INTRODUCTION

Ulcerative colitis (UC) is a chronic, nonspecific, clinically heterogeneous colitis characterized by recurrent attacks and nonspecific clinical symptoms, which have a great impact on patients' physical and mental health and quality of life. In recent years, UC has gradually become a worldwide social and public health problem that must be addressed[1,2].

The diagnosis of UC is relatively difficult. At present, the disease is usually diagnosed through pathological biopsy, enteroscopy, clinical symptoms, and physical findings; however, it is difficult to accurately evaluate the severity of the disease, and there are some limitations in clinical applications[3,4]. In recent years, with the continuous improvement of medical technology, the application of endoscopic ultrasonography (EUS) in the diagnosis and treatment of UC has attracted widespread attention. It has the advantages of both endoscopy and ultrasonography, can effectively evaluate the changes in intestinal wall thickness and hierarchical structure, and allows monitoring for changes in disease activity and severity[5,6].

In this study, we investigated the value of EUS in the evaluation of the status and prognosis of UC.

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MATERIALS AND METHODS

Baseline data

This study was approved by the ethics committee of our hospital. Patients who underwent endoscopic ultrasound to investigate UC at our hospital between March 2019 and December 2020 were eligible for enrollment. Inclusion criteria were as follows: (1) Diagnostic criteria for UC[7] were met; (2) patients or their families provided written informed consent to participate in the study; (3) patient adherence to,and completion of, the investigation; and (4) age > 18 years. Exclusion criteria were as follows: (1)malignant tumors of the digestive system; (2) history of psychosis; (3) history of allergy; (4) kidney,liver, and other organ dysfunction; (5) pregnancy or lactation; (6) contraindications to endoscopy; (7)administration of relevant treatment before inclusion in the study; (8) infectious enteritis (including

,

,

, acute gastroenteritis, and amoebic bowel disease); (9) Beh?et’s disease and Crohn’s disease; and (10) radiation enteritis and ischemic colitis.

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EUS

A Fujinon SP701 micro ultrasonic probe (Fujinon, Omiya, Japan), with frequency of 20 MHz and rotary scanning mode, and a Fujifilm SU-9000 ultrasonic probe (Fujifilm, Minato City, Japan) with frequencies of 7.5, 10, and 12 MHz were used. Before the examination, the patients were examined, and those with contraindications were excluded from analysis. Four hours before the examination, patients were instructed to consume three packets of polyethylene glycol electrolyte powder, diluted in 3 L of warm water, within two hours. After verifying passage of clear water, endoscopy was performed with the patient in the left lying position. Lubricant was applied to the endoscope, and the investigator expanded the patient’s anus moderately. Air and degassed water in the intestinal cavity were aspirated, prior to the endoscope being withdrawn.

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All images were evaluated by physicians with extensive experience in reading endoscopic ultrasound images in our hospital. The UC endoscopic index of severity (UCEIS) and EUS-UC scores were then calculated. The scoring criteria are shown in Table 1 and Table 2 for UCEIS scoring and EUS-UC scoring,respectively.

Evaluation of disease severity

Disease severity was evaluated using the Mayo scale and the modified Truelove and Witts scores. The evaluation criteria are shown in Table 3 and Table 4 for the modified Truelove and Witts and the Mayo evaluation criteria, respectively.

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Treatment method

The UCEIS and EUS-UC scores were higher in moderate cases than in mild cases. The UCEIS and EUSUC scores were higher still in severe cases than in moderate cases, and the differences were statistically significant. The UCEIS and EUS-UC scores in moderate cases were higher than in mild cases. The UCEIS and EUS-UC scores in severe cases were higher than in moderate cases, and the differences were statistically significant. The UCEIS and EUS-UC scores were significantly and positively correlated with disease severity. The UCEIS and EUS-UC scores after 2 mo of treatment and after 6 mo of treatment were lower than the UCEIS and EUS-UC scores before treatment.

Observation indexes

This study investigated the value of EUS in the evaluation of the severity and prognosis of ulcerative colitis.

Statistical analysis

SPSS 22.0 software (IBM Corp., Armonk, NY, USA) was used for data analysis. Measurement data were analyzed using the

-test and are expressed as mean ± SD. Enumerated data were analyzed using the

test and are expressed as

(%). The Spearman method was used for correlation analysis. A

value <0.05 indicated a statistically significant difference.

ONCE there was a gentleman1 who married, for his second wife, the proudest and most haughty1 woman that was ever seen. She had, by a former husband, two daughters of her own humor, who were, indeed, exactly like her in all things. He had likewise, by another wife, a young daughter, but of unparalleled goodness and sweetness of temper, which she took from her mother,2 who was the best creature in the world.

RESULTS

Of the 79 patients with UC included in the analysis, 46 were men and 33 were women. The average age was 49.96 years (range 21-78 years). The lesions were located in the left colon in 17 cases, the rectum in 17 cases, the sigmoid colon in 23 cases, and were extensive in 22 cases.

UCEIS and EUS-UC scores of patients with different Mayo scores

According to the Mayo disease activity index, there were 23, 32, and 24 cases of mild, moderate and severe UC, respectively. The UCEIS and EUS-UC scores were higher in moderate cases (4.98 ± 1.04 and 5.01 ± 0.99, respectively) than in mild cases (1.56 ± 0.82 and 1.64 ± 0.91, respectively). Furthermore, the UCEIS and EUS-UC scores were higher still in severe cases (7.31 ± 1.10 and 7.59 ± 1.02, respectively)than in moderate cases, and the differences were statistically significant (

< 0.05) (Table 5).

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UCEIS and EUS-UC scores of patients with different modified Truelove and Witts scores

Among the 79 cases in this study, 21, 36 and 22 patients were classified as having mild, moderate, andsevere UC according to the modified Truelove and Witts scores. The UCEIS and EUS-UC scores in moderate cases (4.79 ± 1.11 and 4.96 ± 1.23, respectively) were higher than in mild cases (1.71 ± 0.78 and 1.69 ± 0.88, respectively). Furthermore, the UCEIS and EUS-UC scores in severe cases (7.68 ± 1.22 and 7.81 ± 0.90, respectively) were higher than in moderate cases, and the differences were statistically significant (

< 0.05) (Table 6).

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Correlation between UCEIS and EUS-UC scores and disease severity

According to our analysis, the UCEIS and EUS-UC scores were significantly and positively correlated with disease severity (modified Truelove and Witts scores, Mayo score) (

< 0.05) (Table 7).

UCEIS and EUS-UC scores before and after treatment

The UCEIS and EUS-UC scores after 2 mo of treatment (3.88 ± 0.95 and 4.01 ± 1.14, respectively) and after 6 mo of treatment (1.59 ± 0.63 and 1.64 ± 0.59, respectively) were lower than the UCEIS and EUSUC scores before treatment (5.93 ± 1.79 and 6.04 ± 2.01, respectively) (

< 0.05) (Table 8).

First, endoscopy was performed to determine the degree and scope of the lesion; then, endoscopic ultrasound was performed at and around the lesions. Depending on the specific condition of the lesion,each was scanned using one of the two following methods. (1) Degassed water filling method: This method can be implemented in many cases. First, excess air is removed, and 200–300 mL of degassed water is injected into the intestinal cavity through the endoscopic working channel to ensure that the focus and ultrasonic probe are submerged in water; and (2) Direct contact method: The ultrasonic probe at the tip of the endoscope is placed in direct contact with the intestinal mucosa. During the examination, the body position was changed according to the specific investigational needs to ensure that the degassed water effectively filled the space between the probe and the focus. The distance between the probe and the focus was set at 1 cm to ensure optimal ultrasonic images could be acquired at all levels of the intestinal wall.

DISCUSSION

The clinical diagnosis and treatment efficacy of UC are mainly established through histopathological examination, barium enema, and endoscopy. However, histopathological studies and routine endoscopy can only evaluate surface lesions of the intestinal mucosa. Therefore, it is difficult to accurately determine the degree of damage to the intestinal mucosa and submucosa, and the structural changes in the intestinal wall, which can affect the accuracy of the evaluation of the severity of UC[8-10]. Therefore, accurate diagnosis and evaluation of UC is still a research hotspot.

EUS can effectively clarify the disease status of patients with ulcerative colitis, stratify the disease severity, and accurately evaluate the treatment response, to provide an objective basis for the clinical formulation or further adjustment of a patient’s treatment plan.

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When detecting UC, EUS can accurately determine the location of enteritis. The imaging manifestations include abnormally increased thickness of the intestinal wall, abnormal hierarchical structure of the intestinal wall, and irregular or unclear boundaries between various layers of the intestinal wall.Some patients with UC have submucosal vasodilation and extraintestinal lymph node enlargement[15,16]. Other scholars have pointed out that through ultrasonic endoscopy, we can clearly evaluate the condition of the anal canal, terminal ileum, rectum, ileocecal valve, colon, and sigmoid colon with the help of enteroscopy, and we can perform cytological and pathological examination of potentially diseased regions[17,18].

Patients with UC have different degrees of bleeding, mucosal erosion, ulceration, congestion, inflammatory infiltration, and intestinal wall thickening. In addition, the modified Truelove and Witts score and Mayo score are important scales for clinical evaluation of the severity of UC. In this study, these scales and EUS were used to diagnose and evaluate patients with UC. The results showed significant differences in UCEIS and EUS-UC scores in patients with UC, in line with the different disease severity scores according to the modified Truelove and Witts and Mayo scores. Our findings suggest that EUS can accurately detect lesions in patients with UC and can provide an objective reference for the evaluation of disease severity, which is of great guiding significance for diagnosis and treatment. In addition, some studies have pointed out that even if the clinical symptoms of patients with UC are completely relieved and abnormal endoscopic findings are resolved, persistent histological inflammation may still occur in the body, affecting the disease prognosis. EUS can provide more information about UC lesions, especially in the submucosa, muscle layer, serosa, and even outside the serosa.Therefore, EUS may be of great significance in evaluating the severity and prognosis of UC[19,20].

To verify the above findings, the patients included in this study received treatment for UC and were followed up after 2 and 6 mo of treatment. The results showed that the ultrasonic endoscopy findings(UCEIS and EUS-UC scores) of the patients after treatment were improved compared with those before treatment. This confirms that ultrasonic endoscopy also has value in assessing the treatment effect and prognosis of UC. Additionally, the technique can guide clinical prevention and intervention in subsequent exacerbations, so as to improve the treatment effect and prognosis of the disease as a whole.This study confirmed that EUS has significant clinical value in the early treatment of UC, in improving patient prognosis, formulating an effective treatment plan in a timely manner, and, to a certain extent,can assist in the provision of an individualized treatment plan.

However, this study was limited by a small sample size, and some small differences cannot be effectively reflected. In our future research, we will strive to expand the sample size and explore the application value of EUS in individualized treatment.

CONCLUSION

EUS is an auxiliary examination method widely used in clinical practice in recent years. It combines the advantages of digestive endoscopy and ultrasonography, can provide clear images of the gastrointestinal wall and its internal structure, and accurately locate, measure, and evaluate submucosal edema and wall thickening[11,12]. Ultrasound endoscopy involves the installation of an ultrasound probe on the front of the endoscope, which can transmit colonic mucosal images to the computer processing center and present the relevant content on the monitor. Through the display screen, the device can accurately and clearly illustrate the subtle changes in the large intestinal mucosa, including submucosal lesions, diverticula, hemangiomas, polyps, pigmentation, bleeding, ulcers, erosions, and inflammation. The image is more realistic and clearer, and biopsy forceps can be inserted through the endoscope channel to obtain tissues for pathological examination from ultrasound regions of interest, soas to evaluate the nature of lesions[13,14]. Relevant data showed that EUS can directly locate diseased intestinal segments, and the examination results are less affected by subjective and objective factors,thus ensuring the accuracy of diagnosis and evaluation.

ARTICLE HIGHLIGHTS

Research background

Ulcerative colitis (UC) is usually diagnosed through histopathology, enteroscopy, clinical symptoms,and physical findings; however, it is difficult to accurately evaluate disease severity.

Research motivation

In this study, the UC endoscopic index of severity (UCEIS) and endoscopic ultrasonography (EUS)-UC scores of patients were assessed in relation to disease severity, and the correlations between UCEIS and EUS-UC scores and disease severity was also analyzed.

Research objectives

The UCEIS and EUS-UC scores of patients with different disease severities were counted and analyzed.The correlations between UCEIS and EUS-UC scores and disease severity were analyzed. The UCEIS and EUS-UC scores before and after treatment were statistically analyzed.

Research methods

Patients who underwent endoscopic ultrasound to investigate UC at our hospital were eligible for enrollment. A Fujinon SP701 micro ultrasonic probe, with frequency of 20 MHz and rotary scanning mode, and a Fujifilm SU-9000 ultrasonic probe with frequencies of 7.5, 10, and 12 MHz were used.Disease severity was evaluated using the Mayo scale and the modified Truelove and Witts scores.Treatments included oral mesalazine with or without corticosteroids, and intravenous infusion of infliximab. Colonoscopy was repeated 2 and 6 mo after the initiation of treatment.

Research results

According to the consensus on the diagnosis and treatment of inflammatory bowel disease in 2018,targeted interventions were administered according to the patient’s condition. Treatments included oral mesalazine with or without corticosteroids, and intravenous infusion of infliximab. Colonoscopy was repeated 2 and 6 mo after the initiation of treatment.

Research conclusions

EUS can effectively clarify the disease status of patients with ulcerative colitis, stratify the disease severity, and accurately evaluate the treatment response, to provide an objective basis for the clinical formulation or further adjustment of a patient’s treatment plan.

Research perspectives

We will study the application value of this scheme in individualized therapy.

FOOTNOTES

Jin RF and Ye HJ designed this retrospective study; Jin RF wrote the manuscript; Jin RF, Chen YM, Chen PP and Ye HJ sorted the data; all author read and confirmed the revised manuscript.

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Wenzhou Science and Technology Bureau, No. Y2020296.

The study was approved by the Ethics Committee of The First Affiliated Hospital of Wenzhou Medical University.

Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.

The authors have nothing to disclose.

No additional data are available.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

One day his queen presented him with a baby daughter as beautiful as the dawn, and the king himself was so happy and delighted that, for a whole week, he forgot to hunt, and spent the time in public and private rejoicing

Rui-Fang Jin 0000-0001-6904-179X; Yi-Man Chen 0000-0002-1126-9393; Ren-Pin Chen 0000-0002-3211-4702; Hua-Jun Ye 0000-0003-4476-5382.

That doesn t mean it has been easy. I went though， some bad experiences, like being picked last for baseball games (it was hard for me to catch the ball) or the way people looked at me funny when I was out in public. But mostly, people accepted me and helped me. In elementary school, the other kids would help me open my locker3, pick up books or do some of the other tasks that were hard for me.

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