Why Histological Healing Is the New Benchmark for Your Ulcerative Colitis

"This refers to a decrease or even a reversal of the signs of inflammation at the microscopic level," explains Adam Pont, MD, a gastroenterologist with Medical Offices of Manhattan in New York City. "It's assessed by looking at slides of tissue biopsies taken from the colon of affected patients. Healing at this level would mean 'histological remission,' and there's evidence that it may be beneficial as a goal."

Here's a look at the advantages of this cellular-level healing and the treatment advances that may bring UC patients closer to that target.

To understand why histological remission is important, it's helpful to start with a high-level view of what remission really means. With UC and other inflammatory bowel diseases, there are three types: clinical, endoscopic, and histological.

Clinical Remission

With this type, it's all about how you feel, according to Rudolph Bedford, MD, a gastroenterologist at Providence Saint John's Health Center in Santa Monica, California. This is the current standard for remission and tracks symptoms and their effect on everyday activities, he says.

"Clinical remission means the patient isn't experiencing disruptive flares of their ulcerative colitis, such as abdominal pain, urgency, or fatigue," he explains. "This is a subjective measure, but it's easy to track and is something a patient can assess on their own without any invasive testing, so it's the most used for monitoring UC overall."

Endoscopic Remission

Whether there's clinical remission or not, a gastroenterologist may order a scan like a colonoscopy, endoscopy, or sigmoidoscopy to look for signs of damage and ulceration in the gastrointestinal tract.

Endoscopic remission goes beyond clinical remission because it provides evidence of whether the intestinal lining is healing or if further treatment is necessary, says Dr. Bedford. Patients may have endoscopic evidence of inflammation without any symptoms.

Histological Remission

"Histologic remission indicates that there's a deeper level of healing than an endoscopic remission," says Bedford. "This is a relatively new measurement, as we transition away from looking only at symptoms. This has the potential to give us more information about the level of inflammation for someone with ulcerative colitis."

If someone with UC is in clinical remission and is experiencing minimal or even no symptoms, why does it matter if there's still inflammation deep in the tissues? The answer lies in potential long-term health risks, says Dr. Pont.

"Symptomatic relief is important, and a potential clue that the colon is healing, but there may still be inflammation present," he explains. "This residual inflammation in the colon can lead to the development of dysplasia (abnormal cells that may be precancerous) and eventually colon cancer."

• Biologics These are lab-made proteins that target parts of the immune system that cause inflammation, blocking their activity.
• JAK Inhibitors Short for Janus kinase inhibitors, these work by blocking certain enzymes that trigger your immune system’s inflammatory response.
• Sphingosine-1-Phosphase Receptor Modulators Known as S1Ps, these are drugs that reduce inflammation in the gut by keeping lymphocytes (white blood cells) from being released into your intestines.

"All of these options work at a cellular level, and have been shown to be so valuable that there's now a move toward going directly to something like biologic agents first rather than stepping up to them after using anti-inflammatories and corticosteroids," says Bedford. "When you do that, it may be possible to achieve histological healing sooner than you would with a step-up approach."

Histological healing is not yet the standard for UC, in large part because it requires a biopsy and additional testing that may not be covered by most insurance plans, says Bedford. That said, he believes it will increasingly be part of the UC treatment landscape.

"This is definitely part of a new paradigm when it comes to UC management and it's a good step forward," he adds. "Achieving symptom control is helpful, but being able to lower major health risks and staying out of the hospital is even better, and that's what histological healing offers."

• With ulcerative colitis, achieving symptom relief is important, but it's also crucial to resolve inflammation that's in the tissues; this is called histological healing.
• Although histological healing isn't yet the standard as a treatment goal, it's increasingly recognized as playing a significant role in long-term health for those with UC.
• Newer medications like biologics are helping more patients with ulcerative colitis achieve histological healing.