Les scores endoscopiques dans les MICI
Yoram Bouhnik
Hôpital Beaujon, Clichy
&
Laurent Peyrin-Biroulet
CHU de Nancy
Conflits intérêt LPB
• Consultant: Merck, Abbott, Janssen,
Genentech, Mitsubishi, Ferring, Norgine, Tillots, Vifor, Shire, Therakos,
Pharmacosmos, Pilège, BMS, UCB- pharma, Hospira, Celltrion, Takeda, Boerhinger-Ingelheim, Lilly
• Orateur: Merck, Abbott, Janssen, Ferring, Norgine, Tillots, Vifor, Therakos, HAC-
pharma
• Orateur: Abbvie, Falk, Ferring, Given Imaging, Mayoli- Spindler, Norgine Pharma, Vifor Pharma
• Consultant: Sanofi, Abbvie, Norgine Pharma, MSD, Takeda Millenium, Roche
• Participation au capital d’une entreprise : Inception IBD, San Diego, Ca, USA
CONFLITS D’INTÉRÊT YB
ETAT DES LIEUX
Q1: Utilisez-vous parfois un score endoscopique dans la maladie de Crohn dans votre pratique quotidienne ?
Q2: Utilisez-vous parfois un score endoscopique dans la RCH en pratique quotidienne ?
Q3: Utilisez-vous systématiquement un score endoscopique dans la maladie de Crohn dans votre pratique quotidienne ?
Q4: Utilisez-vous systématiquement un score endoscopique dans la RCH en
pratique quotidienne ?
Enquête nationale du CREGG
Definition of the nine elementary lesions
Modigliani R, et al. Dig Dis Sci 1987;32:1370–9
1. Pseudopolyp –
2. Healed ulceration Whitish area with a ‘ground glass’ appearance 3. Frank erythema
(plaques, bands or diffuse)
Slight or moderate erythema should be neglected 4. Frankly swollen mucosa Slight or moderate mucosal swelling should be
neglected
5. Aphtoid ulceration Defined as a tiny (2–3 mm), raised or flat red lesion with a white centre
6. Superficial or shallow ulceration
Defined as any ulceration which was neither aphtoid nor deep
7. Deep ulceration Only frankly deep ulcerations should be recorded under this heading
8. Non ulcerated stenosis Should be impossible or difficult to pass with an adult endoscope
9. Ulcerated stenosis Should be impossible or difficult to pass with an
adult endoscope
Healed ulceration Pseudopolyps
Crohn’s disease: CDEIS (1) The 9 elementary lesions
Modigliani R, et al. Dig Dis Sci 1987;32:1370–9
Frankly swollen mucosa Frank erythema
Crohn’s disease: CDEIS (2) The 9 elementary lesions
Modigliani R, et al. Dig Dis Sci 1987;32:1370–9
Crohn’s disease: CDEIS (3) The 9 elementary lesions
Deep ulcerations Aphtoid
ulcerations
Superficial/shallow ulcerations
Modigliani R, et al. Dig Dis Sci 1987;32:1370–9
Crohn’s disease: CDEIS (4) The 9 elementary lesions Non-ulcerated stenosis Ulcerated stenosis
Modigliani R, et al. Dig Dis Sci 1987;32:1370–9
CDEIS: Elementary lesions
Superficial or deep ulceration?
Superficial or deep ulceration?
CDEIS: Elementary lesions
Important points in calculating CDEIS
For each of the 5 ileocolonic segments explored:
– Distinguish the 9 elementary lesions from normal or sub-normal mucosa
1. Rate the lesion surface area (from 0 to 10 points) 2. Rate the ulcerated surface area (from 0 to 10 points) 3. Score superficial/shallow ulcers (6 points)
4. Score frankly deep ulcers (12 points)
Some tips
– Ulcer surface is always inferior to lesion surface area – An aphtous lesion is not an ulceration !
– Any non-ulcerated stenoses score 3 points – Any ulcerated stenoses score 3 points
– Maximum segmental score is 38
– Maximal global score is 44
Total lesion surface area
Total ulcers surface area
Superficial ulcerations
Deep ulcerations
Total
From 0 to 10
(VAS or IE)
From 0 to 10 (VAS or IE)
(0=absent;
6=present)
(0=absent;
12=present)
Ileum 0
Right colon 0
Transverse colon 0
Sigmoid and left colon 0
Rectum 0
Sub-total (A) 0,0 Number of segments (n) 0
A / n Ulcerated stenosis (0=absent; 3=present) 0
Non-ulcerated stenosis (0=absent; 3=present) 0
CDEIS 0 - 44
The Crohn’s disease index of severity (CDEIS)
www.getaid.org
CDEIS: example 1
Total lesion
surface area
Total ulcers surface area
Superficial ulcerations
Deep
ulcerations Total
From 0 to 10 From 0 to 10 0–6 0–12
Segmental score
Mary JY, et al. Gut 1989;30:983–9
CDEIS: example 1
Total lesion
surface area
Total ulcer surface area
Superficial ulcerations
Deep
ulcerations Total
From 0 to 10 From 0 to 10 0–6 0–12
Segmental score 10
Mary JY, et al. Gut 1989;30:983–9
0 10 x
CDEIS: example 1
Total lesion
surface area
Total ulcer surface area
Superficial ulcerations
Deep
ulcerations Total
From 0 to 10 From 0 to 10 0–6 0–12
Segmental score 10 4
Mary JY, et al. Gut 1989;30:983–9
0 x 10
0 x 10
CDEIS: example 1
Total lesion
surface area
Total ulcer surface area
Superficial ulcerations
Deep
ulcerations Total
From 0 to 10 From 0 to 10 0–6 0–12
Segmental score 10 4 6 0 20
Mary JY, et al. Gut 1989;30:983–9
The 4 keys to a good CEIS score
For each of the 5 ileocolonic segments explored:
– Distinguish the 9 elementary lesions from normal or sub-normal mucosa
1. Rate the lesion surface area (from 0 to 10 points) 2. Rate the ulcerated surface area (from 0 to 10 points) 3. Score superficial/shallow ulcers (6 points)
4. Score frankly deep ulcers (12 points)
VIDEO CDEIS SEG 02
VIDEO CDEIS SEG 03
Score i0 no lesions
Score i1 <5 aphthous lesions
Score i2 >5 aphtous lesions with normal mucosa between the lesions, or skip areas of larger lesions or lesions confined to the ileocolonic anastomosis (i.e. <1 cm in length)
Score i3 diffuse aphtous ileitis with diffusely inflamed mucosa
Score i4 diffuse inflammation with already larger ulcers, nodules,
and/or narrowing
Recap: the Rutgeerts’ score in Crohn’s disease
Rutgeerts P, et al. Gastroenterol 1990;99:956–63
Score i0 no lesions
Score i1 <5 aphthous lesions
Score i2 >5 aphtous lesions with normal mucosa between the lesions, or skip areas of larger lesions or lesions confined to the ileocolonic anastomosis (i.e. <1 cm in length)
Score i3 diffuse aphtous ileitis with diffusely inflamed mucosa
Score i4 diffuse inflammation with already larger ulcers, nodules,
and/or narrowing
Rémission endoscopique = i0-1
Rutgeerts P, et al. Gastroenterol 1990;99:956–63
0.2 0.4 0.6 0.8 1
Years
0 1 2 3 4 5 6 7 8
i0 + i1
i2
i3 i4
Pourquoi le score de Rutgeerts est-il autant utilisé ?
Rutgeerts P, et al. Gastroenterol 1990;99:956–63
QUESTION
Pour ceux qui utilisent un score endoscopique dans le RCH en pratique clinique:
Utilisez-vous le MAYO score ou l’UCEIS ?
Findings of flexible proctosigmoidoscopy
0 = Normal or inactive disease
1 = Mild disease (erythema, decreased vascular pattern, mild friability)
2 = Moderate disease (marked erythema, absent vascular pattern, friability, erosions)
3 = Severe disease (spontaneous bleeding, ulceration)
Schroeder KW et al. N Engl J Med. 1987. D’Haens G et al. Gastroenterology. 2007.
Sous-Score endoscopique Mayo
UCEIS :
variations intra- et inter-observateurs
Item Kappa pondéré
intra-lecteurs
Kappa pondéré inter-lecteurs
Érosions et ulcères 0,65 0,45
Saignement 0,60 0,37
Trame vasculaire 0,61 0,42
Étendue des érosions et ulcères 0,60 0,42
Fragilité spontanée 0,49 0,40
Mucus-pus 0,47 0,40
Granité muqueux 0,45 0,34
Œdème 0,43 0,31
Érythème muqueux 0,43 0,35
Fragilité au contact 0,33 0,34
Travis SPL et al. Gut 2012 ; 61 : 535-42
Score UCEIS : les items
Item Aspect Score
Trame vasculaire
Normal 0
Diminution 1
Disparition 2
Saignement
Absent 0
Points ou stries coagulées, lavables 1
Sang frais luminal peu abondant 2
Sang frais luminal abondant et/ou Saignement spontané
3
Erosions et ulcérations
Absentes 0
< 5 mm, superficielles 1
> 5 mm, enduit fibrineux 2
Creusantes 3
Total 0 - 8
Dignass A, et al, Second EUROPEAN evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis, Journal of Crohn's and Colitis (2012), http://dx.doi.org/10.1016/j.crohns.2012.09.003
Score UCEIS : la trame vasculaire
Item Aspect Score
Trame vasculaire
Normal 0
Diminution 1
Disparition 2
Saignement Absent 0
Dignass A, et al, Second EUROPEAN evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis, Journal of Crohn's and Colitis (2012), http://dx.doi.org/10.1016/j.crohns.2012.09.003
Score UCEIS : le saignement
Item Aspect Score
Saignement
Absent 0
Points ou stries coagulées, lavables 1
Sang frais luminal peu abondant 2
Sang frais luminal abondant et/ou Saignement spontané
3
Dignass A, et al, Second EUROPEAN evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis, Journal of Crohn's and Colitis (2012), http://dx.doi.org/10.1016/j.crohns.2012.09.003
Score UCEIS : les érosions et ulcérations
Item Aspect Score
Erosions et ulcérations
Absentes 0
< 5 mm, superficielles 1
> 5 mm, enduit fibrineux 2
Creusantes 3
Dignass A, et al, Second EUROPEAN evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis, Journal of Crohn's and Colitis (2012), http://dx.doi.org/10.1016/j.crohns.2012.09.003
Validation indépendante du score UCEIS
• Méthode
– 57 films RCH avec lésions endoscopiques d'intensité variable – Relecture des films par 25 investigateurs (USA, Europe) :
• 28 lectures par observateur (dont certains en dupliqué)
• Chaque enregistrement était évalué par 6 à 15 investigateurs
• Résultats
– Cœfficient de corrélation global UCEIS vs EVA = 0,91 (p<0,0001) – Cœfficients de corrélation pour items isolés :
• Vascularisation (0,76, p<0,0001)
• Saignement (0,78, p<0,0001)
• Erosions & Ulcérations (0,86, p<0,0001)
Test-retest fiabilité (kappa valeurs) Descripteur (Nombre de niveaux
sur l'échelle de Likert) Intra-observateur Inter-
observateurs
Trame vasculaire (3 niveaux) 0,827 0,816
Saignement (4 niveaux) 0,559 0,722
Erosions & Ulcères (4 niveaux) 0,765 0,775
D'après Travis S et al. UEGW 2011 - Gut 2012 ; 61 : 535-42
Validation indépendante du score UCEIS
Méthode
– 57 films RCH avec lésions endoscopiques d'intensité variable – Relecture des films par 25 investigateurs (USA, Europe) :
28 lectures par observateur (dont certains en dupliqué)
Chaque enregistrement était évalué par 6 à 15 investigateurs
Résultats
– Cœfficient de corrélation global UCEIS vs EVA = 0,91 (p<0,0001) – Cœfficients de corrélation pour items isolés :
Vascularisation (0,76, p<0,0001)
Saignement (0,78, p<0,0001)
Erosions & Ulcérations (0,86, p<0,0001)
Test-retest fiabilité (kappa valeurs) Descripteur (Nombre de niveaux
sur l'échelle de Likert) Intra-observateur Inter-observateurs
Trame vasculaire (3 niveaux) 0,827 0,816
Saignement (4 niveaux) 0,559 0,722
Erosions & Ulcères (4 niveaux) 0,765 0,775
D'après Travis S et al. UEGW 2011 - Gut 2012 ; 61 : 535-42
UCEIS: example 1
Endoscopic Mayo score /3
Images courtesy of Y Bouhnik
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
UCEIS: example 1 (result)
Endoscopic Mayo score 1/3
Result
1 0 0 1/8
Images courtesy of Y Bouhnik
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
UCEIS: example 2
Images courtesy of Y Bouhnik
Endoscopic Mayo score /3
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
UCEIS: example 2
Images courtesy of Y Bouhnik
Endoscopic Mayo score 2/3
Result
2 0 1 3/8
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
UCEIS: example 3
Images courtesy of Y Bouhnik
Endoscopic Mayo score /3
Result
/8
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
UCEIS: example 3
Images courtesy of Y Bouhnik
Endoscopic Mayo score 3/3
Result
2 2 3 7/8
Item Cotation
Vascular pattern 0–2
Bleeding 0–3
Erosions and ulcers 0–3
Total 0–8
UCEIS
This slide was developed for AbbVie ©
Schoepfer A et al. JCC 2012
Enquête de pratique en Suisse
Pas d’impact des constatations endoscopiques sur la thérapeutique au cours de la RCH !
DDW 2011 – D’après Regueiro M. et al. Su 1180
