ErLangen Endocytoscopy for ColiTis (ELECT) Score Demonstrates Superior Correlation with Histologic Activity Compared to Ulcerative Colitis Endoscopic Index of Severity in Patients with Ulcerative Colitis

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To the Editor Histologic remission has emerged as a more reliable predictor of long-term outcomes in ulcerative colitis (UC) than endoscopic remission alone. While widely used endoscopic indices such as the ulcerative colitis endoscopic index of severity (UCEIS) offer standardized evaluation of mucosal inflammation, they fall short in accurately capturing microscopic disease activity.[ 1 ] The recently validated ELECT (ErLangen Endocytoscopy for ColiTis) score offers an opportunity to assess in vivo histologic changes during real-time colonoscopy using contact-based ultra-high magnification endocytoscopy.[ 2 ] In this observational series, we evaluated six patients with clinically stable UC who underwent high-definition colonoscopy (CF-H290ECI; Olympus, Tokyo, Japan) with both standard white light and endocytoscopic imaging (using 0.05% crystal violet and 1% methylene blue). In addition to routine scoring with UCEIS, each patient was evaluated using the ELECT score, which incorporates crypt shape, crypt distance, vascular distortion, inflammatory cell infiltrates, and the presence of crypt abscess.[ 2 ] Histologic inflammation was assessed using the Nancy histologic index, with histologic remission defined as a Nancy histologic index ≤1 ([ Fig. 1 ]). Fig. 1 Representative endoscopic, endocytoscopic, histologic, and correlation images from a patient with ulcerative colitis. ( A ) Texture and color enhancement imaging (TXI) showing patchy loss of vascular pattern (ulcerative colitis endoscopic index of severity [UCEIS] was scored as 1). ( B–E ) Sequential endocytoscopy images show preserved crypt architecture ( B, C ), vascular distortion: tortuous crowded vessels ( D ), and mild inflammatory infiltrate without any crypt abscess, suggesting an ErLangen Endocytoscopy for ColiTis (ELECT) score of 2. ( F–H ) Histopathology ( F : ×4, G : ×10, H : ×40) reveals mild crypt disarray and mild acute inflammatory infiltrates consistent with histologic activity (Nancy index = 2). ( I ) Spearman's correlation plots: Left—UCEIS versus Nancy index ( r = 0.94, p = 0.005); Right—ELECT score versus Nancy index ( r = 0.98, p < 0.001), showing stronger correlation of the ELECT score with histologic inflammation. Among the six patients (age range: 21–52 years; 33% female), four were in endoscopic remission by UCEIS (score ≤1), and three had an ELECT score ≤2. Histologic remission was achieved in two patients. Interestingly, a patient classified as endoscopically healed by UCEIS had persistent microscopic activity, as indicated by the ELECT score, confirmed by the Nancy index ([ Table 1 ]). The UCEIS score was 0, but ELECT scoring revealed distorted crypts and abnormal vasculature, resulting in an ELECT score of 3 and a Nancy index of 2—indicating histologic inflammation missed by standard endoscopy. Table 1

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