Has the time been reached for pseudopolyps to be re-enrolled in endoscopic inflammatory bowel disease scores?

Patients with inflammatory bowel diseases (IBD) represent heterogeneous groups with different characteristics and different clinical course. A great deal of effort is made to discover proxies for more severe disease needing more intense treatment and early intervention to gain the maximum therapeutic benefit. Endoscopy remains an invaluable method in assessment of patients with IBD. Pseudopolyps are often encountered during endoscopy and, although they are a well described entity, their presence is of unclear importance. In one of our recent studies and in conjunction with one study with a large cohort of patients with IBD and pseudopolyps, patients with pseudopolyps were found to face a higher inflammatory burden in terms of receiving more intense biological treatment. This letter comes as a comment and proposition regarding the concept of re-evaluation of pseudopolyps as a promising marker in IBD scores.

Core tip: Interest in pseudopolyps and their relationship for monitoring inflammatory bowel disease activity has been refreshed by two recent studies that showed the presence of pseudopolyps to be linked with escalation of treatment, including the increased need for use of biological agents. The next logical step in their management is including their evaluation and possible integration, after proper validation, in inflammatory bowel disease scores, as separate markers for prediction of a more severe clinical course.

TO THE EDITOR

The modern mentality of the management of inflammatory bowel diseases (IBDs) is imposed by the concept of the window of opportunity for medical intervention, alongside accurate understanding of and reduction in the inflammatory burden for each patient early in the clinical course[1,2]; the high economic impact of the use of biological agents should also be taken into account[3]. This aspect creates increased needs for recognition of subgroups of IBD patients who benefit from the newer treatments, through the use of validated markers and risk factors. Even though pseudopolyps or post-inflammatory polyps (PIPs) are a well described entity in the literature, their utility as a predictive marker in IBD remains ambitious. Although PIPs were evaluated as a candidate variable in the development of the Crohn's Disease Endoscopic Index of Severity (referred to as CDEIS), they were not integrated into the final score as they did not seem to alter the endoscopist's global evaluation of colitis severity[4].

In a recent publication by Mahmoud et al[5], the authors presented one of the largest populations of patients with PIPs in the literature: 462 patients. In addition to the primary outcome showing negative association of PIPs with colorectal neoplasia in IBD patients, results of great significance were the association of PIPs with higher colectomy rate (P = 0.01) and the association of the presence of PIPs with more severe inflammation occurring in the era of biological treatments [adjusted odds ratio = 1.32; 95% confidence interval (CI): 1.13-1.55]. Another interesting finding of the study, even though mentioned mainly in the tables, is that patients with PIPs received biological agents at a higher rate in comparison with the non-PIPs patients (27.1% vs 17.5% respectively, P < 0.0005).

We have recently presented a retrospective study of a small series of 83 patients with ulcerative colitis, including 25 (30%) with PIPs. We found that the presence of PIPs was associated with higher need for treatment escalation [hazard ratio (HR) = 2.3; 95%CI: 1.2-4.3, P = 0.014][6]. In addition, our analysis also showed a higher need for biological treatment and colectomy in the group of patients with PIPs (HR = 6.3; 95%CI: 1.9-20.7, P = 0.002) and that the need for treatment escalation occurred early (during the first 2 years in the clinical course) for the majority of the patients. Our sample size was small but well studied with tight inclusion criteria regarding the endoscopic data and the clinical follow-up.

From a new perspective, these data collectively support the concept that PIPs are linked with more severe inflammatory burden, as implied by the higher need for more intense immunosuppression. It is our belief that there are sufficient data to restart the discussion about the incorporation of PIPs into endoscopic IBD scores as a distinctive marker. Their utility as a marker is advocated by their relatively simple identification during endoscopy, presenting early in the clinical course and being present both in flares and remission of the IBD. Α distinct parameter of importance for evaluation could be, not just the criteria of their presence but also their histological findings, since the clinical and histological activities are not always parallel in the IBD course[7].

Overall, PIPs are a common and interesting finding in IBD patients and may have an additional role in helping us recognize a subpopulation of IBD patients with high inflammatory burden who may benefit from earlier therapeutic intervention.