Increased Epithelial Gaps in the Small Intestine Are Predictive of Hospitalization and Surgery in Patients With Inflammatory Bowel Disease

Abstract

OBJECTIVES:Epithelial gaps resulting from intestinal cell extrusions can be visualized with confocal laser endomicroscopy (CLE) during colonoscopy and increased in normal-appearing terminal ileum of inflammatory bowel disease (IBD) patients. Cell-shedding events on CLE were found to be predictive of disease relapse. The aim of this study was to assess the prognostic value of epithelial gap densities for major clinical events (hospitalization or surgery) in follow-up.METHODS:We prospectively followed IBD patients undergoing colonoscopy with probe-based CLE (pCLE) for clinical events including symptom flares, medication changes, hospitalization, or surgery. Survival analysis methods were used to compare event times for the composite outcome of hospitalization or surgery using log-rank tests and Cox proportional hazards models. We also examined the relationship of gap density with IBD flares, need for anti-tumor necrosis factor therapy, disease duration, gender and endoscopic disease severity, and location.RESULTS:A total of 21 Crohn's disease and 20 ulcerative colitis patients with a median follow-up of 14 (11–31) months were studied. Patients with elevated gap density were at significantly higher risk for hospitalization or surgery (log-rank test P=0.02). Gap density was a significant predictor for risk of major events, with a hazard ratio of 1.10 (95% confidence interval=1.01, 1.20) associated with each increase of 1% in gap density. Gap density was also correlated with IBD disease duration (Spearman's correlation coefficient rho=0.44, P=0.004), and was higher in male patients (9.0 vs. 3.6 gaps per 100 cells, P=0.038).CONCLUSIONS:Increased epithelial gaps in the small intestine as determined by pCLE are a predictor for future hospitalization or surgery in IBD patients.

Use of probe‐based confocal laser endomicroscopy (pCLE) in gastrointestinal applications. A consensus report based on clinical evidence

“…If the mucosa heals, it is thought that disease complications are unlikely to occur and future hospitalisation and surgery requirements should decrease. pCLE has been shown to allow the visualisation of residual cellular inflammation 41,[43][44][45] even when the patient presents clinical symptoms compatible with remission, redefining the term 'mucosal healing' in vivo.…”

“…Many authors refer to the classification established by Kiesslich et al 38 As for CD, Neumann et al 50 recently developed the CDEAS to assess CD activity in vivo. With biomarkers such as epithelial gaps or vessel leakage, [43][44][45] physicians could predict flares and anticipate relapse.…”

“…The statements reported below acknowledged that mucosal healing was an important prognostic feature of the efficacy of treatment in IBD and could be identified with CLE. [41][42][43][44][45] The integration of CLE and the concept of mucosal healing in the patient management strategy should be further defined in order to enable physicians to characterise the mucosa microscopically, to rationalise therapeutic strategies and to initiate or stop treatment when appropriate.…”

“…As CLE is currently mostly performed with an intravenous injection of sodium fluorescein used as a contrast agent to optimise image quality, fluorescein leakage can be assessed and quantified visually as a marker of intestinal barrier dysfunction. [42][43][44][45][52][53][54] IBD8: Surveillance in IBD using CLE should be performed in macroscopically non-inflamed mucosa.…”

Bowel Cleansing Prior to Pediatric Colonoscopy: The Children´s and Parent’s Perspective

“…A safe, informative, and effective colonoscopy, performed in a child-friendly atmosphere with minimal distress to the child, is the recommended practice in the care of children [14]. The role of colonoscopy is crucial for the diagnosis and monitoring of paediatric gastroenterology with as clean a bowel as possible for the appropriate detection of bowel disorders [e.g., 15,16].A variety of bowel cleansing regimens have been evaluated, but the most common in children are polyethylene glycol with electrolytes (PEG) [16,17 ], which is also generally recommended by the ESPGHAN working group as a standard laxative, due to its cleansing efficacy and safety [18]. The recommended intake of PEG is 25-35 ml/kg bodyweight per hour until clear intestinal fluid is obtained, either orally or by nasogastric tube [19].…”