Maria T. Abreu, MD, Editor

The first article in this issue deals with a patient’s very first endoscopy. Gastroenterologists who are performing an endoscopy on a patient with diarrhea or other gastrointestinal symptoms consistent with IBD must have a plan for what they intend to biopsy and what stool studies to send off. During that first endoscopy, it is critical to get into the terminal ileum and to biopsy both normal and abnormal mucosa throughout the colon. I most often use a pediatric colonoscope for all of my procedures simply because it makes it easier to get into a terminal ileum, especially if it is inflamed. If it is a patient I have scoped previously, I will make a note to myself in the endoscopy report if I think an adult colonoscope is better for that patient.

In a patient with ulcerative colitis, especially longstanding ulcerative colitis, biopsies become essential as well as a very careful look at the mucosa in search of mucosal changes of dysplasia. We have included thoughtful articles in this issue on the use of modern technologies, such as confocal laser endomicroscopy, which will allow us to identify very small foci of abnormalities or to map out the limits of an abnormal area once identified. I would argue that even high-definition white-light endoscopy is very superior to our old technology for identifying abnormal mucosa. It is better to be safe than sorry and to biopsy areas that look abnormal. A recent study found that fecal biotherapy was effective in the treatment of ulcerative colitis. We have dedicated one article on the data for fecal biotherapy in ulcerative colitis with and without Clostridium difficile infection with a focus on “how to” perform these procedures.

In Crohn’s disease, most of the endoscopy revolves around identifying where the patient has disease and the severity of that disease. There are validated endoscopy-reporting tools that allow us to grade the endoscopy and are easily accessible to most gastroenterologists, especially since some of the most commonly used endoscopy reporting software have the endoscopy indices embedded in the program with pull-down menus to fill in the data. This becomes very important to track the patients over time and to have an objective way to compare what their endoscopy has shown previously. It also allows one to communicate with other doctors regarding the severity of the patient’s disease.

In postoperative Crohn’s disease, we are trying to identify inflammation in the neoterminal ileum and occasionally at the anastomosis itself. In this issue, you will find a very detailed article on the different types of anastomoses that occur in Crohn’s disease, but, in general, except for an end-to-end anastomosis, which is rarely done these days, the gastroenterologist is going to have to spend time to identify the neoterminal ileum. Often it is at a very sharp angle to the remainder of the colon, requiring the gastroenterologist to literally make a U turn to get into the neoterminal ileum. Without that information, the colonoscopy is of no value. Commonly, patients with Crohn’s disease who have had surgery will have a stricture at the ileocolic anastomosis, whether it is from ischemia during healing or from recurrence of the disease. We now commonly dilate these strictures, especially when they are not inflamed, using through-the-scope balloons. Dilation can delay the need or prevent the need for another surgery if the disease is limited to the anastomosis.

One of the most common reasons that we are performing endoscopy in patients with IBD is to assess for mucosal healing. Almost by definition, this means having an accurate description and preferably numerical score for how severe the inflammation was before the intervention so that one has a point of comparison afterwards. We have authors that have dealt in this issue with mucosal healing and how to interpret it and the improvement in outcomes in patients who achieve mucosal healing. Like everything in life, there has to be a balance of achieving the greatest degree of mucosal improvement while using medications that are safe and well tolerated for a particular patient. In addition to endoscopy, we cover noninvasive ways to monitor intestinal inflammation through the use of biochemical markers and fecal markers, which have become much more common these days and which can serve to diminish the need for such frequent endoscopy. Patients may also experience many symptoms even when they are in remission. We have provided a fascinating article on motility and functional disorders that arise in IBD patients and need separate management.

I hope that all of you will take some pearls from the accompanying articles. I believe that they will improve your endoscopic strategies for these challenging patients with IBD.