Bowel Ultrasound and Mucosal Healing in Ulcerative Colitis

Abstract

Background and Aim: Mucosal healing (MH) after short-term medical treatment is being considered as an important step in the therapeutic work-up of inflammatory bowel disorder (IBD) patients due to the potential prognostic role of MH in predicting disease outcome. However, IBD patients are reluctant to be re-endoscoped during follow-up; therefore, there is a need for non-invasive alternative index of MH which can replace endoscopy in clinical practice. We evaluated bowel ultrasound (US) as a surrogate of colonoscopy in a series of consecutive patients with active ulcerative colitis (UC). Patients and Methods: 83 patients with moderate to severe UC requiring high-dose steroids were initially recruited; endoscopic severity of UC was graded 0–3 according to Baron score, and US severity was also graded 0–3 according to the colonic wall thickening and the presence of vascular signal at power Doppler. 74 patients responsive to steroids and then maintained on 5-ASA compounds were followed up with repeated colonoscopy and bowel US at 3, 9 and 15 months from entry. Concordance between clinical, endoscopic and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of Truelove, Baron and US scores measured at 3 and 9 months on the development of a UC relapse (Baron score 2–3) at 15 months. Results: An inconsistent concordance was found over time between 0 and I Baron scores and Truelove score (weighted κ between 0.38 and 0.94), with high and consistent concordance between 0 and I Baron scores and US scores (weighted κ between 0.76 and 0.90). On logistic regression analysis, a moderate/severe Baron score, regardless of their Truelove score, at 3 months was associated with a high risk of endoscopic activity at 15 months (OR 5.2; 95% CI: 1.6–17.6); similarly, patients with severe US scores (2–3) at 3 months had a high risk of severe endoscopic activity at 15 months (OR 9.1; 95% CI: 2.5–33.5). Discussion: In expert hands bowel US may be used as a surrogate of colonoscopy in evaluating the response to high-dose steroids in severe forms of UC. US score after 3 months of steroid therapy accurately predicts clinical outcome of disease at 15 months.

Bowel Ultrasonography in Inflammatory Bowel Disease

“…In CD, the wall thickness directly correlates with disease activity as determined by the CD Activity Index (CDAI) or the Harvey-Bradshaw Index (HBI) [7]. In UC, high concordance was demonstrated between endoscopic activity and ultrasound scores [8,9]. The upper limit of the wall thickness in the colon is 3 mm, and the upper limit in the small bowel is 2 mm.…”

“…Sensitivity is higher in the sigmoid and descending colon with a sensitivity up to 97% [22], but low for rectal disease (15%) [8]. High concordance between endoscopic disease activity and ultrasound scores have recently been demonstrated suggesting that bowel ultrasound might be able to determine mucosal healing in UC [8,9,41]. The typical morphological signs in UC are thickening of the mucosa and thickening of hyperechogenic submucosa, which reflects edema of the submucosa.…”

The importance of intestinal ultrasound and elastographic techniques in inflammatory bowel diseases

“…Unlike CD, thickening of the intestinal wall is not constantly correlated with the clinical activity of the disease in UC [88]. While in cases of mild relapse there is no or inconsistent concordance between the bowel wall thickness and clinical and endoscopic scores, in moderate or severe UC, bowel wall thickness can be used as a surrogate for colonoscopy and CRP for monitoring the course of the disease and the response to therapy [89,90].…”

“…Nonetheless, the actual evidence suggests that US findings, bowel wall thickness in particular, correlates with clinical and endoscopic scores both before and after therapy; the results of the studies suggested the effectiveness of US in evaluating treatment response as well as in assessing UC extension [91,92]. It has been pointed out that the US aspect of the intestine after 3 months of therapy can predict the outcome of UC at 15 months, as accurately as endoscopic scores [89,92]. Also, some studies suggest that Doppler US of the superior and inferior mesenteric arteries can be used for assessing the disease severity and the relapsing risk [93,94].…”

Integrating Imaging into Clinical Practice in Inflammatory Bowel Disease

“…2 ). Furthermore, endoscopy has not been compared to other strategies of monitoring of therapy success such as calprotectin or US [4,16,17] .…”