Endoscopy in inflammatory bowel disease when and why

Table 1 Infective causes of inflammation which mimic inflammatory bowel disease

Infective cause	Endoscopic appearance
Salmonella	Friable mucosa with haemorrhages in ileum and colon
Shigella	Patchy intense erythema in ileum and colon
Campylobacter	Erythema and ulcers in colon
E.coli 0157:H7	Mild to moderately severe colitis
Yersinia	Patchy colitis with ileal aphthoid ulcers
C.difficile	Pseudo membranes and predominantly left side colitis
Klebsiella	Haemorrhagic colitis
Mycobacterium	Transverse or circumferential ulcers ileum
Neisseria	Proctitis with ulcers and peri anal disease
Chlamydia	Peri anal abscess, ulcer and fistula
Treponema	Proctitis with ulcers and peri anal disease
Schistosoma	Extensive colitis, may be segmental with polyps
Entamoeba	Acute colitis and ulcers
Herpes	Proctitis with rectal ulcers and perianal disease
Cytomegalovirus	Colitis with punched out shallow ulcers
Aspergillus	Ulcers with bleeding
Histoplasma	Predominantly right side colitis

Table 2 Non infective causes of diarrhoea

Inflammatory	Behcet’s disease
Drugs	Non streroidal anti inflammatory drugs
	Gold
	Penicillamine
Iatrogenic	Radiation colitis
Vascular	Vasculitis
	Ischaemic colitis
Neoplastic	Colorectal cancer

Table 3 Endoscopic indices used in ulcerative colitis

	0	1	2	3	4
Sutherland	Normal	Mild friability	Moderate friability	Exudates and spontaneous haemorrhages	-
Schroeder	Normal or inactive disease	Mild (erythema, decreased vascular pattern)	Moderate (marked erythema, absent vascular pattern)	Severe (spontaneous bleeding, ulceration)	-
Baron	Normal: matt mucosa, ramifying vascular pattern, no spontaneous bleeding/to light touch	Abnormal, but non-haemorrhagic: appearances between 0-2	Moderately haemorrhagic: bleeding to light touch, but no spontaneous bleeding	Severely haemorrhagic: spontaneous bleeding and bleeds to light touch	-
Feagan	Normal, smooth, glistening mucosa, with normal vascular pattern	Granular mucosa; vascular pattern not visible; not friable; hyperaemia	As 1, with a friable mucosa, but not spontaneously bleeding	As 2, but mucosa spontaneously bleeding	As 3, but clear ulceration; denuded mucosa
Powel- Tuck	Non haemorrhagic, no spontaneous bleeding or bleeding to light touch	Haemorrhagic, no spontaneous bleeding, but bleeding to light touch	Haemorrhagic, spontaneous bleeding ahead of instrument at initial inspection with bleeding to light touch	-	-
Lemann, Hanauer	Normal mucosa	Oedema, +/- loss of vascular pattern, granularity	Friability, petechiae	Spontaneous haemorrhage, visible ulcers	-

Table 4 Simple endoscopic score for Crohn’s disease

Variable	Simple endoscopic score
	0	1	2	3
Size of ulcers	None	Aphthous ulcers	Large ulcers	Very large ulcers
Ulcerated surface	None	< 10%	10%-30%	> 30%
Affected surface	Unaffected segment	< 50%	50%-75%	> 75%
Presence of narrowing	None	Single, scope passable	Multiple, scope passable	Scope impassable

Table 5 Differences in the macroscopic appearance between Crohn’s disease and ulcerative colitis

Macroscopic features	UC	CD
Erythema	+++	++
Loss of vascular pattern	+++	+
Granularity of mucosa	+++	+
Cobble stone appearance	-	++
Pseudo polyps	+++	+++
Aphthous ulcers	+	+++
Deep ulcers	-	+++
Patchy inflammation	-	+++
Ileal ulcers	-	+++
Rectal involvement	++++	++

UC: Ulcerative colitis; CD: Crohn’s disease.

Table 6 Rutgeerts scoring system to monitor post surgery Crohn’s disease activity

Score	Endoscopic features
i0	Absence of any lesions at anastomosis and in the neo terminal ileum
i1	Less than 5 aphthous ulcers (< 5 mm)
i2	More than 5 ulcers with normal intervening mucosa or large patchy lesions, or lesions confined to anastomosis (< 1 cm)
i3	Diffuse aphthous ileitis with diffuse inflammation of the ileal mucosa
i4	Diffuse ileitis with large ulcers, nodularity and stenosis.