Superior predictive value of transmural over endoscopic severity for colectomy risk in ulcerative colitis: a multicentre prospective cohort study

Abstract

Background and Aims Endoscopic activity is associated with an increased risk of surgery in patients with ulcerative colitis (UC). Transmural activity, as defined by Milan Ultrasound Criteria (MUC) >6.2, reliably detects endoscopic activity in patients with UC. The study aimed to assess in UC patients whether transmural severity is a better predictor of colectomy as compared to endoscopy. Methods Consecutive adult UC patients were recruited in two IBD Referral Centers and underwent colonoscopy and intestinal ultrasound in a blinded fashion. The need for colectomy was assessed at follow-up. Univariable and multivariable logistic and Cox regression analyses were performed. ROC analysis was used to compare MUC baseline values and Mayo Endoscopic Scores (MES) in predicting colectomy risk. Results Overall, 141 patients were enrolled, and 13 underwent colectomy in the follow-up period. Both MES (HR: 3.15, 95% CI: 1.18–8.37, p=0.02) and MUC (HR: 1.48, 95% CI: 1.19–1.76, p <0.001) were associated with colectomy risk, but only MUC was independently associated with this event at multivariable analysis (HR: 1.46, 95% CI: 1.06–2.02, p=0.02). MUC was the only independent variable associated with colectomy risk in patients with clinically active disease, OR: 1.53 (1.03–2.27) P=0.03. MUC demonstrated higher accuracy than MES (AUROC 0.83, 95% CI: 0.75–0.92 vs. 0.71 95% CI: 0.62–0.80) and better performance for predicting colectomy (p=0.02). The optimal MUC score cut-off value for predicting colectomy, as assessed by the Youden index, was 7.7. Conclusions A superior predictive value was found for transmural versus endoscopic severity for colectomy risk in UC patients.

Leaving behind the Mucosa: Advances and Future Directions of Intestinal Ultrasound in Ulcerative Colitis

“…Notably, MUC, over EMS and even BWT, was the only significant predictor of Cox proportional hazard regression analysis (1.48, 95% CI 1.19-1.76, p < 0.001). The authors identified an optimal cut-off value of 7.7 for MUC in predicting the risk of colectomy with an AUC of 83%, performing better than EMS (71%, p = 0.02) [40]. These results strengthen the feasibility of IUS tight monitoring in UC follow-up.…”

“…In fact, the capability of safely and noninvasively predicting UC's long-standing course could potentially reduce hospitalizations, increasing surgical sparing and reducing the need for drastic rescue therapies. In this setting, the results of the studies by Piazza O. Sed and colleagues and Ilvemark and colleagues represented an innovative breakthrough in the understanding of IUS in UC [40,50]. The rectum is the main downside burdening IUS's role in UC management.…”

“…This organization effort also opened the road to several attempts at learning standardization in other Another issue for IUS is the lack of standardization of parameters to meet consensus among IBD ultrasound experts on how to define remission and treatment response. MUC score is the most efficient activity grading score designed specifically for UC able to accurately predict not only disease activity [39] and response to treatment [38], but also the long-term outcome of the disease, especially the risk of colectomy, drastically improving tight monitoring feasibility of the technique [40]. In fact, the capability of safely and noninvasively predicting UC's long-standing course could potentially reduce hospitalizations, increasing surgical sparing and reducing the need for drastic rescue therapies.…”

“…This was the first study evidencing a potential correlation between IUS parameters and negative outcomes of UC long term, suggesting a clear role of IUS as a fast and efficient assessment tool in UC monitoring [39]. Recently, Piazza and colleagues prospectively followed up with 141 patients for a median of 21.9 months, reporting a higher MUC value in those patients undergoing colectomy for persisting refractory disease versus non-operated patients (9.4, 8.9-11.1 versus 6.4, 4.2-8.9, p ≤ 0.001), together with mean BWT values (5.3, 4.9-6.7 mm versus 4.1, 3.0-5.0 mm, p ≤ 0.001) [40]. Moreover, no MUC ≤ 6.2 patients at baseline later underwent surgery compared to 16.4% of patients showing MUC ≥ 6.2 (p < 0.001) [40].…”

“…Recently, Piazza and colleagues prospectively followed up with 141 patients for a median of 21.9 months, reporting a higher MUC value in those patients undergoing colectomy for persisting refractory disease versus non-operated patients (9.4, 8.9-11.1 versus 6.4, 4.2-8.9, p ≤ 0.001), together with mean BWT values (5.3, 4.9-6.7 mm versus 4.1, 3.0-5.0 mm, p ≤ 0.001) [40]. Moreover, no MUC ≤ 6.2 patients at baseline later underwent surgery compared to 16.4% of patients showing MUC ≥ 6.2 (p < 0.001) [40]. Notably, MUC, over EMS and even BWT, was the only significant predictor of Cox proportional hazard regression analysis (1.48, 95% CI 1.19-1.76, p < 0.001).…”