Evaluating the optimum number of biopsies to assess histological inflammation in ulcerative colitis: a retrospective cohort study

Robert Battat, Niels Vande Casteele, Rish K. Pai, Zhongya Wang, Guangyong Zou, John W.D. McDonald, Marjolijn Duijvestein, Jenny Jeyarajah, Claire E. Parker, Tanja Van Viegen, Sigrid A. Nelson, Brigid S. Boland, Siddharth Singh, Parambir S. Dulai, Mark A. Valasek, Brian G. Feagan, Vipul Jairath, William J. Sandborn*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


Background: The optimal ulcerative colitis biopsy protocol is unclear. Aim: To evaluate the number of biopsies required to accurately assess microscopic disease activity in ulcerative colitis. Methods: Biopsies from patients with ≥4 rectosigmoid samples, and clinical and endoscopic data, were retrospectively obtained from a prospective biobank. Histology and endoscopic videos were read blindly. A 4-biopsy Robarts Histopathology Index (RHI) reference score, consisting of the worst item-level ratings from four biopsies, was compared to 1-, 2- and 3-biopsy estimates. Agreement was determined using bivariate errors-in-variable regression analysis (acceptance interval: ±8.25). Endoscopic activity and disease location subgroup analyses were also performed. Results: Forty-six patients had ≥4 rectosigmoid biopsies available (N = 287). The 2-biopsy (tolerance interval: −7.66, 4.79) and 3-biopsy (tolerance interval: −4.86, 3.46) RHI scores demonstrated acceptable agreement with 4-biopsy scores. One-biopsy scores demonstrated unacceptable agreement (tolerance interval: −13.99, 7.78). Mean RHI scores using the 2-, 3- and 4-biopsy approaches were similar (6.1 ± 9.6 P = 0.36; 6.8 ± 10.5, P = 0.7; 7.5 ± 11.2), whereas the 1-biopsy estimate was lower (4.4 ± 8.1, P = 0.06). Histological remission rates were identical for the 2-, 3- and 4-biopsy methods (65.2%, P = 1.0). Subgroup analysis demonstrated that three biopsies were required in patients with endoscopically active disease. Sampling additional colonic locations yielded lower histological remission rates compared to rectosigmoid sampling alone (33.3% vs 61.9%, P = 0.1). Conclusions: A minimum of two — conservatively, three — biopsies are required to reliably assess disease activity in a single colonic segment using the RHI. Further studies are needed of endoscopically active patients and sampling locations. These results have implications for biopsy strategies in clinical trials and practice.

Original languageEnglish (US)
Pages (from-to)1574-1582
Number of pages9
JournalAlimentary Pharmacology and Therapeutics
Issue number10
StatePublished - Nov 1 2020

ASJC Scopus subject areas

  • Gastroenterology
  • Pharmacology (medical)
  • Hepatology


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