Ana Ignjatovic

Optimising monitoring in the management of Crohn's disease: A physician's perspective

Management of Crohns disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohns disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.

Comparison of ulcerative colitis surveillance strategies. an analysis of cost-effectiveness

Introduction The latest (2010) British Society of Gastroenterology (BSG) guidelines on colonoscopic surveillance in colitis (1) propose surveillance intervals based on risk of dysplasia determined by endoscopic and histological findings using pan-colonic chromoendoscopy. The 2010 surveillance strategy is projected to be significantly more cost-effective than previous BSG guidelines (2002). Our unit employs a two-tiered strategy using high-risk features including and additional to those of the BSG 2010 guidelines. We aim to compare the different surveillance guidelines (BSG 2002, BSG 2010 and two tier strategy) with respect to cost of surveillance and detection of endoscopically visible dysplasia. Methods Patients who had a surveillance colonoscopy for colitis between 2003 and 2008 and had an endoscopic resection of a dysplastic lesion were identified from the endoscopic database. Colonoscopy and histopathology reports and clinical notes were reviewed. Surveillance intervals, based on the findings of predysplasia colonoscopy, were predicted using each of the three strategies. The cost of colonoscopy was based on national tariff cost of £476. If the colonoscopy at which dysplasia was detected was within the predicted surveillance interval, the surveillance strategy was deemed to have been successful at detecting dysplasia. Results Twenty-six patients meeting inclusion criteria were identified. 16 (60%) patients were male. The median age was 66 years (IQR 47–70 years) and the median duration of disease 23 years (IQR 17–33 years). The calculated cost of surveillance per year for the 26 patients was £7933 for BSG 2002 guidelines, £5522.6 for BSG 2010 guidelines and £11 107 for two-tiered strategy. Using BSG 2002 guidelines, 22 of 26 patients (85%) would have a surveillance colonoscopy that would have detected dysplasia, 12 of 26 (46%) according to BSG 2010 guidelines and 24 of 26 patients (92%) according to two-tiered strategy. Conclusion BSG 2010 guidelines are less costly than BSG 2002 guidelines and two-tiered strategy. However, using the surveillance intervals based on BSG 2010 guidelines would not have detected as many patients with dysplasia as BSG 2002 guidelines or two-tiered strategy. However, as the outcome of low-grade dysplasia in colitis is not certain, it is unclear whether that would have altered patient outcomes. Prospective audit of patient outcomes using 2010 surveillance intervals is needed to assess the effect of delayed detection of dysplastic lesions in ulcerative colitis.

A randomised trial of NBI for adenoma detection in high risk groups: flat adenomas, bowel preparation and endoscopist sub-group analysis

Introduction Narrow band imaging (NBI) has been investigated as a technique to improve adenoma detection; however most randomised studies have shown no differences from white light examination (WLE). We recently reported no significant difference in adenoma detection rate for our trial of NBI for detection in high risk patients (n=214; 73% NBI vs 66% WLE, p=0.26)1; however patients were not evenly matched by gender in NBI and WLE groups. We therefore undertook a multivariate analysis to account for this and investigate other subgroups Methods The primary outcome measure, patients with at least one adenoma detected, was reanalysed after adjustment for demographic and clinical variables including all of: age, gender, indication (3+ adenomas, cancer follow up, +ve FOBT), family history of colorectal cancer, bowel preparation (good or adequate), endoscopist (three operators), and withdrawal time, using logistic regression. Count outcomes (polyp numbers by type) were analysed by Poisson regression. An interaction was noted with both endoscopist and bowel preparation, which were analysed as subgroups Results Following multivariate analysis there was no significant difference for the primary outcome measure between WLE and NBI arms, p=0.30, OR (adjusted) 1.46 (95% CI 0.72 to 2.96). No difference was seen for total number of adenomas, total polyps, advanced adenomas or non-adenomatous polyps; however the mean (SD) number of flat adenomas was higher in NBI arm 0.4 (0.9) versus 0.2 (0.4), adjusted comparison ratio 2.58 (1.42–4.68), p=0.002. One of three endoscopists performed significantly better with NBI (table 1). In patients with good bowel prep NBI significantly outperformed WLE for numbers of adenomas detected, but there was no difference with adequate bowel prep (table 1). Table 1 OC-091 Comparison ratios for numbers of adenomas detected by WLE or NBI Subgroup Ratio (95% CI) p value Endoscopist A 1.05 (0.83 to 1.34) 0.67 Endoscopist B 1.92 (1.07 to 3.44) 0.03 Endoscopist C 0.71 (0.38 to 1.32) 0.29 Adequate bowel prep 1.01 (0.82 to 1.23) 0.94 Good bowel prep 1.55 (1.11 to 2.16) 0.01 Conclusion Overall, after adjustment, NBI did not improve adenoma detection; however detection of flat adenomas appears improved. One of three endoscopists performed better with NBI than white light, and NBI was more effective in patients with good bowel preparation. Under optimal conditions, NBI may assist some endoscopists to optimise detection particularly of flat adenomas. Aggregated results of randomised controlled trials may obscure situations where advanced imaging techniques could provide benefit. ClinicalTrials.gov identifier NCT00279357.

Randomised multicentre trial of narrow band imaging (NBI) for dysplasia detection at colonoscopic surveillance in ulcerative colitis

Introduction Chromoendoscopy at colonoscopy for surveillance in colitis, improves detection of dysplastic lesions by 3–4 fold, but has not gained widespread acceptance due to perceived increase in time for the procedure. Narrow band imaging (NBI) has been described as ‘electronic chromoendoscopy’. The aim of this trial was to assess the effect of NBI on dysplasia detection in colitis. Methods 112 patients with long-standing UC were randomised in a 1:1 ratio to intervention group of examination with high definition NBI (n = 56) or to a control group of high definition WLE (n = 56) for colonoscopic extubation (Lucera; Olympus, Tokyo) in a parallel group design at 2 tertiary endoscopy units in the UK (6 endoscopists). Targeted biopsies of suspicious areas and quadrantic random biopsies every 10 cm were taken in both groups. The primary outcome measure was the proportion of patients with at least one area of dyplasia detected, which was analysed on an intention-to-treat basis. Outcome data were compared between the groups, both unadjusted and adjusted for withdrawal time, family history of colorectal cancer and previous history of dysplasia. Results There was no difference in the primary outcome between the two groups, with five patients having at least one dysplastic lesion in each group (OR 1.00, 95% CI 0.27 to 3.67, p = 1.00), nor when adjusted for other variables (OR 0.69, 95% CI 0.16 to 2.96, p = 0.62). Overall dysplasia detection was 9% in each arm. During NBI colonoscopy, 17 endoscopically suspicious lesions were detected in 13 patients. Histopathology confirmed five dysplastic lesions in five patients (all five low-grade dysplasia).In the WLE arm, 11 suspicious lesions were detected in 8 patients and 7 lesions (in 5 patients) were neoplastic (low-grade dysplasia, n = 5 and high-grade dysplasia n = 2). Although there was a trend that NBI detected more false positive lesions, this was not statistically significant (p = 0.06). Yield of dysplasia from random non-targeted biopsies was 1/2707 (0.04%). Conclusion Overall in this multi-centre parallel group trial, even after adjustment, there was no difference in dysplasia detection when using NBI compared to high definition WLE colonoscopy. This confirms previous single centre tandem data, which suggests no improvement with NBI for colitis surveillance. Random background biopsies were ineffective in picking up dysplasia and we would therefore support the use of chromoendoscopy and targeted biopsies as the current endoscopic surveillance strategy of choice as suggested in the 2010 BSG guidelines.