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Mucosal healing should be the end goal in treating patients with ulcerative colitis

Mon, 11/27/2017 - 14:01
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The pooled odds ratio for colorectal neoplasia was 3.5 in those with any mucosal inflammation and 2.6 in those with histologic inflammation, when compared with those with mucosal healing

The absence of inflammatory and ulcerative lesions in all segments of the colon – or mucosal healing - should be the end goal in treating patients with ulcerative colitis according to an editorial, ‘Zeroing in on endoscopic and histologic mucosal healing to reduce the risk of colorectal neoplasia in inflammatory bowel disease,’ published in the journal Gastrointestinal Endoscopy. The authors write that an analysis in the study by Flores et al, ‘Impact of Mucosal Inflammation on Risk of Colorectal Neoplasia in Patients with Ulcerative Colitis: A Systematic Review and Meta-Analysis,’ published in the same journal reaffirms the suspicion that ongoing colonic inflammation not only increases the risk of abnormal growth of colorectal tissue (pre-cancer and/or cancer), but also may affect guidelines for surveillance colonoscopies.

"There are several reasons to target mucosal healing in patients with ulcerative colitis, reducing cancer risk being one of them. If we are truly aiming for mucosal healing, this may mean more aggressive medical therapy early in the treatment course even if histologic activity is not necessarily reflected in patients' symptoms," said one of the authors of the editorial, Dr Francis A Farraye, professor of medicine at Boston University School of Medicine and clinical director in the section of gastroenterology at Boston Medical Center.

In the paper, ‘Impact of mucosal inflammation on risk of colorectal neoplasia in patients with ulcerative colitis: a systematic review and meta-analysis,’ the authors from Beth Israel Deaconess Medical Center, Boston, Massachusetts and St James's University Hospital, Leeds, UK, systematically analysed the risk of colorectal neoplasia in patients with ulcerative colitis who have ongoing mucosal inflammation to better inform surveillance strategies.

They performed a systematic review and meta-analysis of the effect of endoscopic and/or histologic inflammation on the risk of colorectal neoplasia in cohort and case-control studies. In total, six studies met the inclusion criteria, incorporating outcomes in 1,443 patients although no study used a single validated measure for mucosal inflammation.

The pooled odds ratio for colorectal neoplasia was 3.5 (95% confidence interval [CI], 2.6-4.8; p<0.001) in those with any mucosal inflammation and 2.6 (95% CI, 1.5-4.5; p=0.01) in those with histologic inflammation, when compared with those with mucosal healing.

“The presence of objective evidence of mucosal inflammation during follow-up in patients with ulcerative colitis is associated with a greater risk of subsequent colorectal neoplasia than in those with mucosal healing,” the authors if the systematic review concluded. “This risk factor should be considered in guidelines on surveillance intervals for these patients.”

"Arguably, the first step is to better define histologic remission and healing. In addition, the use of validated endoscopic scoring systems that provide objectivity, uniformity and standardisation in reporting mucosal appearances, augmenting clinical decision making and ultimately affecting appropriate treatment targets and desirable patient outcomes," said Farraye.

“The meta-analysis by Flores and colleagues raises several important questions, challenging our perceptions regarding mucosal healing and highlighting the need for universal adoption of validated scoring systems internationally,” the editorial concludes. “As we “zero in” on endoscopic healing, bolder definitions of disease control along with improved surrogate outcomes (including CRN) will hinge on robust data from well-designed prospective trials using rigorous endpoints. We are now poised to witness the dawn of a new era of collaborative efforts, and as we aim higher, zero may well be the goal.”

To access the editorial, please click here

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