A consensus guideline from the Global Interventional IBD Group has highlighted the challenges of diagnostic endoscopy in the surgically altered bowel of IBD patients.
The guideline incorporates 76 recommendations covering principles and techniques of endoscopy after bowel resection and anastomosis, stoma, ileal pouch, diverted bowel, strictureplasty and bypass surgery.
The recommendations, published in The Lancet Gastroenterology & Hepatology, follow a literature review and Delphi method incorporating virtual consensus meetings of IBD experts including gastrointestinal endoscopists, radiologists, pathologists and surgeons.
Commenting on the guideline, Professor Rupert Leong told the limbic the high level document has presented valuable consensus in areas where the evidence is scarce.
“Which means that recommendations are based on the subjective opinions of this group of experts. So one of the examples where there is a paucity of data is the diverted bowel.”
Professor Leong, Director of Endoscopy and Head of the IBD Services at Concord Hospital, said one of the complications, diversion colitis or diversion proctitis, was not easily differentiated from the primary IBD.
“It’s a difficult area clinically due to paucity of data and the Group was brave in trying to develop some consensus guidelines in terms of what to do with surveillance. But it tells us it is safe to look at the diverted bowel, that you will get a lot of bleeding and there is a very small change of dysplasia occurring.”
The guideline included advice for endoscopy with minimal air insufflation and superficial biopsy to minimise the risk of bleeding, bacterial translocation, and perforation, as the mucosa of the diverted bowel is often friable.
It also noted that “diversion-associated injury, in contrast to IBD, is characterised by extensive lymphoid aggregates on mucosal biopsy.”
Professor Leong also noted recommendations around the need for endoscopic evaluations of the ileal pouch.
“This Group are able to demonstrate in the literature that there is some consistency in being able to manage a lot of the postoperative complications endoscopically and their bias is to perform pouchoscopies in certain scenarios, to use radiological examination where it is appropriate and to guide the continuing use or cessation of medications prior to doing endoscopic therapy…” he said.
He noted one of the rare complications in an uncommon scenario was the development of cancer or dysplasia in a pouch.
“This is something that is very uncommon but they were able to say that there are basically three indications for surveillance endoscopy: patients who have had surgery for prior dysplasia, those who have had primary sclerosing cholangitis, and those who have Crohn’s disease of the pouch.”
“Therefore you can limit the amount of pouchoscopies to those patients with risk factors.”
Professor Leong said the comprehensive guideline would be particularly useful to less experienced IBD practitioners. In particular, the guideline would support gastroenterologists in some of the postoperative management and evaluation of IBD patients which traditionally might be more in the domain of the surgeon who performed the procedures.
A guidance statement on therapeutic endoscopy for Crohn’s disease strictures have been described in a similar Review article in The Lancet Gastroenterology and Hepatology last year.