Impact of endoscopic and histologic healing on relapse in patients with Ulcerative Colitis-McGill University mucosal healing cohort

Background: Ulcerative colitis (UC) is an idiopathic inflammatory bowel disease that results in chronic inflammation of the colon with potential serious complications. Symptomatic control is currently considered insufficient and endoscopic healing of the mucosa is nowadays considered a key goal. We still do not know what the role of histologic healing on disease outcome is.Aim: To determine the role of complete remission defined as both endoscopic mucosal healing and histologic inactivity on the risk of disease relapse. Methods: We performed a prospective cohort study with a 1-year follow-up period at the McGill University Health Center between 2013 and 2015. We included consecutive adult patients with UC diagnosed by endoscopy and histology criteria presenting to the endoscopy unit for a colonoscopy to assess disease activity or for neoplasia surveillance. Patients were required to be in clinical remission as defined by Mayo clinical score 2 with no subscore > 1, with a stable dose of medical therapy and without the use of corticosteroids for 3 months prior to endoscopy. Patients were excluded if they had previous bowel resection related to UC, were in clinical remission without disease flare for > 10 years. At the time of endoscopy, all patients had serum measurement of C reactive protein (CRP), stool level of fecal calprotectin, endoscopic evaluation with the Mayo score, and rectal biopsies for the assessment of histology with the Geboes score and documentation of basal plasmacytosis. Patients were divided into 3 groups: complete remission (group 1), endoscopic remission alone (group 2) or active endoscopic disease (group 3). Patients were followed for 1 year with visits every 3 months to document disease activity with clinical Mayo score. Measurement of CRP and fecal calprotectin in addition to repeat endoscopies with biopsies were performed if disease relapse occurred or at the end of the follow-up period to document disease recurrence. Results: We enrolled 100 patients in our study with median age of 49 years (interquartile range 39-59 years), 55% being male. Disease distribution was the following: 16% had proctitis, 40% had left-sided colitis and 44% had pancolitis. Medical therapy included 5-aminosalicylates in 71% of patients, thiopurines in 28% and biologics in 12%. Endoscopically, 61% had Mayo score 0, 29% score 1, 7% score 2, and 3% score 3. Geboes score ≥ 3.1 was seen in 55% of patients and basal plasmacytosis was documented in 37%. The relapse rate was similar between group 1 (24.4%), group 2 (22.2%), and group 3 (20.0%). Although inconclusive results, female sex (odds ratio (OR) = 0.45, 95% confidence interval (CI): (0.17-1.21)) and biologic therapy (OR = 0.64, 95% CI: (0.13-3.15)) were potentially associated with remission while the presence of basal plasmacytosis (OR = 2.04, 95% CI: (0.42-10.22)) or a Geboes score ≥ 3.1 (OR = 1.21, 95% CI: (0.17-8.59)) trended to predict relapse. A cutoff value for fecal calprotectin > 150 µg/g showed the most clinically relevant sensitivity (75%) and specificity (65%) to predict active endoscopic disease. Conclusion: Although inconclusive results due to the sample size, the presence of basal plasmacytosis and active histologic disease are potential predictors of disease relapse while biologic therapy could be protective. Further studies with a larger sample size are warranted to better document these associations.

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