Clinical Parameters Correlate With Endoscopic Activity of Ulcerative Colitis: A Systematic Review

Abstract

BACKGROUND & AIMS: Optimal management of patients with ulcerative colitis (UC) requires assessment of disease activity-usually by endoscopy, which is invasive, costly, and not risk free. We performed a systematic review to determine whether clinical symptoms correlate with findings from endoscopy assessments of patients with UC. METHODS: We performed a systematic review of publication databases from January 1980 through July 2018 to identify clinical trials and observational studies reporting correlations among symptoms, disease activity index scores and/or patient reported outcomes (rectal bleeding and/or stool frequency), and endoscopic disease activity. Correlations were ascertained in patients with active vs inactive disease and by disease extent and treatment type. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Because of significant heterogeneity, meta-analysis was not possible. Results were synthesized qualitatively and systematically. RESULTS: Our final analysis included 23 studies (1 randomized trial, 22 observational studies) comprising 3320 patients with UC. The studies used a variety of measures to assess clinical activity, endoscopic activity, and measures of correlation (sensitivity, specificity, correlation coefficients, area under the receiver operator curve). Overall, studies were at moderate-high risk of bias. Composite clinical measures, including rectal bleeding and stool frequency, had moderate to strong correlations with endoscopic disease activity; the absence of rectal bleeding identified patients with inactive disease with higher levels of sensitivity than normalization of stool frequency. In general, symptoms correlated more strongly with endoscopic activity in patients with left-sided colitis than extensive colitis. The effect of different medications on the correlation between clinical and endoscopic activity has not been well studied. CONCLUSIONS: In a systematic review, we found a moderate to strong correlation between clinical activity, particularly the combination of rectal bleeding and stool frequency, and endoscopic activity in patients with UC. Although these clinical assessments could help prioritize patients for endoscopic evaluation in resource-limited settings, challenges associated with treating patients based on symptoms alone preclude adaptation of current management algorithms.

Prevalence of endoscopic improvement and remission according to patient‐reported outcomes in ulcerative colitis

“…Their importance in management has been recognised in the consensus guidelines that identify resolution of rectal bleeding and normalisation of stool frequency as treatment targets . Prior work has suggested that the majority of patients with complete resolution of rectal bleeding and normalisation of stool frequency achieve endoscopic improvement (MES 0/1); however, these studies did not evaluate several important factors that may influence endoscopic disease activity including classification of endoscopic remission (MES 0) vs improvement (MES 0 or 1), timing of assessment (post‐induction vs maintenance), evolution in scoring conventions regarding friability or the influences of central scoring of endoscopy. In a pooled analysis of individual participant data for over 2500 participants from pivotal ulcerative colitis clinical trial programs, we have made several important observations, which extend prior work in this arena.…”

“…In ulcerative colitis, the most commonly used patient‐reported outcomes are the rectal bleeding sub‐score (RBS) and stool frequency sub‐score (SFS) of the Mayo score . Two recent systematic reviews which evaluated the operating properties of the RBS and SFS for non‐invasive assessment of endoscopic inflammation concluded that normalisation of these assessments is strongly associated with the presence of endoscopic improvement (Mayo endoscopic sub‐score [MES] 0 or 1) which comprises both endoscopic remission (MES 0) and mildly active disease (MES 1) . Notwithstanding that these reviews underscored the importance of patient‐reported outcome assessment in ulcerative colitis, several limitations remain in our understanding of the relationships between patient‐reported outcomes and endoscopy that warrant further investigation.…”

Effectiveness of vedolizumab dose intensification to achieve inflammatory bowel disease control in cases of suboptimal response

“…These findings could indicate that dose intensification is perhaps more effective for UC than CD but is more likely due to the operating characteristics of the clinical disease activity indices involved. The low baseline HBI in several patients despite objective evidence of active disease is indicative of the fact that clinical disease activity indices used for CD (ie, HBI and Crohn's disease activity index (CDAI)) correlate less well with disease activity than those used for UC 25 26…”

Intestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC study

“…Symptoms often correlate poorly with the endoscopically defined disease in patients with CD, making it challenging to monitor the disease. To some extent, this also applies to UC 3 4. Furthermore, Narula et al in a systemic review and meta-analysis described that many patients still had an abnormal stool frequency despite endoscopic remission 5…”