# The Role of Histology Alongside Clinical and Endoscopic Evaluation in the Management of IBD—A Narrative Review

## TL;DR

This review discusses the role of histology in managing inflammatory bowel diseases, highlighting its potential and limitations compared to clinical and endoscopic assessments.

## Contribution

The paper provides a narrative review on the current evidence and ongoing research regarding histological assessment in IBD management.

## Key findings

- Persistent histological inflammation in UC may increase relapse risk despite endoscopic remission.
- Histological assessment in CD is limited by disease characteristics and lack of validated scoring systems.
- Interim results from the VERDICT study suggest histological remission does not improve clinical outcomes in UC.

## Abstract

Inflammatory bowel diseases (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions requiring continuous monitoring. Today, endoscopy is the gold standard for assessing disease activity, with histological evaluation providing additional insights. Studies suggest that persistent histological inflammation, despite endoscopic remission, may be associated with a higher risk of relapse in UC, suggesting its role in treatment decisions. In CD, histological assessment is limited by its patchy nature, transmural inflammation and lack of validated scoring systems. Few retrospective studies with conflicting results have examined the prognostic value of histological remission in CD, and its role in predicting long-term outcomes remains unclear. This narrative review aims to summarize and discuss the available evidence regarding the additional value of histological assessment in IBD management. In UC, the ongoing VERDICT study is expected to provide evidence on the impact of incorporating histological remission as a treatment target compared to a strategy based on clinical and endoscopic activity. Recently published interim results indicate that targeting histological remission does not lead to better clinical/biochemical disease activity. Thus, while patients achieving histological healing are associated with better outcomes, the question arises whether achieving histological remission is an intrinsic (biological) characteristic of the patient and indicator of an easier to treat patient group or a result of more effective therapy.