The pediatric IBD Porto Group of ESPGHAN has updated endoscopy guidelines: S Oliva et al. JPGN 2018; 67: 414-430. In total, the authors make 17 recommendations –here are a few of them:
A) In non-emergency situations, the diagnostic evaluation for suspected IBD in children should include a combination of EGD and colonoscopy. Multiple biopsies from each segment are recommended even in the absence of macroscopic disease.
B) Endoscopic evaluation is recommended for the following:
- before major treatment changes
- in symptomatic patients when it is not clear whether the symptoms are inflammation-related
- in Crohn’s disease(CD) to ensure mucosal healing during clinical remission
- in Ulcerative colitis (UC) to ensure mucosal healing during clinical remission only if fecal calprotectin is elevated
C) 6-12 months after bowel resection to identify postoperative recurrence
D) Endoscopic surveillance in pediatric UC after 10 years from the onset of disease (as early as 8 years in older children (>16 years) with risk factors like extensive disease and strong family history
E) In patients with concurrent primary sclerosing cholangitis (PSC), surveillance colonoscopy may be considered every 1-2 years, starting from time of PSC diagnosis. However, in children <12 years of age, surveillance could be postponed based on individual risk factors.
In addition to discussions of conventional endoscopy, the authors favor evaluation of small bowel inflammation: “the choice to perform CE [capsule endoscopy], MRE or both, depends on local availability and expertise.” The authors caution to consider strictures and the potential need for patency capsule prior to CE.
Conclusion of authors: “Endoscopy in pediatric IBD provides a more definitive diagnosis and disease extent evaluation, assesses therapeutic efficacy and leads to targeted therapy, which lessens complications and progression.”
My take: While I agree that endoscopy increases our understanding of disease extent and response to treatment, I do have some concerns about the recommendations (under section B above) regarding assessment of mucosal healing. Part of the concern is that there is not a single accepted definition of mucosal healing. Also, as a practical matter, there needs to be a discussion of the costs and more proof that frequent endoscopy will improve outcomes; it is possible that increased use of endoscopy will lead to some detrimental outcomes in some patients based on the interpretation of the results (eg. dropping a therapy that may be helping and replacing with a less effective treatment)..
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