlled study revealed
that patients with UC with cecal patch had a similar rate
of remission, relapse, and proximal extension compared
with those with no cecal patch.12
Endoscopy together with other diagnostic modalities
can differentiate CD from UC in R 85% of patients.13 In
a prospective study of more than 350 patients with IBD
followed up for more than 22 months, index colonoscopy
and biopsy were accurate in distinguishing CD from UC in
www.giejournal.org
INTRODUCTION
Endoscopy is an important diagnostic and therapeutic
modality in inflammatory bowel disease (IBD), being useful for both Crohns disease (CD) and ulcerative colitis
(UC). Endoscopy is used to make an initial diagnosis of
IBD, distinguish CD from UC, assess the disease extent
and activity, monitor response to therapy, allow for surveillance of dysplasia or neoplasia, and provide endoscopic
treatment, such as stricture dilation.
ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
needed to assess response to the therapy.31-33 In more recent pharmaceutical trials, the documentation of endoscopic mucosal healing has become a critical component
of outcome measurement.29,34
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FLEXIBLE SIGMOIDOSCOPY
Under certain circumstances, flexible sigmoidoscopy
may provide useful information in patients with IBD. An
adequate diagnosis may be obtained, and it should be performed preferentially when colonoscopy is considered
high risk (eg, fulminant colitis).33 In patients with established UC, flexible sigmoidoscopy may define disease activity and is useful in evaluating for superimposed
colitides including cytomegalovirus (CMV) and Clostridium difficile infections or ischemic colitis when disease
exacerbations occur.
ESOPHAGOGASTRODUODENOSCOPY
Esophagogastroduodenoscopy (EGD) can be a useful in
the evaluation of patients with IBD. Upper gastrointestinal
(GI) tract involvement (proximal to the ligament of Treitz)
occurs in up to 13% of patients with CD.35,36 CD can involve
the esophagus,37 stomach,38 and duodenum.39 It appears
that duodenal biopsy specimens more often display granulomas (40%-68%) than do colon biopsy specimens.39-41 In
patients with indeterminate colitis, upper GI tract involvement can help establish a diagnosis of CD.42 However,
when the upper GI tract is involved in CD, disease is usually
present elsewhere, such as the terminal ileum, colon, or
perianal area. Therefore, routine EGD is not recommended in all patients suspected of having CD. Additionally,
patients with UC may also have upper GI inflammation,
such as diffuse duodenitis.43 Endoscopic features in these
patients include edema, erythema, erosions, and thickened
mucosal folds.44 Histologic examination may show active
chronic inflammation with architectural mucosal distortion,44 villous atrophy, and intraepithelial lymphocytosis.45
Other applications of EGD with small bowel biopsy in patients with IBD include evaluation of concomitant celiac disease43,46 eosinophilic enteritis,45 common variable immune
deficiency,47 and small bowel neoplasia.44,48 In patients with
CD, symptomatic duodenal strictures may respond to endoscopic balloon dilation.49
ENTEROSCOPY
Push enteroscopy has a limited role in the management
of patients with IBD, especially in the era of capsule endoscopy (CE). In patients with abnormalities seen on
other imaging studies that are within reach, push enteroscopy allows endoscopic and histologic evaluation and
therapeutic intervention.50,51 Intraoperative endoscopy
ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
has been used in selected patients with indeterminate colitis at the time of total colectomy and ileal pouchanal
anastomosis.
radiographic evidence of small bowel narrowing in the setting of CD should not undergo CE. Capsule retention
above a CD stricture may be treated with anti-inflammatory medications, although there are no published
studies.76
CAPSULE ENDOSCOPY
CE allows for direct and minimally invasive visualization
of small bowel mucosa. It may help identify superficial lesions not detected by traditional endoscopy and radiography. It might be useful in the initial diagnosis of CD, for
detecting recurrences, for establishing extent of disease,
for assessing response to therapy, and for differentiating
CD from UC or indeterminate colitis. Data from retrospective studies, case series, and prospective studies have
shown that CE is useful for the diagnoses of CD when
small bowel follow through (SBFT) and ileoscopy are negative or unsuccessful.52-66 The diagnostic yield of CE
ranges from 10% to 71% depending on the clinical setting.
CE has been shown to be more sensitive in the detection
of small bowel CD than is computed tomographic (CT)
enterography,66 SBFT,66 and enteroclysis.67 In patients
with mild to moderate disease and a normal SBFT,68 CE
may allow for the detection of small bowel changes that
are not within reach of push enteroscopy (PE). A recent
prospective study of 42 patients compared SBFT, CT enterography, colonoscopy with ileoscopy, and CE in the assessment of small bowel CD. Of these 4 modalities, CE had the
highest sensitivity (83%) with the lowest specificity (53%)
and colonoscopy with ileoscopy had the highest specificity
(100%) with a sensitivity of 74%.69 A recent study in 39 patients, the majority with known CD, reported CE sensitivity
and specificity of 89.6% and 100%, respectively.70 Few studies have evaluated the benefit of CE in the evaluation of indeterminate colitis. One study found that 5 of 22 patients
with colitis were found to have mucosal breaks in the small
bowel on CE, thus changing their diagnosis to CD.62
The main limitations of CE in the assessment of small
bowel CD are the lack of uniform criteria for diagnosing
CD, inability to allow for tissue acquisition or therapeutic
intervention, and the risk for capsule retention. It is important to note that the finding of mucosal breaks the
small bowel is not necessarily indicative of CD. A variety
of disease entities can cause mucosal ulcerations such as
infection, ischemia, radiation injury, and drug-induced injury, particularly NSAIDs.71 In addition, it has been reported that up to 14% of healthy individuals had
mucosal breaks and other nonspecific lesions on CE.67
Capsule retention in CD patients resulting from underlying small bowel strictures is a major concern, occurring
in 1% to 13% of patients with known CD.72,73 Retained
capsules may require surgery74 in patients that may otherwise have not required surgery. A preingestion radiologic
study (CT or SBFT) is recommended73-75 because asymptomatic CD strictures occur in as many as 22%.73 Patients
with obstructive symptoms or with endoscopic and
560 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
ENDOSCOPIC ULTRASONOGRAPHY
Ultrasonography (US) including transperineal US and
endoscopic US (EUS) with a rigid scope or with flexible
endoscopes has been used to assess disease activity of colitis, transmural disease,77 fistulae,78-81 abscess,79-81 and regional lymphadenopathy.79 For patients with perianal
disease, EUS can accurately characterize perianal disease
to reduce the risk of incomplete healing, recurrent fistula,
or inadvertent sphincter injury if fistula anatomy is incorrectly delineated or an occult abscess missed at surgery.82
EUS has an excellent accuracy in the assessment of
Crohns perianal fistula and abscess.79,83 EUS may be
used to monitor medical and surgical therapy for CD
perianal fistulae.81,84-87 The EUS finding of transmural disease may allow for the differentiation of CD and UC.79-81
ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY FOR
PRIMARY SCLEROSING CHOLANGITIS
The role of endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis
has been addressed in a previous document.98
CANCER SURVEILLANCE
Individuals with long-standing UC and extensive CD colitis are at increased risk for development of dysplasia and
colorectal cancer (CRC) and should undergo colonoscopic
surveillance. The risk of CRC increases with longer duration and extensive severe colitis, family history of CRC,
young age at onset of disease, presence of backwash ileitis, and personal history of primary sclerosing cholangitis.96,97,99,100,101 The presence of proctitis alone does not
increase the risk for CRC. Patients with UC who have
left-sided colitis or more extensive disease are at increased
risk. In Crohns colitis, those patients with extensive disease involving more than a third of the colon also have
an increased risk of CRC, similar to patients with
UC.102,103 The extent of colonic involvement should be
based on both endoscopic and histologic criteria, whichever reveals more extensive disease.104 In a case-control
study of UC patients undergoing colonoscopic surveillance, there was a reduction in mortality resulting from
CRC in those patients in surveillance programs.105
Patients with UC or extensive Crohns colitis (greater
than one third colonic involvement) should undergo surveillance colonoscopy every 1 to 2 years beginning 8 to 10
years after disease onset.103 Biopsy specimens of the colon in patients with documented pancolitis should be obtained in all 4 quadrants every 10 cm from the cecum to
the rectum, to obtain a minimum of 32 biopsy samples.106,107 In patients with less extensive colitis, biopy
specimens can be limited to the microscopically involved
segments.106,107 Diagnosis of dysplasia should be confirmed by a second gastrointestinal pathologist.103 The
management of dysplastic polypoid lesions is currently
evolving. The presence of high-grade dysplasia or multifocal low-grade dysplasia in flat mucosa is an indication for
colectomy. The management of unifocal low grade dysplasia is controversial as to whether colectomy should be
performed. Biopsy specimens should be obtained of strictures, mass lesions, and macroscopic abnormalities other
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ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
symptomatic patients, endoscopy is indicated for assessment and biopsy to exclude possible malignancy, especially in the setting of UC, where a stricture should be
considered malignant until proven otherwise. If it cannot
be thoroughly examined and biopsy performed117 surgical
resection should be considered. The finding of a colonic
stricture in the setting of CD is more likely to be benign,
although complete examination with biopsy is recommended. Balloon dilation may be required to completely evaluate the stricture. Endoscopic balloon dilation has been
investigated in patients with Crohns strictures of the small
bowel, colon, and anastomosis. The majority of these
studies are retrospective and the main outcome measurement is symptom relief and avoidance of surgery.
Endoscopic balloon dilation may relieve symptoms. Complications include perforation and bleeding.118121 Corticosteroid injection into the stricture at the time of
balloon dilation may improve outcome.122,123
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www.giejournal.org
Prepared by:
STANDARDS OF PRACTICE COMMITTEE
Jonathan A. Leighton, MD
Bo Shen, MD
Todd H. Baron, MD, Vice Chair
Douglas G. Adler, MD
Raquel Davila, MD
James V. Egan, MD
Douglas O. Faigel, MD, Chair
Seng-Ian Gan, MD
William K. Hirota, MD
David Lichtenstein, MD
Waqar A. Qureshi, MD
Elizabeth Rajan, MD
Marc J. Zuckerman, MD
Trina VanGuilder, RN, SGNA Representative
Robert D. Fanelli, MD, SAGES Representative