Pancolonic Endoscopic and Histologic Evaluation for Relapse Prediction in Patients With Ulcerative Colitis in Clinical Remission

Miyuki Kaneshiro; Kento Takenaka; Kohei Suzuki; Toshimitsu Fujii; Shuji Hibiya; Ami Kawamoto; Maiko Motobayashi; Hiromichi Shimizu; Masakazu Nagahori; Eiko Saito; Ryuichi Okamoto; Kazuo Ohtsuka; Mamoru Watanabe

Disclosures

Aliment Pharmacol Ther. 2021;53(8):900-907. 

In This Article

Abstract and Introduction

Abstract

Background: Mucosal healing is an important treatment target in patients with ulcerative colitis.

Aims: To explore the optimal colonoscopic strategy to determine the risk for clinical relapse in patients with ulcerative colitis.

Methods: We enrolled 325 consecutive patients with ulcerative colitis in clinical and biochemical remission from April 2018 to March 2019. Five colonic segments were endoscopically and histologically assessed systematically. For endoscopic evaluation, we used three different modes of the Ulcerative Colitis Endoscopic Index of Severity (UCEIS): "original," "worst affected," and "pancolonic." The Geboes score was used for histological evaluation. We prospectively followed up the patients and defined clinical relapse as the primary endpoint.

Results: Within 1 year after colonoscopy, 18.2% of patients experienced a clinical relapse. Receiver operating characteristic curve analysis showed areas under the curve of 0.755, 0.817, and 0.852 for the "original," "worst affected," and "pancolonic" groups, respectively; hence, pancolonic UCEIS obtained the highest predictive value. Using the pancolonic UCEIS cutoff value of 3, Kaplan–Meier curve analysis showed that patients with endoscopic activity had a significantly lower relapse-free rate than those with endoscopic remission (P < 0.01). Multivariate analysis demonstrated endoscopic (pancolonic UCEIS >3) and histological (Geboes >3.0) activities as independent risks for relapse (HR: 3.96 and 3.48, respectively). Combining pancolonic UCEIS ≤3 and Geboes score ≤3.0 to provide 1-year relapse avoidance was 92.0% sensitive and 97.0% specific.

Conclusion: Evaluating disease remission by complete colonoscopy is relevant, and the combination of pancolonic endoscopic and histological evaluations may appropriately evaluate mucosal healing.

Introduction

Endoscopic assessment of inflammation severity is critical when clinically managing patients with ulcerative colitis. In ulcerative colitis, mucosal healing is the important treatment goal, and achieving it has been associated with relatively low relapse, few hospitalisations, and surgery prevention.[1–3] Compared with clinical assessment, mucosal healing is a feasible and more beneficial strategy that can help guide treatment optimisation in patients with ulcerative colitis.[4]

However, achieving mucosal healing through an endoscopy-based approach has several limitations. First, although numerous endoscopic scoring systems for ulcerative colitis including the Mayo Endoscopic Score[5] and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS)[6,7] have been generally used, especially in clinical trials, endoscopic remission is differently defined amongst previous studies.[8] Second, patients may display patchy healing, but the outcomes of partial mucosal healing remain unreported. The UCEIS is a scoring system that has less variability amongst endoscopists[6,7] and exceeds the Mayo Endoscopic Score in predicting prognosis.[9] Originally, the UCEIS score was only used for the most severe colonic area and not for the evaluation of the extent of the disease activity. Furthermore, the true severity may be underestimated because endoscopic evaluation is often limited to flexible sigmoidoscopy, owing to complications and patients' tolerance.[10] Finally, even in cases with apparent endoscopic remission, the histological activity may be seen in the colonic mucosa, and histological remission might be another goal that can predict clinical outcomes.[11] Therefore, histological assessment is an adjunct to endoscopic assessment,[12] and their combination could be a new endpoint of mucosal healing.[13] However, optimal approach of using histology has not yet been appropriately defined.

In this study, we aimed to prospectively evaluate the colonoscopic strategy to determine the risk of clinical relapse in patients with ulcerative colitis in remission. Specifically, we examined whether the extent of the disease on the pancolonic evaluation might predict the prognosis.

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