Mucosal healing in ulcerative colitis: surveillance or colectomy?

A 38-year-old patient presented with bloody diarrhea (7 to 8 bowel movements per day), abdominal pain and weight loss. Blood tests showed moderate anemia and an increased Creactive protein. Stool culture and Clostridium difficile toxin were negative. Ileocolonoscopy revealed moderate-severe pancolitis: the mucosa from rectum to cecum showed superficial and deep ulcers, friability and spontaneous bleeding of mucosa. Histology showed characteristic findings of ulcerative colitis (UC). He was treated for 5 days with i.v. methylprednisolone without improvement and then he started infliximab therapy. Intestinal symptoms significantly improved after induction. One-year colonoscopy showed mucosal healing (MH) with diffuse pseudopolyps (Fig. 1 A,B). MH has an important role in determining treatment effectiveness and long-term prognosis in patients with UC. MH in UC is linked with a lower risk of relapse, a reduced risk of colorectal cancer, a decreased need for surgery and improved quality of life [1]. Surveillance colonoscopy is strongly recommended to control the increased risk of colorectal carcinoma in patients with long-standing UC [2]. MH in UC is currently defined as “absence of friability, blood, erosions and ulcers in all the visualized segments” [3]. In this patient, the Mayo endoscopic score is 0, but the presence of numerous large pseudopolyps raises some questions: could the endoscopic findings be defined as complete MH? How does one implement and manage surveillance in this patient: colonoscopy or colectomy?