This includes brief history of endoscopy, then describes variation of different forms of appearances of IBD/ Ulcerative Colitis, Crohn's diseases, with current guidelines, and recommendations of surveillance.
20. Why Endoscopy
• Diagnosis, distribution, severity
• Histology: 2 samples of Ileum, and each segment
even if it looks normal.
• Response to treatment
• Prevention of cancer
• Therapy: ? Dilatation
Avoided (?sigmoidoscopy): Megacolon or
?Severe Colitis
21. Risk in Severity
• Risk of Perforation 1% : 0.6% (non-IBD)
• Old Age
• Female gender
• Stenosis/ Dilatation
• Poor preparation
Navaneethan, J Crohns Colitis 2011;5:189
26. INTERCHANGEABLE diagnoses
• 43% changed from UC> CD
• 17% changed from CD > UC1
• 12% have colectomy for US > diagnosed as CD2
• Insufficient clinical / Radiological information
• Fulminant colitis
• Variations
• Presence of secondary infection3
1- Farmer, Am J Gastroenterol 2000;95:3184
2- Murrel, J Gastroenterol Hepatol 2005;20:1696
3- Odze, Mod Pathol 2003;16:347
41. UC-EIS
- mucosal healing (partly validated)
MAYO Score
- Used common, not Validated
Baron/ Modified Baron Index
Rchmilewitz Index
Sutherland Index
Powel –Tuck Index
Matts Index
Gastro. Endosc. N. Am 2014;24:367
43. Mayo Score Limitations
• Overlap of different features points
• Friability is subjective variable
• Inconsistency among users
D’Haens Gastro 2012;143:1461
Kamm, Gastro 2007;132:66
Lichtensteing, Clin Gas Hep 2007;5:95
49. CD: limitation of Endoscopic Score
• Response , Remission (endoscopiv view)
• Does visible healing correlated to absent
ulcers?
• Is visible mucosal activity reflective of
transmural activity?
• Small Bowel: is viewing Terminal Ileum
indicative of the rest of small bowel?
50.
51.
52.
53.
54.
55.
56.
57.
58. Indeterminate Colitis
• About 10 %
• In sever intermittent
• Wen too numerous pseudopolyps
• Serology may help: pANCA, ASCA
• Distinction in CD (!avoidance of ileo-anal
anastomosis)
61. CDEIS: Crohn’s Disease Endoscopy Index of Severity
Weighing
Factor
DescriptionVariable
12# segments affected with deep ulcers divided by
segments (rectum-ileum)
1
6# segments affected by superficial ulcers / # segments2
1Disease: Degree of each segment to have
(pseudopolyps, healed ulcer, erythema,
swelling/edema, aphthous, superficial ulcer, deep
ulcer, nonulcer stenosis) and estimate cm involvement
(1 or more lesions) in each 10 cm length of a segment.
Sum divided by number of segments involved.
3
Ulcers: The degree of ulceration in each segment is
determined by examining each segment for ulceration
(aphthoid ulcers,
superficial ulcers, deep ulcers, ulcerated stenosis) in
each 10 cm portion from each segment. Sum /
number of segments.
4
3Presence of nonulcerated stenosis5
3Presence of ulcerated stenosis6
Total CDEIS=
(0-44) Above 15 severe disease
Gastroenterology. 1990;98:811
62. Sum – 1.4 (#affected segments)
Daperno, GIE 2004;60:505
66. Endoscopicaly
visible single
lesion in COLITIS
Distinct border
No Submucosal attachment
Snare Polypectomy
EMR
ESD
Followed by tattoo
Histology: free margin, en-block,
confirmed dyplasiaYES
NO6 months repeat
colonoscopy with
biopsies from the site.
NO
Tattoo/ Mark
SURGERY
PROCTOCOLECTOMY
67. Colonoscopy
• Prevents of colon cancer incidence and
mortality ( Pan J, et al: Am J Gas 2016;111:355)
• Reduced 53% deaths after Polypectomy Zuber et
al, NEJM 2012;366:387
68. • Preferred Test for Ca Colon Screening:
- Colonoscopy every 10 years past age 50
- Alternatives:
- Fecal Occult Blood: Annual (x3)
- Fecal DNA: q 3 years
- CT Colonosgraphy / Barium DE
- Flex-Sig q 5 years
Editor's Notes
Bozzini developed a primative endoscope, for cystoscopy, the Lichleiter, wth illumination provided by a burning candle. Bozzini published his finding and instrument in 1805, as light conductor to visulaize the urinary bladder. He was censored by the Medical Faculty of Vienna for (undue curiosity).
In 1853 Desormeaux in France developed first instrument of clinical value primarily for urological disease. The endoscope comprised a viewing tube and a light source unit, a gazogene lamp lit by a mixture of alcohol and turpentine. The viewing tube, at its junction with the light source, had an angled mirror with a small hole in the center reflecting light from the flame through the viewing tube into the attached speculum. Observation was through a small hole at the end of the tube, which swiveled at its connection to the light source so that the source stayed vertical.
German physician, performed rigid gastroscopy over obturator. Candle light was not enough until, Edisson Lamp.
Two directions
Royal College of Glasgow, 1914 publication.
Beginning in the 1930s came a period that saw the development of semiflexible endoscopes. Schindler was an integral character during this era. The first recorded flexible esophagoscope, however, was by Kelling in 1898. The lower third of his instrument could be flexed up to a 45° angle. Schindler’s breakthrough came about in 1932 in the form of the semiflexible gastroscope. The distal half of this endoscope was constructed from a spiral of bronze with a protective covering of rubber. Key to his design, though, was the discovery that using a tube filled with very thick lenses with short focal distances allowed for bending in several planes without distortion of the transmitted image. Schindler introduced an updated version 4 years later that used an electric globe as the light source. The maximal bending angel was only 30°, as greater angles would not allow for image transmission, and thus there were significant blind spots not visualized by the endoscope
Camera, (wire), lamp and lense, film.
Alexander Graham Bell – 1880s – He contributed to the invention of photophone.
John Tyndall – 1854 – A British physicist, who proved that the light rays can pass through a bent stream of water without fluctuation.
William Wheeler – 1880 – The lights that used the electric arc lamp from the basement of houses that helped in illuminating the house was discovered by him.
John Logie Baird – England – For transmitting television signals, the idea of using arrays of transparent rods, was designed by him along with W. Hansell.
American David Smith – 1898 – He is the one who owns the patent for a bent arc lamp that is employed in surgeries
Up to 10% of patients with active pan-colitis may develop “backwash ileitis,” which can extend
several centimeters into the terminal ileum –
Chutkan RK, Waye JD. Endoscopy in inflammatory bowel disease. In: Kirsner JB,
editor. Inflammatory bowel disease. 5th edition. Baltimore (MD): Williams and
Wilkins; 2000. p. 453–77.
The earliest endoscopically visualized changes in UC are erythema and vascular
congestion of the mucosa. As edema becomes more prominent, small mounds may
form resulting in a fine granular appearance. The mucosa may be friable and bleed
with minor contact. As inflammation becomes more severe, ulcerations form, and
bleeding may occur spontaneously. Coalescence of small ulcers may result in large
or linear ulcerations.
Chronic inflammation can result in mucosal atrophy with loss of the haustral folds
and luminal narrowing. Mucosal atrophy may lead to pseudopolyps, which can
assume diverse shapes as well as form mucosal bridges. Typically, they appear as
long, glistening, fingerlike projections that are friable and bleed easily when biopsied.
Pseudopolyps can also be seen in CD but are typically seen in UC.
Giant pseudopolyps can lead to intussusception and obstruction.
Truelove-Wittz
Bristol Medico-Chirurgical Journal Volume 103 (i) February 1988, page 9.
In CD, involvement is typically patchy and can affect any segment from the mouth to
the anus. In the setting of colonic CD, the rectum is spared in up to 50% of patients
and is often most severe in the cecum and right colon. Esophageal CD can either
be focal or extensive, with single or multiple erosions, often surrounded by healthy
mucosa. In upper gastrointestinal CD, the most frequently involved areas are the
duodenum and gastric antrum. Gastroduodenal CD occurs in 0.5% to 4% of
patients with ileocolonic disease, although it occurs very rarely as an isolated entity