Editorial: Advancing care in Crohn's disease—Time to standardise bowel preparation scales

Abstract

A reliable bowel preparation (BP) scale is an essential prerequisite in the screening, surveillance and monitoring of disease activity of several gastrointestinal conditions such as colorectal cancer, inflammatory bowel disease (IBD) and dysplasia in IBD.^1-3 However, most patients consider cleansing to be the most arduous part of colonoscopy.² Inadequate BP negatively influences the accuracy of colonoscopies, leading to the inconvenience of repeated colonoscopies, thus rendering the procedures burdensome and cost-ineffective.¹ Moreover, the evaluation of BP quality in patients with Crohn's disease (CD) may be cumbersome in the presence of inflammation, strictures, and/or bowel resections.⁴

Studies on the assessment of efficacy and quality of BP scores in IBD are meagre.^{3, 5} Furthermore, studies comparing BP scales are absent.³ The literature provides an assortment of BP quality scales that differ vastly in their grading methodology.⁵ Clinicians and researchers often utilise de novo, dichotomous scoring scales that are inadequate and non-validated, and, therefore, inconsistent in BP quality assessments.^{3, 5} Therefore, a standardised assessment tool with simple validated scoring criteria will improve colonoscopy assessment, which has a direct impact on improving the quality of care.⁴

Solitano et al. examined BP quality assessment scales to identify and standardise an optimal instrument to be utilised across clinical trials as well as in clinical practice.⁶ The BP indices reviewed were the BBPS, mBBPS, HCS, FDA BCAS, 100 mm VAS of BP quality and 100 mm VAS of endoscopic severity. They included 50 endoscopic videos of routine assessment of disease activity in 40 patients with CD from archives of the University of California San Diego Research Biobank (San Diego, CA). To exclude any bias, the videos were selected by a trained endoscopist who was not included in the central reading. The study utilised three central readers who independently evaluated the BP quality and endoscopic disease activity at insertion and withdrawal phase, thus increasing the reliability of the study results.

The study also addressed the grading of individual segments of the colon. There was misrepresentation of endoscopic disease activity in the left colon due to the sub-optimal BP, thus emphasising the need for segmental scoring and diligent BP along segments. We believe that the addition of a minimal quality measure for BP is essential to enhance confidence in the assessment of endoscopic disease activity, which is a primary endpoint in IBD.

In summary, this study provides evidence about the reliability of BP scales in patients with CD and lays the foundation for the use of such scores in clinical practice and their inclusion in clinical trials. The addition of a minimal threshold for the quality of BP in clinical trials should become a standard measure to allow for a more accurate assessment of endoscopic disease activity.

Mohammad Shehab: Conceptualization; writing – original draft. Talat Bessissow: Writing – review and editing; supervision.

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MS has received Speaker/advisory board fees from Abbvie, Hikma, Ferring, Janssen, Acino, Pfizer, Sandoz and Takeda. TB has received consulting or speaker honorarium from Abbvie, Alimentiv, Amgen, Bristol Myers Squibb, Eli Lilly, Ferring, Iterative scope, Janssen, Merck, Pfizer, Roche, Sandoz, Sanofi, Takeda, Gilead, Viatris and Fresenius Kabi.

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This article is linked to Solitano et al papers. To view these articles, visit https://doi.org/10.1111/apt.18210 and https://doi.org/10.1111/apt.18288