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How does mucosal healing occur?

I've been on a flare since October. When my doctor checked the MRI report, she said: "This is a very good sign! Now you have inflammation only in the last part of the large intestine (rectum, sigma and a portion of the distal colon)". I asked how it was, if my affectation is indeed ileocolonic. She explained: "The mucosa starts healing from top to bottom".

The appointment is short, so I couldn't ask any more questions about it. But now I'm curious to know how it really works.

Intuitively, I used to think that when the immune system ceased to attack, it did so everywhere equally and the mucosa could heal evenly. I thought so because immunosuppressants don't act locally.

Another interesting thing is that although I now have fewer active locations, the inflammation in the remaining area is worse than at the beginning of the flare.

Do you know anything else about the subject? Experiences? An explanation to it? Any contribution will be interesting.
 
I think what the doc means is the outer mucosal layer heals first, then deeper layers. It makes sense to me: UC is top layer inflammation vs Crohn's deep layer inflammation with complications such as fistulas.
 
I think what the doc means is the outer mucosal layer heals first, then deeper layers. It makes sense to me: UC is top layer inflammation vs Crohn's deep layer inflammation with complications such as fistulas.
I have not "evidence" but I do also believe that healing occurs from the outer layers, because one can have mucosal healing but not transmural healing.

However, in this case, my doctor was indeed talking about the locations that are healed first, I'm 100% sure. She meant that, e.g., generally the ileo would heal sooner than the colon. And proximal colon would heal sooner than distal colon.
 
Perhaps you could contact the doc for more information or ask for sources on that? I'd be curious to know the answer to this as well. I'm at the point where the only symptom I have remaining (in an attempt to achieve remission) is an occasional bit of mucus at the very beginning of my stool when I have a movement. I was wondering why I was only having mucus at the tip of my stool, near the rectum, and nowhere else in my movement. This theory of healing from top to bottom would answer that and suggest it is the last part to heal, but I have never read anything on this.
 
Very strange observation... never heard such thing...

At least your gi is positive. Mine will always look to negative things, and dont care if some part of the bowel are healed if others are still inflammed...
 

my little penguin

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So what we have seen with Ds is that the first to show signs of inflammation in his case was the rectum and worked its way up to the terminal ileum (patchy areas ) and when he started biologics the healing process went in reverse
The rectum was the last to heal
No idea why
But happened with him
Mucosal healing

Mucosal Healing
The assessment and monitoring of disease activity is indispensable for the optimal therapeutic management of IBD patients. Our therapeutic decisions are based on its evaluation, and analysis of disease activity is essential for endpoints in clinical trials. The mere improvement of clinical symptoms alone is not regarded as sufficient anymore, but must be ideally accompanied by mucosal restitution. This process has been termed mucosal healing, and it was proposed that it might lead to the modification of the natural disease course by slowing down or even preventing the progression of disease [5,6,7]. Mucosal healing is predominantly defined by endoscopic assessment of intestinal inflammation and is mostly referred to as the absence of mucosal ulcerations in Crohn's disease [8]. In ulcerative colitis, there is more disparity in the published definitions; however, an international consensus defined it as the absence of friability, blood, erosions, and ulcers of the gut mucosa (fig. 1) [9]. In order to evaluate the presence or absence of mucosal healing on endoscopy, various endoscopic scoring systems have been developed. The most frequently used endoscopic activity indices in Crohn's disease are the Crohn's Disease Endoscopic Index of Severity (CDEIS), the Simple Endoscopic Score for Crohn's Disease, and the Rutgeerts score. In ulcerative colitis, the Mayo Clinic endoscopic subscore and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) are those most widely used [5,6]. These indices allow us to determine improvements of endoscopic lesions, even when the rather rigid endpoint of mucosal healing and thereby the total disappearance of all mucosal ulcerations is not met. Other measures of assessing the disease activity are represented by the biomarkers C-reactive protein and fecal calprotectin. They are currently not regarded as targets for treatment but are helpful indices in monitoring the patient. Histopathology is another measure of inflammation but can also not be defined as a therapeutic target at the moment [10]. However, several recent studies suggest that histologic healing of intestinal inflammation is a better predictor of long-term patient outcomes in ulcerative colitis as compared to mucosal healing on endoscopy.



Fig. 1
Endoscopic images of a Crohn's disease patient a with mucosal ulcerations in the terminal ileum and b subsequent mucosal healing as defined by absence of ulcers and CDEIS scoring. Endoscopic images of an ulcerative colitis patient c with inflammation in the sigmoid and d subsequent mucosal healing as defined by absence of friability, blood, erosions, and ulcers as well as reduction of the endoscopic Mayo score.
http://www.karger.com/WebMaterial/ShowPic/832537



Mucosal healing can only represent an indispensable treatment goal if it serves as a validated surrogate marker for effective control of the disease and subsequently for the positive modulation of the disease course. Until now, there have been no long-term interventional studies comparing the outcome of clinical versus mucosal healing-based approaches for the disease course of IBD patients. There is no prospective evidence that mucosal healing, for example, predicts a reduced need for surgeries as an endpoint for disease modification. In contrast, there are substantial indirect indications from large case series that mucosal healing is associated with better patient-related outcome matters such as reduced risk of relapse, better steroid tapering, fewer hospitalization and surgeries, lower rate of colectomies, and improved ability to work [5,6]. These are important correlative findings, as the selected endpoints define improved quality of life for the IBD patient. Nevertheless, some aspects have to be taken into account before defining mucosal healing as an obtainable treatment goal in all IBD patients.

In this regard, one has to consider that in some patients, especially those with long-standing Crohn's disease, mucosal healing may not always reflect healing of all layers of the tissue, as endoscopy only addresses mucosal rather than transmural healing. Furthermore, one has to consider safety aspects when trying to achieve mucosal healing by intensifying the ongoing therapy, thereby increasing the risk of potentially severe side-effects. Additionally, cost aspects associated with the adaption of therapies to attain mucosal healing cannot be disregarded. Altogether, definite prospective proof that an intensification of the therapy to achieve mucosal healing is able to modulate the natural disease course is still missing. This aspect should be demonstrated in prospective trials investigating the course of disease, as it would only then be justified to escalate therapy in a patient with clinical remission to achieve mucosal healing. It should therefore be carefully evaluated in which individual circumstances mucosal healing may be proposed as the target for therapeutic interventions.

From


 
So what we have seen with Ds is that the first to show signs of inflammation in his case was the rectum and worked its way up to the terminal ileum (patchy areas ) and when he started biologics the healing process went in reverse
The rectum was the last to heal
No idea why
But happened with him
Mucosal healing




From


Fascinating. This all makes sense with my experience. I experienced fistulas just inside my rectum prior to developing more systemic issues. Thank you for posting!
 
More antidotal evidence here. My daughter had a scope on 5/10. GI said rectal and sigmoid inflammation. Almost two weeks later, she was hospitalized for sepsis and the CT scan showed inflammation along the entire left side and starting across the transverse colon. Two weeks after that hospitalized again and inflammation throughout the entire colon and into the TI.

After 33 days of hospitalization and steroids etc she is now starting to heal. Stool is becoming more solid however, she is still bleeding a lot. To me this suggests that maybe she is healing further up and the rectum is lagging a bit behind.

Not exactly a scientific theory...take it for what it is worth.
 
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