Assessing mucosal healing in ulcerative colitis: the simpler, the better…

We read with great interest the article by Iacucci et al. on endoscopic and histological mucosal healing in ulcerative colitis [1]. The authors are to be complimented for their thorough approach, which adopted state-of-the-art technology to confirm that even in apparently macroscopically healed mucosa (the parameter on which healing evaluation in inflammatory bowel diseases usually relies), histological abnormalities are still often present. As we are persuaded that complete histological healing should be the ultimate target for assessment of the effectiveness of a given therapeutic approach in this setting [2] [3], we also believe that, apart from scientific purposes as in the Iacucci study, the daily histological assessment should be kept as simple as possible, in order to ensure the widest possible common language between pathologists and to increase reproducibility [4]. In fact, although the specific literature displays several scoring systems [2], these are usually not utilized in real life because of their subjectivity and complexity [2] [3] [5]. These concepts also apply to the study of Iacucci et al. where another, relatively complex and subjective scoring system is proposed. Although we have no doubts concerning its validity in a research setting, we are quite skeptical about its widespread use in routine clinical practice.

So, what are the basic elements that every pathologist in whatever place in the world should report to assess mucosal healing? We feel that some simple descriptive features, such as epithelial cell damage (cryptitis, crypt abscesses, erosions, ulcers), an increase of lymphocytes and plasma cells, and the presence of neutrophils in the lamina propria [2] can be assessed everywhere and by every pathologist. The presence of neutrophils, in particular, should be considered as the hallmark for the differentiation between active and resolving/quiescent phases, in order to determine therapeutic efficacy [5].

Concerning the endoscopic aspects, it must be stressed that the results apply only to those endoscopy services that have access to the specific instruments used in the Iacucci study. Again, this setting is not universally extended to routine practice, although we are convinced that a more in-depth knowledge of the enormous possibilities offered by these new technologies will surely improve the diagnostic yield. However, the day-to-day reality is still quite unsatisfactory: for instance, a recent report showed that the endoscopic/pathologic prerequisites for a correct diagnosis of inflammatory bowel disease are widely unfulfilled in clinical practice [6], suggesting the need for continued educational efforts in this field.

Thus, although we warmly welcome every new bit of knowledge concerning the issue of mucosal healing in inflammatory bowel disease, there is still a note of caution on the best approach to pursue it, and we can conclude with the old statement: it’s a long way to go…

• References

• 1 Iacucci M, Gasia MF, Hassan C et al. Complete mucosal healing defined by endoscopic Mayo subscore still demonstrates abnormalities by novel high definition colonoscopy and refined histological gradings. Endoscopy 2015; DOI http://dx.doi.org/10.1055/s-0034-1391863
• 2 Villanacci V, Antonelli E, Geboes K et al. Histological healing in inflammatory bowel disease: a still unfullfilled promise. World J Gastroenterol 2013; 19: 968-978
• 3 Mazzuoli S, Gugliemi FW, Antonelli E et al. Definition and evaluation of mucosal healing in clinical practice. Dig Liver Dis 2013; 45: 969-977
• 4 Canavese G, Bassotti G, Astegiano M et al. Inflammatory bowel disease: a proposal to facilitate the achievement of an unequivocal diagnosis. World J Gastroenterol 2013; 19: 426-428
• 5 Villanacci V, Bassotti G, Langner C. Histological remission in inflammatory bowel disease: where are we, and where are we going?. J Crohns Colitis 2015; 9: 428
• 6 Canavese G, Villanacci V, Sapino A et al. The diagnosis of inflammatory bowel disease is often unsupported in clinical practice. Dig Liver Dis 2015; 47:: 20-23