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ENDOSCOPY ROLE IN INFLAMMATORY BOWEL DISEASE, ENDOSCOPY HISORY
- 1. ULCERATIVE COLITIS CROHNS DISEAE INDETERMINATE ENDOSOCOPY HISTORY Khalid A. Zaalook, MD
- 3. Desormeaux 1853 Lens view through perforated mirror transmitting light
- 5. Filament Light Bulb (1879)
- 7. 1898وSchaaf’s Device • Intra-gastric Photograph
- 11. OLYMPUS- UJI, et al. 1950 GASTROCAMERA
- 13. 1927John Baird England • Light beams in Fiber-Optics FIBERGLASS
- 14. Heinrich Lamm 1930 Germany •Third year medical student Transmission of image through fiberglass
- 15. Basil Hirschwitz 1957 ( U Michigan) Coated glass fiber for light-image Transmission FIBEROPTICS
- 18. Quality of Colonoscopy Rex et al, ASGE (Gas Endo 2006;63:S16)
- 19. ULCERATIVE COLITIS CROHNS DISEAE INDETERMINATE INFLAMMATORY BOWEL DISEASE
- 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
- 23. Ulcerative Colitis *Subgroups: Affect the Cecum sparring Rt Colon; some involve patches Rt Colon only. [?INDETERIMATE -solo] Beyeon, Inflamm Bowel Dis 2005;11:366
- 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
- 27. APPEARANCE of UC CONFLUENT • Initially - vascular congestion - erythema - granularity • More severe: - Friability/ Bleeding surface - Erosions - Ulcers • Atrophies > pseudopolyps • HEALING/Remission • Absent above in all visible colon segments. Gastro 07;132:763
- 40. In Remission?
- 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
- 42. MAYO Scoring Remission ≤2, Mild 3-5, Moderate 6-10, Severe 11-12 Shroeder, NEJM 1987:317:1625
- 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
- 44. CROHN’s Bristol Medico-Chirurgical Journal Volume 103 (i) February 1988, page 9.
- 45. Appearance of Crohns PATCHY, SKIP LESIONS LOCATION • Erythema, Villous blunting • Aphthous ulcers • Discrete ulcers • Superficial ulcer • Linear Ulcer • Serpiginous ulcer • Cobblestoning • Tranas-mural inflammation • Stricture • Fistula GI clin NA 2002;31:93
- 47. Crohns Activity Score • CDEIS: ulcers, erosions, inflammation - Complex 0-44 - Difficult - Not Validated • SES-CD: Simple Endoscopic Score - No consensus validation - Score 0-60 • Rugeerts Score: aphthous, inflammation, ulcers, narrowing - On for prospective recurrenced, - No endpoint for healing Daperno,Gastro 2002;122:A216,- Mary,GUT 1989;30:983,- Rutgeerts Gastro 1990;99:956
- 48. Cohn's Severity
- 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?
- 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)
- 59. Inflam Bowel Dis. 5-6:8;2000
- 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
- 63. Rutgeert’s Score (Risk after surgery) GIE 2015;81:1103
- 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