Comparison of transmural healing and mucosal healing as predictors of positive long-term outcomes in Crohn’s disease

Abstract

Background: Transmural healing (TH) is being increasingly recognized for reflecting deep remission in Crohn’s disease (CD). The long-term clinical significance of achieving TH is still not fully known. We aimed to evaluate TH as a predictor of long-term positive outcomes using intestinal ultrasonography (US), with comparison with the established endpoint mucosal healing (MH). Methods: CD patients were consecutively recruited from September 2015 to August 2018 at a single tertiary hospital. All patients were evaluated at baseline and followed up at 6 months prospectively with a guideline-based treatment regimen. Achieving TH/MH or not was evaluated by US/colonoscopy at the first follow-up. Long-term outcomes including steroid-free clinical remission (CR), drug escalation, hospitalization, and surgery, were recorded after at least another 12 months. Results: We identified 77 patients with a median age of 30 years (range, 12–73 years). Twenty-five (32%) patients achieved TH, and 31 (40%) patients achieved MH. TH and MH were poorly correlated (Cohen’s κ = 0.387; p < 0.05). Univariate analysis showed that both MH and TH were associated with better long-term outcomes. In multivariate analysis, TH was an independent predictor of steroid-free CR [odds ratio (OR), 52.6; p < 0.001], drug escalation (OR, 0.1; p = 0.002), and hospitalization (OR, 0.05; p = 0.005), while MH was an independent predictor of drug escalation (OR, 0.3; p = 0.05). Smoking habit was the only predictor of surgery (OR, 6.6; p = 0.02). Conclusion: TH is an independent predictor of more favorable long-term outcomes than MH, suggesting that TH could become the potential treatment endpoint in CD. Plain language summary Transmural healing predicts good prognosis in Crohn’s disease The therapeutic endpoints of Crohn’s disease keep evolving. The long-term clinical significance of achieving transmural healing is not fully discovered. Transmural healing is an independent predictor of more favorable long-term outcomes than mucosal healing. Transmural healing could become the potential treatment endpoint in Crohn’s disease.

The value of multi-modes of ultrasound in evaluating segmental mucosal healing in patients with Crohn's disease

“…[ 42 , 54 ]. In previous studies, as one significant step of TH, MH was not directly reflected by cross-sectional imaging [53] .…”

The Impact of Intestinal Ultrasound on the Management of Inflammatory Bowel Disease: From Established Facts Toward New Horizons

“…For instance, Civitelli et al ( 27 ) added the complete normalization of vascularization assessed by using Doppler US, normal bowel wall stratification, absence of mesenteric fat hypertrophy, nodes enlargement, and disease complications (i.e., strictures, fistulas). Ma et al ( 26 ) used these same features to define TH.…”

“…A prospective, longitudinal cohort study ( 26 ) conducted in a single tertiary hospital in China investigated the impact of TH assessed with IUS on long-term positive outcomes compared to mucosal healing. Both the mucosal healing and TH were associated with better long-term outcomes based on the univariate analysis, while in the multi-variate analysis, TH was an independent predictor of steroid-free CR [odds ratio (OR), 52.6; p < 0.001], drug escalation (OR, 0.1; p = 0.002), and hospitalization (OR, 0.05; p = 0.005).…”

Recent advances in clinical practice: advances in cross-sectional imaging in inflammatory bowel disease

“…Point-of-care IUS to monitor disease activity promises to enable earlier treatment optimisation. Long-term patient outcomes are better when transmural healing is achieved compared with endoscopic mucosal healing only, although inconsistencies between cross-sectional and endoscopic assessment need to be clarified 8 9. While both approaches measure disease activity, cross-sectional techniques can also monitor disease progression, demonstrating the progression of cumulative bowel damage,10 11 an important endpoint in disease modification trials.…”

“…Long-term patient outcomes are better when transmural healing is achieved compared with endoscopic mucosal healing only, although inconsistencies between cross-sectional and endoscopic assessment need to be clarified. 8 9 While both approaches measure disease activity, cross-sectional techniques can also monitor disease progression, demonstrating the progression of cumulative bowel damage, 10 11 an important endpoint in disease modification trials. However, more prospective studies are needed to determine the best use of cross-sectional imaging techniques during treatment follow-up and how to optimise their role in conjunction with non-invasive biomarkers and/or endoscopy.…”