Post written by Bo Shen, MD, FASGE, from the Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.

Endoscopy plays a key role in diagnosis, assessment of disease activity and treatment response, postoperative disease monitoring, dysplasia surveillance, and delivery of therapy. Ileocolonoscopy (occasionally with upper endoscopy or enteroscopy) establishes the diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) with proper biopsy protocol and histologic confirmation. Advances in medical therapy with extensive use of biological and small-molecule agents have largely changed the disease course and natural history of inflammatory bowel disease (IBD).

Effective medical therapy has been targeted for mucosal and transmural healing in the case of CD. Endoscopy provides a valuable tool for documenting mucosal or transmural healing. With cross-sectional imaging (such as CT, magnetic resonance imaging, and intestinal US), it may help demonstrate transmural healing; and with tissue biopsy, it makes recording of histologic mucosal healing possible.

Endoscopy with biopsy has become a preferred modality for monitoring disease activity, assessing treatment response, and guiding medical therapy. Various endoscopy scoring instruments for measuring disease activity in CD, UC, and pouchitis have been proposed and are increasingly used. Image-enhanced endoscopy and computer-assisted artificial intelligence make endoscopic disease activity measurement more reliable and objective and less labor-intensive.

The advances in medical treatment also have favorably impacted the frequency and indications of surgical intervention for CD and UC. Endoscopy is the most valuable tool for postoperative disease monitoring and diagnosis and management of anastomotic adverse events in CD (with bowel resection and anastomosis, strictureplasty, and ileostomy) and UC (with ileal pouch-anal anastomosis and continent ileostomy). Endoscopic scores have been developed to measure disease activity, calculate the risk for disease progression, and guide proper medical and endoscopic therapy.

High-definition endoscopy with image-enhanced endoscopy (such as dye-based or virtual chromoendoscopy and magnified endoscopy) is a main tool for dysplasia surveillance in UC and Crohn’s colitis. Both random biopsy (the 33-piece Seattle protocol) and targeted biopsy (with image-enhanced endoscopy) are used for surveillance in patients with average risk. Random and targeted biopsies are preferred in patients at high risk, such as those with concurrent primary sclerosing cholangitis, a history of atypia or dysplasia, and colonic strictures.

The natural history of UC varies greatly, determining the surveillance interval (every 1-5 years for left-sided or extensive UC) as proposed by the American Society for Gastrointestinal Endoscopy (ASGE) IBD Endoscopy Consensus Panel. Some panelists have raised concern that surveillance every 5 years might be too long. Clinical judgment is needed to execute proper surveillance strategies.

The field of interventional IBD or endoscopic therapy for IBD- and IBD surgery—associated adverse events has progressed rapidly over the last decade. The main indications for interventional IBD are (1) primary and anastomotic strictures; (2) fistulas and abscesses; (3) removal of intraluminal lesions or materials (such as pedunculated inflammatory polyps, bezoars, and foreign bodies); (4) IBD surgery—associated anastomotic adverse events (such as strictures, acute or chronic leaks, and bleeding); and (5) resection of colitis-associated neoplasia with polypectomy, EMR, or endoscopic submucosal dissection. The ASGE has provided resources for training IBD interventionalists in performing endoscopic balloon dilation, endoscopic stricturotomy, anastomotic bleeding control, endoscopic fistulotomy and sinusotomy, EMR, and endoscopic submucosal dissection.

Diagnostic and therapeutic endoscopy is an important part of the management armamentaria in CD and UC. With a better understanding of etiopathogenesis, emerging disease-modifying anti-inflammatory agents, and advances in endoscopy technology, imaging, and artificial intelligence, the role of gastroenterologists, endoscopists, and IBD specialists is expanding beyond diagnosis and disease monitoring. Together, we can relieve patients’ pain, halt or hinder tissue structural damage and adverse events, timely detect and manage dysplastic lesions, and reduce adverse events, disease-related hospitalization, and risk for surgery.

Endoscopic scoring of mucosal inflammation in Crohn’s disease using the Simple Endoscopy Score for Crohn’s Disease (SES-CD). A, SES-CD ulcer score of 0, no erosions or ulcers. B, SES-CD ulcer score of 1: aphthous ulcers .1 to .5 cm. C, SES-CD ulcer score of 2, large ulcers .5 cm to 2 cm. D, SES-CD ulcer score of 3, very large ulcers >2 cm.

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