Dr. Javier Martín de Carpi
Hospital Sant Joan de Déu. Barcelona
SPECIAL FEATURES OF PAEDIATRIC GASTROINTESTINAL ENDOSCOPY
Paediatric patients have physical and emotional peculiarities, a peculiar cognitive development, phenotype and presentation of inflammatory bowel disease (IBD) all of which determine the need for a differential and customised approach compared to adult patients. This reality, applicable to therapeutic regimens, should also be considered in diagnostic techniques, including gastrointestinal endoscopy. It is a commonly-accepted fact that diagnostic-therapeutic gastrointestinal endoscopy should be encompassed within the practice of paediatric gastroenterologists with knowledge and experience in paediatric patients and their pathology, and with sufficient training in endoscopic techniques applicable to these patients. Sometimes these techniques are carried out by certain paediatric surgery departments, essentially due to their tradition in developing intervention techniques in paediatric care. Without doubt, these being techniques requiring a learning curve and accumulated experience, close collaboration must be established with the adult endoscopy departments for advanced examinations, such as endosonography, enteroscopy, retrograde cholangiopancreatography, or for basic techniques in centres where there are no specialists in paediatric gastroenterology with experience in endoscopy. In these cases, it will be necessary for the adult endoscopists and the paediatric team or paediatric gastroenterology department to get together and collaborate in order to work collectively.
In regards to performing endoscopy on a paediatric patient, it is important to consider a series of differential aspects prior to planning the test. On one hand, the importance of psychosocial factors in the patient and family members, such as reports of previous anxiety, fear of intravenous placement or separation from parents during the performance of the tests. Obtaining an accurate and complete medical history will also be relevant, as well as a detailed physical examination, since having as much information possible is important when looking for specific manifestations of certain paediatric gastrointestinal diseases. On the other hand, the need to provide information about the procedures adapted to the age and sociocultural level of the patient and family members or guardians must be considered, as well as the specific implications entailed in the fact that signing the informed consent is not
the responsibility of the patient who will undergo the endoscopy, but rather of the parent or person responsible for the patient. Other important aspects include the need to customise the bowel cleansing techniques in children and adolescents based on age, weight, medical condition and compliance, adjusting fasting periods as much as possible, and the general recommendation to perform the endoscopy under sedation/anaesthesia.
Endoscopy preparation should begin prior to the day of the test. Ideally, preparation should be done by way of an outpatient pre-endoscopy visit, or in a specific meeting during hospitalisation, and and it can be carried out by a nurse involved in the endoscopy. The most effective preparation must include a plan to educate the family. Said education is an invaluable mechanism to dispel parents’ fears and concerns. Various techniques have been described as part of this educational plan: videos, charts, diagrams, etc. Therapeutic play consists of a series of structured activities designed according to age, cognitive development and psychosocial aspects in order to promote the physical and psychological well-being of the hospitalised child. Recent works show the benefits of this strategy in preparing for surgical interventions and gastrointestinal endoscopy in paediatric patients1,2. With this objective, various elements can be utilised such as informative books and brochures, dolls that simulate the various interventions to be performed (venopuncture, surgical interventions, colonoscopies, etc.) or various games related to the disease and the doctor-patient relationship.
In regards to pre-colonoscopy bowel cleansing, there are no commonly-accepted protocols. Therefore, in most cases, many opt for adapting the protocols used on adults. In 2010, a group of Israeli experts established the first recommendations for such protocols, determining the most adequate regimens based on the existing evidence according to age groups3.
Both the patient and family often express anxiety regarding separation during the procedures, which is why the topic should be addressed during the preparation phase. It has been proven that the parents’ presence during the induction of anaesthesia in paediatric procedures reduces stress for both the patient and the parents themselves, which is why it is recommended as standard practice4. Objects commonly used by the child, such as dolls, toys or blankets can provide additional comforts and should remain with the child during the process, and this should be communicated beforehand. One must inform the parents that the induction of anaesthesia is not always pleasant. It is important that they understand that reactions like anxiety or loss of inhibition may occur. If parents are aware of this possibility, they will be less likely to be scared or surprised if it occurs. It is also important that the parents are sure beforehand whether they would like to be with the child until the sedation or anaesthesia has taken effect, since sometimes this situation may not be pleasant to see. Nevertheless, it must be taken into consideration that parental presence during these stages of the procedure can be determined by the particular policies of each department or hospital. All families must receive written information in which the logistics of the examination are explained in detail. If possible, an orientation visit to the endoscopy room is a significant reinforcement at this stage of preparation. Care must be taken to ensure that the endoscopy room is decorated in a way that is attractive to the child, in an effort to create a homely, comfortable atmosphere that reduces anxiety, and thus, the degree of sedation required.
Obviously, one of the factors that have favoured the development of paediatric gastrointestinal endoscopy has been the availability of equipment and material adapted to paediatric age. Thus, besides being able to use standard colonoscopes (11.7–13 mm in diameter) for adolescent patients, there are smaller colonoscopes on the market (less than 11.7 mm in diameter) useful for performing colonoscopies in pre-school and school-aged children, and even neonatal fibrogastroscopes, via which colonoscopies are performed on infants. However, based on age and weight, adult gastroscopes can also be used. In regards to biopsy forceps, those that adjust to paediatric endoscopes are for the performance of more superficial biopsies, which minimise the risk of perforation of the wall, in areas with a thinner wall. Lastly, it is important to have auxiliary material available that is also adapted to the size of the child and adolescent (intravenous routes, facial and laryngeal masks, laryngoscopes, endotracheal tubes, etc.), and to adapt the anaesthesia/sedation medication to the adequate dose for paediatric age.
GASTROINTESTINAL ENDOSCOPY IN DIAGNOSING PAEDIATRIC INFLAMMATORY BOWEL DISEASE. PORTO CRITERIA
Performing a complete colonoscopy with ileal intubation is the fundamental tool for diagnosing paediatric IBD and must not be replaced by any other imaging technique (scan for significant leukocytes, ultrasound, barium transit, magnetic resonance or capsule endoscopy), although any of these can be useful and supplemental when adding information to that obtained in the endoscopy.
Several differential characteristics between paediatric and adult IBD determine the diagnostic approach in these patients. On one hand, the entity currently known as IBD unclassified (IBDU), previously named indeterminate colitis, is worth special mention. Compared to the adult population, in which it is estimated to represent 10% of diagnosed cases, up to 30% of IBD-P begins as IBDU. Furthermore, in adults, 80–90% of these forms will over time meet the diagnostic criteria for ulcerative colitis (UC) or Crohn’s Disease (CD), while 60% of paediatric forms keep the same diagnosis. On the other hand, in paediatric CD, the segment affected most often is the colon, which is why sometimes the finding of a more or less extensive colitis does not allow for a differential diagnosis between CD and UC to be established, especially in cases in which diagnosis is based on the performance of a partial colonoscopy without reaching the ileum or the performance of a rectoscopy.
Based on these differential characteristics, the need to obtain as much information as diagnostic techniques can provide seems only logical (Video 1 and Video 2).
In order to establish a firm diagnosis, considering that involvement of the upper tracts (oesophagus, stomach, duodenum) is described in up to almost 50% of paediatric CD, the ESPGHAN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition) established the Porto Criteria in July of 2005 (Fig. 1) for suspected IBD-P, in order to achieve a definitive diagnosis between the different entities encompassed under the term IBD (CD, UC, IBDU) as reliably as possible5.
Basically, the Porto Criteria consists of performing a complete endoscopic test that includes colonoscopy with ileoscopy and upper gastrointestinal endoscopy on any patient who is suspected of having IBD, taking multiple biopsies of all sections examined. Moreover, exploration of the upper tracts of the small intestine with imaging techniques (preferably barium transit) is recommended in all cases, except in those in which the endoscopic findings consistently suggest a diagnosis of UC. Other non-ionising imaging techniques of recent development and generalisation (MR enterography, capsule endoscopy) that are currently being used are already included in the guidelines as preferred alternatives to transit in centres in which they are available.
Complete colonoscopy and ileoscopy
As mentioned, we established the need to perform complete a colonoscopy with biopsies of the entire tract explored (terminal ileum, caecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum) to properly document the location and extent of the inflammation, macro- and microscopically. Therefore, in paediatric IBD, the diagnosis must not be based solely on the findings obtained in a rectosigmoidoscopy or in an incomplete colonoscopy. Ileal intubation with ileoscopy must be one of the key objectives in any colonoscopy. Various test performed on adults report high rates of ileal intubation when the technique is performed by experienced personnel. Cherian et al., in 2004, in a test that assessed the degree of achievement with ileoscopy in more than 2,500 colonoscopies, conclude that ileoscopy was the gold standard when documenting the success of a colonoscopy and that, with experience, it can be performed in at least 85% of the examinations. According to these authors, in expert hands, the procedure does not take more than 3 additional minutes and significantly contributes to ensuring the quality and diagnostic value of the test6. The most recent studies, also in adults, report a 95% ileal intubation rate in colonoscopies7. There is no paediatric data available on the success of ileal intubation in colonoscopies. A recent article written by the ESPGHAN IBD research team prospectively evaluated the diagnostic plan conducted in more than 2,000 new patients diagnosed with IBD in 44 European paediatrician centres in 18 countries (EUROKIDS registry). In it, ileal intubation was reported in 72% of all procedures8. Similarly, another recent work evaluated the data from a single reference site in our country. In this study, the authors report an ileal intubation rate of 88.9% in paediatric patients in which a colonoscopy was performed due to suspected IBD in the 5 years following publication of the Porto Criteria (2005–2009)9.
Ileoscopy in paediatric patients with suspected IBD will provide a better differentiation between CD and UC, which will contribute to minimising the diagnoses of IBDU. Besides, although less common than in the adult form of the disease, isolated ileal or ileocaecal involvement can be the only location of paediatric CD (Fig. 2). In these cases, the diagnostic value of ileoscopy with biopsy increases. The recent SPIRIT registry, which evaluated changes in the incidence of paediatric IBD in our country during the period between 1996–2009, and which collected data from more than 2,000 patients, reported isolated ileocaecal involvement in 26.6% of all patients with CD10. Geboes et al. found endoscopic and histologic abnormalities in the terminal ileum as the only finding in 17% of adult patients investigated due to suspected IBD. In addition, some patients with disease limited to the left colon had terminal ileitis, which determined the reclassification of the disease to CD11. In this regard, the diagnostic value of ileoscopy and ileal biopsy has been reported at 16.7% and 19% respectively in adult patients with colonic IBD5. McHugh et al. report a diagnostic value of the biopsies of up to 40% in patients with suspected CD and up to 17.6& in those with suspected UC12. The same conclusions with respect to the diagnostic value of ileoscopy with biopsy in paediatric patients with IBD have been reported, which reinforces the fact that a histology of limited rectal and sigmoidal biopsies is insufficient when establishing a diagnosis of CD or UC in children13.
Identifying non-caseating granulomas (primarily those distal from the crypts) in biopsies obtained in the endoscopic study significantly contributes to the differential diagnosis between CD and UC. The Heresbach study, which focused on the frequency and signs of granulomas in a cohort of incidental cases of CD in adults, showed that the detection of granulomas increased with the number of samples collected, with the location of the sample having no influence in this finding14.
Other uses for complete colonoscopy would be to identify “atypical” forms of UC. In recent years, we have seen a redefining of some concepts of IBD considered “classic”. Ideas previously considered as immovable in differentiating CD and UC have become arguable. Thus, concepts such as rectal preservation (absolute or relative), the possibility of patchy forms (including “UC at the ends” or periappendicular impairment in distal colitis, reflux ileitis (Fig. 3) (or backwash ileitis) in pancolitis, the impairment of the upper gastrointestinal tracts, or even fulminant transmural inflammation (Video 2), have enriched the traditional view of UC as an always continuous inflammation, with a proximal extension from the rectum and exclusively mucosal involvement. This changing spectrum of the disease also has been described in paediatric population. In a recent analysis of 643 paediatric patients with UC enrolled in the aforementioned EUROKIDS registry, the following were observed:
• Macroscopic rectal preservation in 5% of cases.
• Reflux ileitis in 10%.
• High impairment in 4%.
• Presence of periappendicular (or caecal patch) impairment in 2% of them15.
In order to incorporate these new diagnostic challenges into paediatric practice and establish the use of endoscopy and histology when establishing the differential diagnosis between CD and UC, the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) published a complete guide in 2007 classifying various findings of the typical or atypical forms of ulcerative colitis in children (Table I and Table II). This guide included a great number of histologic differential findings for both entities (classifying them as typical or definitive, uncommon but compatible and incompatible) (Table III), tried to establish a more accurate definition for indeterminate colitis (or IBDU) and proposed a detailed algorithm to establish a firm diagnosis (Fig. 4)16.
Upper gastrointestinal endoscopy
The Porto Criteria recommends oesophagogastroduodenoscopy in any paediatric patient with suspected IBD, regardless of the presence or absence of upper gastrointestinal symptoms, which suggests a fundamental difference with standard practice in IBD adult units. It is considered that the histologic findings of the upper gastrointestinal tract (including the presence of specific lesions [Fig. 5] such as aphthoid ulcers or granulomas) could confirm a CD diagnosis that would otherwise go unnoticed in 11 to 29% of cases.
Complete study of the gastrointestinal tract for an accurate classification
Lastly, another advantage offered when meeting the Porto Criteria will be to establish the extension of the impairment, providing an accurate classification of the forms of both CD and UC. A recent amendment of the Montreal Criteria known as the Paris classification, which is specific for paediatric IBD (Table IV and Table V), established new categories in regards to growth delay in CD and the severity of UC, and partially extended the classification according to location; thus, in the case of CD, it redefines L1 forms as those with exclusive ileal or ileocaecal impairment, in an attempt to avoid the erroneous classification of the ileocaecal forms as ileocolonic or L3, and differentiate forms L4, L4a (with high proximal involvement to the angle of Treitz) and L4b (impairment proximal to the terminal ileum and distal to the angle of Treitz).
Moreover, in regards to UC, a fourth scenario (E4) is currently being considered for cases of pancolitis, which are more common in paediatric age17 (Video 3).
Meeting the Porto Criteria
The Porto Criteria publication has amended the diagnostic strategies developed in sites involved in treating paediatric patients with IBD. Thus, in the aforementioned EUROKIDS registry, the diagnostic strategies carried out between 2004–2009 on 2,087 patients have been assessed, along with their degree of correlation to the recommendations established in the Porto Criteria and the changes observed therein throughout the period of the study.
Noteworthy among the results collected is a gradual increase in the proper completion of the complete endoscopic test (colonoscopy and upper gastrointestinal endoscopy), with levels that increased from 52% to 71%. However, the performance of ileoscopy on all patients did not exceed 72%. The performance of any imaging test on the small intestine was not changed throughout this period (84%), confirming a decrease in the gastrointestinal barium transit of up to 44% and a parallel increase of magnetic resonance and computed tomography (42% and 7% respectively)7.
Compliance with the complete Porto Criteria increased significantly from 45% in the first year of registry to 64% in the fifth year. When differentiating the type of disease, a significant change was observed in the tendency to meet this criteria for patients diagnosed with CD or UC, but not in the case of those diagnosed with IBDU, for which compliance with the Porto Criteria barely increased, up to 44%. It can therefore be suspected that many of these cases classified as IBDU could have benefited from the strict observance of this criteria when establishing a final diagnosis of CD or UC. Remarkably, “large” (>30 new cases/year) met the complete Porto Criteria to a lesser extent (51 %) than smaller sites (<15 new cases/year) or intermediate sites (15–30 new cases/year: 59% and 60% respectively).
Given the data provided by the aforementioned study, with significant variability among the various participating sites, a similar study conducted at a single reference site on paediatric IBD in our country, which was mentioned previously, also attempted to assess the variation in compliance with the Porto Criteria between two periods: the one prior to their publication (January 1999-June 2005) and the second following said publication (July 2005-December 2008)8. The Porto Criteria were met in 495 of the cases throughout the period covered by the study, with significant differences between the two periods (33.3% before publication, 64.8% afterwards). Upper gastrointestinal endoscopy was performed in 58% of cases: 38.9% before versus 72.2% after, finding relevant endoscopic or histologic impairment in the upper tracts in 51% of patients with CD. The performance of a complete colonoscopy with ileoscopy reached 85.2% of all cases, without any differences being observed between the two periods. Depending on the type of disease, ileoscopy was performed in 86% of patients with CD, 81% of UC cases and 100% of patients classified as IBDU. With the data collected in the EUROKIDS study (coming from sites with full geographic dispersion and variability), this work shows the benefits associated with criteria uniformity when performing endoscopic tests. The fact that this study comes from a paediatric gastroenterology department with the ability to have endoscopic techniques performed by the same staff involved in treating IBD patients is probably the reason why the rates at which complete colonoscopies are performed with ileal intubation in these cases are significantly higher, as well as the fact that the percentage of patients diagnosed with IBDU (4.6%) is less than the amount reported in the European registry (9%).
Implementing the Porto Criteria should also allow updated information on the diagnostic yield, (understood as the capability of a technique to detect a disease that would have gone unnoticed with other techniques) to be collected from the proposed endoscopic tests (especially upper endoscopy and ileoscopy). Thus, in the EUROKIDS registry, the diagnostic yield of both techniques in patients with CD was 7.5% and 13% respectively, based on both endoscopic and histologic findings. De Matos studied the findings obtained in 184 children with CD who underwent upper gastrointestinal endoscopy and ileocolonoscopy when diagnosed18. Granulomas were identified in 61% of the patients with a full investigation, including a significant proportion in which a colonoscopy up to the caecum would have been insufficient to reach a diagnosis. According to this article, the biopsies of the upper gastrointestinal tract and the terminal ileum were essential in obtaining a diagnosis in 42% of patients that had granulomas. In this regard, another recent study indicated how, in a cohort of 172 children who underwent gastrointestinal endoscopy due to suspected IBD, up to 11% of the patients with CD had been diagnosed based solely on the detection of granulomatous inflammation in the upper gastrointestinal tract19. Likewise, initial diagnosis based exclusively on ileocolonic biopsies was changed to CD following the histologic study of biopsies obtained in an upper endoscopy in 11% of all patients investigated.
However, although a priori it seems logical that all sites would participate in the same diagnostic policy, reality can be very different. Proper compliance with this criteria requires adequate availability and motivation from the teams involved. Given the existing variability in the care of paediatric patients with IBD (with regards to performing endoscopic techniques, the treatment of the disease by paediatric or adult teams, varying transition age for adult care, etc.) it seems logical to think that the overall approach to these patients by paediatric staff experienced in endoscopic techniques and accustomed to treating the disease in children and adolescents will offer advantages in regards implementing this criteria.
Review of the Porto Criteria
At the heart of the ESPGHAN’s IBD research team, the Porto Criteria are currently in advanced review phase. This is done to integrate the most recent evidence in regards to diagnostic methods of IBD, clearly define the disease subtypes according to the Paris phenotype classification and emphasize existing diagnostic limitations, for the purpose of providing a reliable diagnosis in order to offer personalised care to an entire new generation of paediatric patients with IBD.
Recommendations continue to be the same: base the IBD diagnosis on the combination of clinical signs, physical examination, laboratory tests, upper gastrointestinal endoscopy, colonoscopy with ileoscopy, taking of multiple biopsies of all tracts explored and imaging techniques that analyse the small intestine, except in cases with a firm UC diagnosis. The new contributions of this review are, on one hand, that atypical variants in the occurrence of UC in children are incorporated when establishing a firm diagnosis and, on the other, the attempt to minimise a IBDU diagnosis based on the presence of a series of findings considered more or less compatible with the possibility of UC. For example, the diagnosis of IBDU is defended in cases of colitis in which one of the criteria is defined as very uncommon (<5 % of cases) in UC, and in the diagnosis of CD if more than 2 of these criteria appear. Furthermore, the presence of at least 2 or 3 of the criteria defined as uncommon (5%-10% of cases), would also contribute to it being classified as IBDU.
Another new aspect of this review of the Porto Criteria in 2013 is the recommendation for the use of MR enterography as the imaging technique of choice for diagnosing patients with paediatric IBD (Fig. 6). Capsule endoscopy is considered an alternative technique in analysing the small intestine in cases in which conventional endoscopy and radiologic techniques have not been diagnostic, and for those in which the MR enterography cannot be performed due to reasons inherent to the patient or the availability of the technique. Therefore, the barium bowel transit would be relegated in the IBD diagnosis versus the new non-ionising techniques. In this respect, the longest series has recently been published, in which the findings of small bowel MRI were compared to barium transit findings in 87 paediatric patients with CD20. The authors describe up to 31 of patients in which MR enterography had detected lesions not apparent in the bowel transit. In addition, using histologic findings as standard criteria when defining the impairment of the terminal ileum, barium transit achieved a sensitivity and specificity of 76% and 67% respectively, versus the 83% and 95% offered by MRI. In this regard, and in accordance with the new Porto recommendations, the authors of this work conclude that MR enterography should become the standard imaging technique in children with IBD in sites with proper experience, since it offers the advantages of being a better technique than barium transit and exempt from radiation.
ENDOSCOPY IN THE FOLLOW-UP OF PAEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE
Despite the commonly accepted fact that endoscopy constitutes the method of choice for assessing IBD for diagnosis, there is no consensus with regard to the use of endoscopy during the follow-up of paediatric patients. Theoretically, paediatric IBD presents a series of determinants which would justify close monitoring of the progression of inflammatory mechanisms and the active search of the highest possible level of healing in all aspects (clinical, analytic, endoscopic, histologic and even transmural). On one hand, paediatric IBD normally presents with more severe symptoms, higher level of impairment and poor response to conventional treatments. On the other hand, and unlike the adult form, the paediatric forms of IBD (both CD and UC) (Video 3) have a higher tendency for progression over time, affecting a large number of segments throughout their progression21,22,23. Moreover, in paediatric patients, given the current reservations in regards to the possible role of combined therapy with thiopurine agents and anti-tumour necrosis factor (antiTNF) treatments in the pathogenesis of hepatosplenic T-cell lymphoma, the tendency is to restrict this combination and change to monotherapy, in which case the confirmation of mucosal healing prior to this therapeutic change is ideal (Fig. 7 and Video 4). Therefore, it has commonly been accepted that histologic assessment constitutes the only reliable diagnostic method for assessing IBD activity, since clinical indices are unreliable in this regard for patients of these ages24 and the macroscopic findings many times underestimate both the extent as well as the degree of inflammation25. Paradoxically, while all the aforementioned factors would especially indicate an endoscopic review, the fact that colonoscopy is identified as an aggressive, invasive and uncomfortable test (including bowel cleansing) requiring anaesthesia or deep sedation (with the inherent theoretical risks), leads to a tendency to often limit the number of endoscopic explorations in this patient group .
In this regard, and in parallel to the development of other techniques and markers of disease activity (serological, faecal and imaging), attempts have been made to correlate these indicators with the degree of endoscopic and histologic impairment, although there are little data available in the literatures on paediatric IBD. The first study with regard to children with IBD related the levels of faecal calprotectin with histologic findings, proving its value as a sensitive, specific marker of the relapse of the disease26. These authors’ discoveries were equivalent to a cut-off point of 275 µg/g with previous data that showed the correlation between calprotectin and activity indices in this type of paediatric patient27,28. Furthermore, the authors describe a higher accuracy in the correlation of UC with respect to CD, although higher cut-off points would contribute a higher accuracy in patients with CD. A recent systemic review on the use of faecal calprotectin in the diagnosis of IBD and in the detection of relapses in paediatric patients concludes that it is useful in both scenarios with a sensitivity of between 94.4% and 100% and a specificity of between 71.9% and 100% when detecting relapses for a cut-off point of 50 mg/g, although in this review it is not specified in comparison to the parameter (clinical, endoscopic, histologic) that evaluates its use in the 34 tests analysed29.
In recent years, more and more work is being published based on the experience of performing MR enterography in paediatric patients affected with IBD30,31. Special interest is given to those that have tried to relate the findings of this technique with those that are obtained via endoscopy. Thus, recently Sauer et al. assessed the findings obtained through MR enterography in 119 paediatric patients with CD and assessed the degree of their correlation with other signs of activity such as inflammatory parameters, endoscopic images and histologic findings32. The authors found a notable concordance between the signs of active inflammation in MR enterography and the presence of ulcers in the mucosa, and a moderate concordance with pathological signs, with early stages of inflammation being not as successfully detected. Therefore, MR enterography does not appear to be, to date, the technique of choice for following up on and detecting incipient lesions that could lead to more severe and complicated endoscopic activity.
Therefore, despite the promise of these techniques, in situations in which it is imperative to confirm “deep” or complete endoscopic and histologic healing, considering that this confirmation constitutes a prognostic factor of better disease progression (less progression for complicated forms, less need for surgery, less hospitalisations and even less potential risk of malignancies), disease follow-up should be completed by means of follow-up endoscopies.
These situations can be summarised as:
1. Confirm the inflammatory activity in symptomatic patients, since symptom relapse does not always mean mucosal damage (Fig. 8 and Fig. 9).
2. Confirm an actual treatment failure, excluding other complications such as stenosis or infections (cytomegalovirus).
3. Prior to intensifying or modifying treatments (Video 3).
4. Establish remission level in patients who have achieved clinical remission. In cases in which complete endoscopic and histologic remission has not been achieved, treatment prior to discharge should be intensified to achieve this objective (Video 4).
5. Identify patients with prognostic factors of poor progression. Not all subjects require the same intensive treatments. A series of predictive factors for diseases with an aggressive course have been identified, such as ileal impairment or the combination of ileal and colonic disease, which determine a faster progression with surgery and debilitating disease, respectively. The identification of extensive, deep ulcers also constitutes a predictive factor of an aggressive course (Fig. 7) (Case 3).
6. Control of the post-surgical recurrence.
It has been demonstrated that post-surgical endoscopic recurrence precedes clinical recurrence, with the extent and severity of this recurrence being a predictive factor of the subsequent clinical progression. Endoscopic assessment throughout the year following intervention could help in the treatment decision.
7. Assessment of deintensifying or discontinuation strategies for the treatments. Although the discontinuation of maintenance treatments in paediatric IBD is not standard practice, there are situations in which the clinical stability may suggest the reduction of the number of drugs, the deintensification of biologic treatments that have previously required intensification or the switch from combined antiTNF and immunosuppressant therapy to a monotherapy of one kind or another to avoid intense immunomodulation. Before making any of these decisions, true mucosal improvement or healing should be confirmed via follow-up endoscopy.
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