Intestinal barrier healing & IBD outcomes

Intestinal barrier healing & IBD outcomes

March 7, 2023

Issue 05

Clinical Question

Is intestinal barrier healing an accurate predictor of major clinical outcomes in IBD?

Editor’s Bottom Line

Functional assessments of intestinal barrier integrity using confocal laser endodomicroscopy (CLE) predict the course of IBD better than traditional endoscopic and histologic outcomes.


Rath T, Atreya R, Bodenschatz J, et al. Intestinal Barrier Healing Is Superior to Endoscopic and Histologic Remission for Predicting Major Adverse Outcomes in Inflammatory Bowel Disease: The Prospective ERIca Trial. Gastroenterology. 2023 Feb;164(2):241–55.


To better understand the relationship between intestinal barrier healing and disease outcomes in IBD, researchers in Germany prospectively examined 100 patients with Crohn’s disease (CD) and 81 patients with ulcerative colitis (UC) treated between 2017 and 2019. All patients were in clinical remission at baseline and underwent ileocolonoscopy at study outset and during follow-up. Functional assessments of the integrity of the intestinal barrier were performed using confocal endomicroscopy. Researchers correlated endoscopic, histologic and mucosal barrier healing with disease outcomes.

At baseline, 26% and 27% of CD and UC patients, respectively, demonstrated colonic barrier healing, and 25% of CD patients had ileal barrier healing. Between 50% and 60% of patients in either group met criteria for endoscopic and histologic remission.

During a mean follow-up of 35 months in the CD group and 25 months in the UC group, 73% and 69% of patients, respectively, experienced at least one major adverse outcome, defined as disease relapse, IBD-related hospitalization or surgery, or an increase or initiation of IBD medical treatment.

Statistical analyses showed that barrier healing at baseline was a more accurate predictor of subsequent major adverse outcomes than endoscopic or histologic parameters. Specifically, in UC patients, endoscopic remission, defined as a Mayo endoscopy score (MES) <1, was 70.4% accurate in predicting major adverse outcomes, endoscopic healing, defined as an MES of 0, was 75.3% accurate, histologic remission was 66.7% and 69.1% accurate using the Robarts histopathology index (RHI) and Nancy histological index (NHI), respectively, while barrier healing in the colon was 85% accurate in predicting subsequent major disease outcomes.

Additionally, in CD, endoscopic remission was 54% accurate in predicting major adverse outcomes in this population, when defined as the absence of erosions and ulcerations, or 62% accurate when defined as a simplified endoscopic index of severity (SES-CD) score <3. Histologic remission was 56% accurate when defined according to a mRiley score, and barrier healing in the colon and ileum were 72.7% and 88.7% accurate, respectively, in predicting major adverse outcomes.


Study Design: Prospective observational

Funding: The German Research Foundation

Allocation: Not applicable

Setting: Multicenter

Level of Evidence: 1b