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Ileal and Rectal Ulcers Heal Slower and May Be More Refractory to Therapy Than Colonic Lesions in Crohn’s Disease

Monika Fischer, MD, reviewing Narula N, et al. Am J Gastroenterol 2020 Aug.

Researchers performed a post hoc analysis of endoscopic outcomes in participants of the pivotal SONIC trial that compared the efficacy of azathioprine, infliximab, and the combination of the two treatments for induction and maintenance of remission in Crohn’s disease. They compared 172 patients’ baseline and week 26 endoscopic findings using the Crohn’s Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for Crohn’s Disease (SES-CD). They found that ileal ulcers were less likely to heal than colonic ulcers in any segment of the colon by week 26 (P<.0001). Large ileal and rectal ulcers (>2 cm) were less likely to heal compared with smaller ulcers (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11–0.89 and OR, 0.26; 95% CI, 0.08–0.80, respectively), whereas the size of colonic ulcers did not impact achievement of endoscopic remission. Deep ileal and rectal ulcers were even less likely (about 10-fold less likely) to heal compared to superficial ulcers. Surprisingly, high SES-CD scores (≥16) or CDEIS scores (≥12), denoting severe inflammation at baseline, did not affect the rate of endoscopic healing by week 26.

Monika Fischer, MD, FASGE


This study shows that large and deep ileal and/or rectal ulcers in Crohn’s disease are less likely to heal compared to colonic ulcers within 6 months of treatment initiation. This suggests that ileal and rectal ulcers, particularly large and deep ulcers, need more aggressive therapy and may take longer to heal compared to colonic ulceration. We should keep this in mind when scheduling follow-up colonoscopy to evaluate response to therapy and/or achievement of endoscopic remission/mucosal healing; the optimal timing might be closer to 9 to 12 months following treatment initiation. In the meantime, close monitoring of clinical symptoms and biomarkers of inflammation, such as fecal calprotectin and C-reactive protein, might be helpful to guiding therapy.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Narula N, Wong ECL, Aruljothy A, et al. Ileal and rectal ulcer size affects the ability to achieve endoscopic remission: a post hoc analysis of the SONIC trial. Am J Gastroenterol 2020;115:1236–1245. (

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