The role of endoscopy in inflammatory bowel disease

1. We recommend colonoscopy with ileoscopy for the initial evaluation of IBD and for differentiating IBD subtypes. 2. We recommend mucosal biopsy specimens from multiple sites during the initial endoscopic evaluation of IBD. 3. We recommend flexible sigmoidoscopy in patients with IBD when colonoscopy is contraindicated and to evaluate for other inflammatory etiologies before escalating therapies in patients with refractory disease. 4. We recommend that EGD be performed in pediatric patients with suspected IBD at the time of ileocolonoscopy. 5. We recommend CE to evaluate the small intestine in patients with suspected CD who have no obstructive symptoms and negative ileocolonoscopy results. 6. We recommend that a patency capsule, small-bowel follow-through, CT enterography, or magnetic resonance enterography be performed before CE inpatients with known small-bowel CD involvement. 7. We recommend CE in patients with known CD and unexplained symptoms only when abnormalities detected with CE will alter management. 8. We suggest enteroscopy in patients with IBD who have abnormalities within reach of the enteroscope seen on other imaging studies to facilitate endoscopic and histologic evaluation and the potential for therapeutic interventions. 9. We suggest EUS for characterizing and managing fistulous perianal CD in conjunction with other imaging modalities. 10. We recommend the Montreal Classification System 26 be used to standardize reporting of disease extent and IBD phenotypes for both UC and CD. 11. We recommend endoscopic and histologic assessment of the pouch and afferent limb in symptomatic patients. 12. We suggest endoscopic evaluation of the neoterminal ileum 6 to 12 months after surgery in order to riskstratify patients whose medical management may be affected by endoscopic recurrence. 13. We recommend that all patients with UC or CD colitis undergo a screening colonoscopy 8 years after disease onset to (1) re-evaluate extent of disease and (2) initiate surveillance for colorectal neoplasia. 14. We recommend surveillance colonoscopy be performed every 1 to 3 years beginning after 8 years of disease in patients with UC with macroscopic or histologic evidence of inflammation proximal to and including the sigmoid colon and for patients with Crohn's colitis with greater than one-third of colon involvement. 15. We recommend chromoendoscopy with targeted biopsies as the preferred surveillance technique to maximize dysplasia detection. 16. We suggest that chromoendoscopy-targeted biopsies are sufficient for dysplasia surveillance in patients with IBD and that consideration should be given to taking two biopsies from each colon segment for histologic staging to assess extent and severity of inflammation. 17. We suggest that random biopsies with targeted biopsies of any suspicious appearing lesions remain a reasonable alternative for dysplasia surveillance if the yield of chromoendoscopy is reduced by significant underlying inflammation, significant pseudopolyposis, or poor preparation or if chromoendoscopy is not available. 18. We recommend that patients with IBD whose polypoid dysplastic lesions have been removed completely receive endoscopic surveillance at 1 to 6 months and at 12 months, with yearly surveillance thereafter. 19. We suggest that patients with IBD whose non-polypoid dysplastic lesions have been removed completely receive endoscopic surveillance at 1 to 6 months and at 12 months, with yearly surveillance thereafter. 20. We recommend proctocolectomy in patients with IB Dif a detected lesion is not endoscopically resectable,if there is evidence of dysplasia at the base of the lesion, or if endoscopically invisible HGD or multifocal LGD is found in the colon during a high-quality chromoendoscopy examination. 21. We recommend IBD-associated benign strictures 4 cm in length manifesting obstructive symptoms be managed with endoscopic balloon dilation when feasible.