1. health and fitness
2. disease

GUIDELINE
ASGE guideline: endoscopy in the diagnosis and treatment
of inflammatory bowel disease
Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy
0016-5107/$32.00
doi:10.1016/j.gie.2006.02.005
drugs (NSAIDs)3 can cause mucosal changes mimicking IBD, these agents should be avoided before initial
colonoscopy.
Patients with other colitides can have similar clinical presentations and similar endoscopic features to the patients
with IBD. These colitides include infectious colitis, druginduced colitis, ischemic colitis, and radiation colitis. The
value of endoscopy alone in distinguishing IBD from nonIBD colitides is limited.4 However, the acquisition of the detailed information from index colonoscopy is important for
the differential diagnosis of CD and UC because, once therapy is started, it may obscure discriminating features of CD
from UC such as segmental colitis (patchiness) and rectal
sparing.5,6 In a study of 39 patients with treated UC, 44%
of patients had endoscopic patchiness and 13% had endoscopic rectal sparing; 33% had histologic evidence of patchiness and 15% had histologic sparing.6 At the time of
colonoscopy, attention should be paid to the anal and
perianal area because abnormalities are commonly seen
in the setting of CD. The most useful endoscopic features
(particularly the initial or index endoscopy) used to differentiate CD from UC are segmental colitis (ie, patchiness),
rectal sparing, involvement of the terminal ileum, and
anal or perianal disease. Other endoscopic features suggestive of CD include aphthous ulcers, discrete ulcers, serpiginous ulcers, and cobblestoning of mucosa. However, none
of the endoscopic features is specific for CD or UC.
Ileoscopy is important to distinguish true CD ileitis
from backwash ileitis, which occurs in up to 10% of cases
of active pancolitis in UC.7 Features that favor CD ileitis include discrete ulcers or strictures of the terminal ileum or
ileocecal valve.7-9
UC may progress proximally over time.10 The finding of
inflammatory changes around the appendiceal orifice (cecal patch or periappendiceal patch) in the setting of UC
with an otherwise normal right colon should not be confused with CD.11,12 The clinical implication of cecal patch
is not clear, although a recent controlled study revealed
that patients with UC with cecal patch had a similar rate
of remission, relapse, and proximal extension compared
with those with no cecal patch.12
Endoscopy together with other diagnostic modalities
can differentiate CD from UC in R 85% of patients.13 In
a prospective study of more than 350 patients with IBD
followed up for more than 22 months, index colonoscopy
and biopsy were accurate in distinguishing CD from UC in
558 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
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This is one of a series of statements discussing the use
of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this
text. In preparing this guideline, a MEDLINE literature
search was performed, and additional references were
obtained from the bibliographies of the identified articles
and from recommendations of expert consultants. When
little or no data exist from well-designed prospective
trials, emphasis is given to results from large series and
reports from recognized experts.
Guidelines for appropriate use of endoscopy are based
on a critical review of the available data and expert consensus. Further controlled clinical studies are needed
to clarify aspects of this statement, and revision may be
necessary as new data appear. Clinical consideration
may justify a course of action at variance to these
recommendations.
INTRODUCTION
Endoscopy is an important diagnostic and therapeutic
modality in inflammatory bowel disease (IBD), being useful for both Crohn’s disease (CD) and ulcerative colitis
(UC). Endoscopy is used to make an initial diagnosis of
IBD, distinguish CD from UC, assess the disease extent
and activity, monitor response to therapy, allow for surveillance of dysplasia or neoplasia, and provide endoscopic
treatment, such as stricture dilation.
COLONOSCOPY WITH ILEOSCOPY
Colonoscopy with ileoscopy allows direct visualization
and biopsy of the mucosa of rectum, colon, and terminal
ileum. Unless contraindicated because of severe colitis or
possible toxic megacolon, a full colonoscopy with intubation of the terminal ileum should be performed during the
initial evaluation of patients with a clinical presentation
suggestive of IBD. Because sodium phosphate–based
bowel preparations1,2 and nonsteroidal anti-inflammatory
ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
89% of cases. IBD diagnosis was revised in 4% of cases,
and the diagnosis of indeterminate colitis remained in
7% of cases.14
Mucosal biopsy is a critical component of endoscopic
examination for patients with suspected IBD to differentiate IBD from other causes of colitis such as bacterial infection, ischemia, and NSAID use. Although there is no single
diagnostic pathologic criterion that can definitively establish an IBD diagnosis, biopsy specimens can help differentiate CD from UC and differentiate CD and UC from other
colitides. Specimens should be taken of both diseased and
adjacent normal-appearing mucosa. The biopsy specimens
from different locations should be separately labeled. Several features suggest chronicity (indicating IBD rather
than an acute self-limited or infectious colitis) such as architectural distortion, basal plasmacytosis, increased cellularity of lamina propria, pyloric gland metaplasia, and
Paneth cell metaplasia.15-17 Although the presence of granulomata suggests CD, the frequency of detection of granulomas varies from 15% to 36% of endoscopic biopsy
specimens.18 Higher detection rates of granulomas can
be achieved when biopsy specimens are taken from the
edge of ulcers and aphthous erosions.19 Granulomas are
not pathognomonic for CD and they can be found in
other disease conditions such as tuberculosis, fungal and
bacterial infections, diversion colitis, sarcoidosis,20 and foreign body reaction (particularly from the suture line in patients with prior bowel resection surgery).
Mucosal biopsy also helps to establish the extent of colon that is inflamed, which aids in determining prognosis,
directing appropriate medical and surgical therapy, and
stratifying risk for dysplasia. The extent inflammation
can be classified as proctitis, left-sided colitis (inflammation up to the splenic flexure), or extensive (inflammation
proximal to the splenic flexure) or pancolitis. Macroscopic
proximal extension of proctitis or left-side colitis occurs in
approximately one third to one half of patients.21,22 However, regression of disease to the extent of pancolitis was
also common after a long duration of disease (eg, 25
years).23 The extent of endoscopic inflammation does
not necessarily correlate with histologic inflammation. Colonoscopy underestimates the extent of disease compared
with histology.24 The extent of colitis (pancolitis, left-sided
colitis, or proctitis) should be based on histologic examination rather than on endoscopy.25
Endoscopy is an objective tool to assess the disease activity of CD and UC, whereas subjective symptoms are not
a reliable indicator of disease severity. Additionally, there is
a poor correlation between symptom scores and degree of
endoscopic inflammation and between clinical remission
and mucosal healing.27 Endoscopy may be helpful in predicting the need for intensified medical therapy or surgical
intervention.28,29 There are numerous disease activity
scores that are based on clinical symptoms or endoscopic
findings.24-26,30 With the use of immunomodulator and biologic therapy for IBD, objective endoscopic findings are
needed to assess response to the therapy.31-33 In more recent pharmaceutical trials, the documentation of endoscopic mucosal healing has become a critical component
of outcome measurement.29,34
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Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 559
FLEXIBLE SIGMOIDOSCOPY
Under certain circumstances, flexible sigmoidoscopy
may provide useful information in patients with IBD. An
adequate diagnosis may be obtained, and it should be performed preferentially when colonoscopy is considered
high risk (eg, fulminant colitis).33 In patients with established UC, flexible sigmoidoscopy may define disease activity and is useful in evaluating for superimposed
colitides including cytomegalovirus (CMV) and Clostridium difficile infections or ischemic colitis when disease
exacerbations occur.
ESOPHAGOGASTRODUODENOSCOPY
Esophagogastroduodenoscopy (EGD) can be a useful in
the evaluation of patients with IBD. Upper gastrointestinal
(GI) tract involvement (proximal to the ligament of Treitz)
occurs in up to 13% of patients with CD.35,36 CD can involve
the esophagus,37 stomach,38 and duodenum.39 It appears
that duodenal biopsy specimens more often display granulomas (40%-68%) than do colon biopsy specimens.39-41 In
patients with indeterminate colitis, upper GI tract involvement can help establish a diagnosis of CD.42 However,
when the upper GI tract is involved in CD, disease is usually
present elsewhere, such as the terminal ileum, colon, or
perianal area. Therefore, routine EGD is not recommended in all patients suspected of having CD. Additionally,
patients with UC may also have upper GI inflammation,
such as diffuse duodenitis.43 Endoscopic features in these
patients include edema, erythema, erosions, and thickened
mucosal folds.44 Histologic examination may show active
chronic inflammation with architectural mucosal distortion,44 villous atrophy, and intraepithelial lymphocytosis.45
Other applications of EGD with small bowel biopsy in patients with IBD include evaluation of concomitant celiac disease43,46 eosinophilic enteritis,45 common variable immune
deficiency,47 and small bowel neoplasia.44,48 In patients with
CD, symptomatic duodenal strictures may respond to endoscopic balloon dilation.49
ENTEROSCOPY
Push enteroscopy has a limited role in the management
of patients with IBD, especially in the era of capsule endoscopy (CE). In patients with abnormalities seen on
other imaging studies that are within reach, push enteroscopy allows endoscopic and histologic evaluation and
therapeutic intervention.50,51 Intraoperative endoscopy
ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
has been used in selected patients with indeterminate colitis at the time of total colectomy and ileal pouch–anal
anastomosis.
radiographic evidence of small bowel narrowing in the setting of CD should not undergo CE. Capsule retention
above a CD stricture may be treated with anti-inflammatory medications, although there are no published
studies.76
CAPSULE ENDOSCOPY
CE allows for direct and minimally invasive visualization
of small bowel mucosa. It may help identify superficial lesions not detected by traditional endoscopy and radiography. It might be useful in the initial diagnosis of CD, for
detecting recurrences, for establishing extent of disease,
for assessing response to therapy, and for differentiating
CD from UC or indeterminate colitis. Data from retrospective studies, case series, and prospective studies have
shown that CE is useful for the diagnoses of CD when
small bowel follow through (SBFT) and ileoscopy are negative or unsuccessful.52-66 The diagnostic yield of CE
ranges from 10% to 71% depending on the clinical setting.
CE has been shown to be more sensitive in the detection
of small bowel CD than is computed tomographic (CT)
enterography,66 SBFT,66 and enteroclysis.67 In patients
with mild to moderate disease and a normal SBFT,68 CE
may allow for the detection of small bowel changes that
are not within reach of push enteroscopy (PE). A recent
prospective study of 42 patients compared SBFT, CT enterography, colonoscopy with ileoscopy, and CE in the assessment of small bowel CD. Of these 4 modalities, CE had the
highest sensitivity (83%) with the lowest specificity (53%)
and colonoscopy with ileoscopy had the highest specificity
(100%) with a sensitivity of 74%.69 A recent study in 39 patients, the majority with known CD, reported CE sensitivity
and specificity of 89.6% and 100%, respectively.70 Few studies have evaluated the benefit of CE in the evaluation of indeterminate colitis. One study found that 5 of 22 patients
with colitis were found to have mucosal breaks in the small
bowel on CE, thus changing their diagnosis to CD.62
The main limitations of CE in the assessment of small
bowel CD are the lack of uniform criteria for diagnosing
CD, inability to allow for tissue acquisition or therapeutic
intervention, and the risk for capsule retention. It is important to note that the finding of mucosal breaks the
small bowel is not necessarily indicative of CD. A variety
of disease entities can cause mucosal ulcerations such as
infection, ischemia, radiation injury, and drug-induced injury, particularly NSAIDs.71 In addition, it has been reported that up to 14% of healthy individuals had
mucosal breaks and other nonspecific lesions on CE.67
Capsule retention in CD patients resulting from underlying small bowel strictures is a major concern, occurring
in 1% to 13% of patients with known CD.72,73 Retained
capsules may require surgery74 in patients that may otherwise have not required surgery. A preingestion radiologic
study (CT or SBFT) is recommended73-75 because asymptomatic CD strictures occur in as many as 22%.73 Patients
with obstructive symptoms or with endoscopic and
560 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006
ENDOSCOPIC ULTRASONOGRAPHY
Ultrasonography (US) including transperineal US and
endoscopic US (EUS) with a rigid scope or with flexible
endoscopes has been used to assess disease activity of colitis, transmural disease,77 fistulae,78-81 abscess,79-81 and regional lymphadenopathy.79 For patients with perianal
disease, EUS can accurately characterize perianal disease
to reduce the risk of incomplete healing, recurrent fistula,
or inadvertent sphincter injury if fistula anatomy is incorrectly delineated or an occult abscess missed at surgery.82
EUS has an excellent accuracy in the assessment of
Crohn’s perianal fistula and abscess.79,83 EUS may be
used to monitor medical and surgical therapy for CD
perianal fistulae.81,84-87 The EUS finding of transmural disease may allow for the differentiation of CD and UC.79-81
ENDOSCOPY IN PATIENTS WITH IBD-RELATED
SURGERY
Ileal pouch endoscopy
Ileal pouch anal anastomosis (IPAA) has become the
surgical treatment of choice for patients with UC who
required colectomy. IPAA significantly improves healthrelated quality of life, although complications can occur.
In addition to the immediate postoperative complications
such as pouch leak and abscess, long-term inflammatory
and noninflammatory complications commonly develop,
including pouchitis, ‘‘cuffitis,’’ irritable pouch syndrome,
and CD of the pouch. Pouchitis is the most common
long-term complication and symptom assessment alone
is not diagnostic.86,88 Endoscopic and histologic assessment allow the diagnosis of pouchitis and exclude other
causes of symptoms.88,89 Pouch endoscopy is also important for the evaluation and management of CD of the
pouch, cuffitis, pouch stricture, and irritable pouch syndrome.90-92 A gastroscope is easier to use than a flexible
sigmoidoscope for pouch evaluation because of its smaller
caliber and greater maneuverability. Endoscopic therapy
such as pouch stricture dilation can be performed.92,93 Endoscopic evaluation is also useful for evaluating symptomatic patients with ileal pouch–rectal anastomoses, Kock
pouches, and Brooke ileostomies.
Colonoscopy after partial colectomy or partial
ileocolectomy. Recurrence of CD after partial colectomy or partial ileocolectomy is common, typically occurring at the surgical anastomosis and neoterminal ileum.
Endoscopic recurrence rates range from 70% to 90%
within 1 year of surgery.30,94,95 Endoscopic recurrence
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ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
typically precedes relapse of symptoms. Changes in the
neoterminal ileum after surgery are the most prognostic
factor for recurrence.96,97 Therefore, some investigators
recommend postoperative colonoscopy with inspection
of the neoterminal ileum 6 to 12 months after resection
to identify patients who are at risk for relapse and who
may benefit from appropriate medical therapy.
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY FOR
PRIMARY SCLEROSING CHOLANGITIS
The role of endoscopic retrograde cholangiopancreatography in patients with primary sclerosing cholangitis
has been addressed in a previous document.98
CANCER SURVEILLANCE
Individuals with long-standing UC and extensive CD colitis are at increased risk for development of dysplasia and
colorectal cancer (CRC) and should undergo colonoscopic
surveillance. The risk of CRC increases with longer duration and extensive severe colitis, family history of CRC,
young age at onset of disease, presence of backwash ileitis, and personal history of primary sclerosing cholangitis.96,97,99,100,101 The presence of proctitis alone does not
increase the risk for CRC. Patients with UC who have
left-sided colitis or more extensive disease are at increased
risk. In Crohn’s colitis, those patients with extensive disease involving more than a third of the colon also have
an increased risk of CRC, similar to patients with
UC.102,103 The extent of colonic involvement should be
based on both endoscopic and histologic criteria, whichever reveals more extensive disease.104 In a case-control
study of UC patients undergoing colonoscopic surveillance, there was a reduction in mortality resulting from
CRC in those patients in surveillance programs.105
Patients with UC or extensive Crohn’s colitis (greater
than one third colonic involvement) should undergo surveillance colonoscopy every 1 to 2 years beginning 8 to 10
years after disease onset.103 Biopsy specimens of the colon in patients with documented pancolitis should be obtained in all 4 quadrants every 10 cm from the cecum to
the rectum, to obtain a minimum of 32 biopsy samples.106,107 In patients with less extensive colitis, biopy
specimens can be limited to the microscopically involved
segments.106,107 Diagnosis of dysplasia should be confirmed by a second gastrointestinal pathologist.103 The
management of dysplastic polypoid lesions is currently
evolving. The presence of high-grade dysplasia or multifocal low-grade dysplasia in flat mucosa is an indication for
colectomy. The management of unifocal low grade dysplasia is controversial as to whether colectomy should be
performed. Biopsy specimens should be obtained of strictures, mass lesions, and macroscopic abnormalities other
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than pseudopolyps.108,109 Adenomatous-appearing polyps
encountered should be completely removed by polypectomy and biopsy samples should be obtained from the adjacent flat mucosa to determine the presence of dysplasia.
If a dysplastic polyp is identified outside an area of inflammation and there is no evidence of dysplasia in the adjacent mucosa, it can be managed as a sporadic polyp
similar to polyps in individuals without UC or Crohn’s colitis. If a dysplastic polyp is in an area of active inflammation (DALM [dysplasia associated lesion or mass]) and is
sessile, not amenable to endoscopic removal and there
is evidence of dysplasia in the adjacent mucosa, colectomy
is indicated.103,106,107,110-113 If a discrete polyp amenable
to polypectomy is found in an area of inflammation, it
should be completely removed and a biopsy specimen
of the mucosa adjacent to the polypectomy site should
be obtained and placed in separate jars.113 Tattooing of
the site should also be considered. If complete removal
was not possible or if there is evidence of flat dysplasia
in any other sites, then a total colectomy is recommended.
The finding of indefinite dysplasia requires repeat colonoscopy in 3 to 6 months and close follow-up.103
There is no clear evidence that surveillance colonoscopy
prolongs survival in patients with extensive colitis.114 However, patients in surveillance programs tend to have cancers
detected at an earlier stage and have a correspondingly
better prognosis, although these findings may be due to
lead-time bias.114 There is indirect evidence that surveillance is effective in reducing the risk of death from IBDassociated CRC and is acceptably cost-effective.114
Chromoendoscopy offers the potential for improved
sensitivity during colonoscopic surveillance by allowing
for targeted biopsies of enhanced mucosal abnormality.
Prospective trials of methylene blue and indigo carmine
staining reported improved detection of dysplasia in patients with UC.115,116 With chromoendoscopy using 0.1%
methylene blue staining, the detection of high- or lowgrade dysplasia in macroscopically normal mucosa was
increased 6-fold with the number of detected flat intraepithelial neoplasia of 24 in the chromoendoscopy group
versus 4 in the conventional colonoscopy group (P Z
.0007).115 In a separate study of back-to-back colonoscopy
and chromoendoscopy using 0.1% indigo carmine spray,
the overall detection rates of dysplasia (2% vs 7%) between the conventional colonoscopy and chromoendoscopy were not statistically different.116 While promising,
chromoendoscopy has not yet been adopted in routine
practice.
STRICTURE EVALUATION AND DILATION
Colonic strictures may complicate CD, and to a lesser
extent UC. In patients with CD, strictures may occur at
the ileocolonic valve, terminal ileum, and ileocolonic
surgical anastomosis and can be asymptomatic. In
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ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease
symptomatic patients, endoscopy is indicated for assessment and biopsy to exclude possible malignancy, especially in the setting of UC, where a stricture should be
considered malignant until proven otherwise. If it cannot
be thoroughly examined and biopsy performed117 surgical
resection should be considered. The finding of a colonic
stricture in the setting of CD is more likely to be benign,
although complete examination with biopsy is recommended. Balloon dilation may be required to completely evaluate the stricture. Endoscopic balloon dilation has been
investigated in patients with Crohn’s strictures of the small
bowel, colon, and anastomosis. The majority of these
studies are retrospective and the main outcome measurement is symptom relief and avoidance of surgery.
Endoscopic balloon dilation may relieve symptoms. Complications include perforation and bleeding.118–121 Corticosteroid injection into the stricture at the time of
balloon dilation may improve outcome.122,123
d
d
d
there is no dysplasia in flat mucosa surrounding the
polyp or elsewhere in the colon (B).
EUS is highly accurate for characterizing perianal
Crohn’s disease (C).
A colonic stricture in the setting of UC should be considered malignant until proven otherwise. If adequate evaluation cannot be performed, then colectomy is
indicated (C).
Chronic benign fibrotic strictures associated with obstructive symptoms may be managed with endoscopic
balloon dilation with or without steroid injections (B).
REFERENCES
Colonoscopy with ileoscopy should be performed in
the evaluation of IBD and for differentiating UC from
CD (B).
Mucosal biopsy specimens are important for the diagnosis of IBD and may help differentiate CD from UC (B).
When colonoscopy is contraindicated, or the extent of
disease is limited, flexible sigmoidoscopy may provide
an adequate diagnosis (C).
EGD or enteroscopy may be helpful for diagnosing IBD
when other studies have negative results and for differentiating CD from UC in indeterminate colitis (B).
CE is a less invasive technique for evaluating the small
intestine for Crohn’s involvement and has been shown
to be more sensitive than radiologic and endoscopic
procedures for detecting small bowel lesions (B).
In patients with CD and known or suspected high-grade
strictures, CE should not be performed (C). Small bowel
follow-through or CT enterography should be obtained
before CE in patients with CD to assess for high-grade
strictures (C).
CRC risk is increased in both UC and extensive Crohn’s
colitis and surveillance colonoscopy with multiple biopsies should be performed every 1 to 2 years beginning
after 8 to 10 years of disease (B).
The finding of dysplasia in flat mucosa, especially if multifocal, is an indication for total colectomy (B). Colectomy is indicated for colorectal cancer, high-grade
dysplasia or low-grade dysplasia (particularly multifocal)
in flat mucosa. A dysplastic mass lesion that cannot be
removed endoscopically, or is associated with dysplasia elsewhere in the colon, is an indication for total
colectomy (B).
Dysplastic polypoid lesions may be managed as sporadic
adenomas provided they are completely resected and
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www.giejournal.org
Volume 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY 565
Prepared by:
STANDARDS OF PRACTICE COMMITTEE
Jonathan A. Leighton, MD
Bo Shen, MD
Todd H. Baron, MD, Vice Chair
Douglas G. Adler, MD
Raquel Davila, MD
James V. Egan, MD
Douglas O. Faigel, MD, Chair
Seng-Ian Gan, MD
William K. Hirota, MD
David Lichtenstein, MD
Waqar A. Qureshi, MD
Elizabeth Rajan, MD
Marc J. Zuckerman, MD
Trina VanGuilder, RN, SGNA Representative
Robert D. Fanelli, MD, SAGES Representative