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

We would like to thank Professors Shehab and Bessissow for their commentary¹ on our paper ‘Performance of bowel preparation quality scales in patients with Crohn's disease’.² Our study addresses the neglected area of assessment of bowel preparation (BP) quality in patients with Crohn's Disease (CD). Effective BP is important for diagnosis, assessment of disease distribution, assessment of response to therapy and detection of dysplasia. Inadequate BP can complicate disease assessment, leading to increased procedural difficulty and potential for repeat colonoscopies.³ Patients with inflammatory bowel disease are a population of special interest due to the increased need for colonoscopies throughout their lifetime.⁴ The quality of bowel cleansing in these patients can be compromised by active inflammation or other disease-related factors, such as altered post-surgical anatomy and other complications such as the presence of strictures.

In our study, we assessed the reliability and validity of four BP instruments—Boston Bowel Preparation Scale (BPPS), modified Boston Bowel Preparation Scale, Harefield Cleansing Scale, and Food and Drug Administration Bowel Cleansing Assessment Scale—in patients with CD. We found that all these instruments had substantial reliability and validity for assessing BP quality. Additionally, we explored the relationship between BP quality and endoscopic disease activity. This identified a negative correlation between BP quality and disease activity in the colon; notably, the left colon showed the lowest correlation, highlighting the potential for BP to affect the accuracy of disease activity measurement in this segment. We agree that the study's findings highlight the importance of grading individual colonic segments to ensure an accurate assessment of endoscopic disease activity.⁵ Clinicians should be mindful of these implications and consider strategies to enhance BP quality for better patient management.

We concur that incorporating a minimal quality measure for BP is essential to enhance confidence in endoscopic evaluations. By establishing and adhering to a minimal threshold for BP quality, this would help to improve disease activity assessments, which are pivotal endpoints in IBD clinical trials and important in daily clinical practice.⁶

Our study provides robust evidence supporting the reliability of existing BP scales in CD patients and establishes a foundation for their use in research and clinical care. Based on these findings, the BBPS is recommended as the preferred BP assessment tool for CD patients due to its frequent use and endorsement in current guidelines.⁷ Furthermore these data also provide a framework for inclusion of patients with CD in studies to evaluate novel BP formulations, which are historically conducted in healthy volunteers.

Virginia Solitano: Conceptualization; writing – original draft. Christopher Ma: Conceptualization. Vipul Jairath: Conceptualization; writing – original draft.

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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.18269