Endoscopic evaluation in diagnosis and management of inflammatory bowel disease

Table 1 Mimics of active inflammatory bowel disease

Condition	Comment	Ref.
ITB	Skip lesions, cobblestoning of mucosa, apthous and linear ulcers are found more frequently in patients with CD compared to ITB	[8,9]
	Patulous ileocaecal valve, transverse ulcers more common in ITB	[9,10]
Segmental colitis associated with diverticulosis	Inflammatory changes limited to the segment of bowel containing the diverticula with rectal sparing	[11]
CMV colitis superimposed in IBD	Mucosal bleeding on light contact, wide mucosal defects and punched out ulcers more common in UC complicated by CMV	[12]
	The presence of ulcers helps predict CMV in patients with UC but not CD	[13]
	Other studies could not identify striking differences on endoscopy	[14]
	Biopsies of inflamed mucosa needed assess for inclusion bodies characteristic for CMV colitis
Clostridium difficle associated disease	Pseudomembranes seldom occur in patients with IBD and Clostridium difficile infection	[15]
Campylobacter colitis	Can produce similar appearences to that of UC, detailed endoscopic assessment can help discern from IBD, in addition to stool cultures and biopsies	[16,17]
Ischaemic colitis	Typically a segmental disease, with normal mucosa proximal and distal to affected region of colon	[18]
	Rectum usually spared	[19]
Medication effects	Endoscopic assessment of Ipilimumab induced colitis reveals absent vascular pattern, and erythema in most patients. Variety of endoscopic features described in recent retrospective study	[20]
	NSAID induced colopathy can affect the whole colon, but has a right sided predominance. Colonic findings include ulceration, strictures and diaphragm like strictures	[21]
Solitary rectal ulcer syndrome	Ulcerative lesions (either single or multiple) most common finding, however can present with erythema or polypoid lesions	[22]
Behçet disease	Predilection for ulcers in the ileo-caecal region. Ulcers are typically larger than 1 cm, deep and have discrete margins	[23]
Amebic colitis	Endoscopic findings can vary from procto-sigmoiditis to right colonic involvement, biopsy and microscopic identification of Entamoeba species useful in evaluation of suspected amebiasis	[24]

IBD: Inflammatory bowel disease; ITB: Intestinal tuberculosis; CMV: Cytomegalovirus; CD: Crohn’s disease; NSAID: Non-steroidal anti-inflammatory drug.

Table 2 Endoscopic activity indices

Endoscopic score	Comment	Variables	Ref.
Ulcerative colitis endoscopic index of severity	Easy to use. Scoring based on area of bowel most severely affected. Correlates well with patient reported symptoms	Vascular pattern, bleeding, ulcers/erosions	[83-85]
Mayo endoscopic score	Commonly used in clinical practice, four point scale (0-3) (Figure 1)	Vascular pattern, erythema, bleeding, friability, erythema, erosions and ulcers	[86]
Modified mayo endoscopic score	Total endoscopic mucosal activity accounted. Easy to use. Correlates well with clinical and histological activity	Combines disease extent with MES severity	[87]
Ulcerative colitis colonoscopic index of severity	Total score based on parameters throughout the colon. Validated	Vascular pattern, ulceration, granularity, friability/bleeding	[88]
CDEIS	Complex scoring system, time consuming. Validated. Utilised to monitor endoscopic response to treatment	Deep and superficial ulceration, surface of ulcerations, surface of lesions	[33,89]
SES-CD	Correlates well with CDEIS and clinical parameters Utilised to monitor endoscopic response to treatment	Ulcer size, stenosis, ulcerated and affected surfaces	[34,90]
Rutgeerts’ score	To assess degree of postoperative recurrence at ileo-colonic anastomosis in Crohn’s disease. Easy to use in clinical practice	Apthous ulceration, large ulcers, stenosis, nodularity and ileitis	[30]

SES-CD: Simple endoscopic score for Crohn’s disease; CDEIS: Crohn’s disease endoscopic index of severity.