"Clinical remission" vs "Mucosal remission"

After many years of great difficulties, I haven't had any visible or noticable ulcerative colitis symptoms for almost three years. This was after multiple rounds of Prednisone every few months, and a couple terrible flu effects with intense stomach cramping, possibly from the Azathioprine-related immune suppression.

Currently I'm on 2 generic Lialda a day along with 100mg of Azathioprine.

However, when I went for my latest colonoscopy, it was found that there are still tiny ulcers bleeding a small amount of blood. Also my last blood count found I was maybe 1% lower than the normal range for MCHC (hemoglobin?), which I am guessing is related. My general doctor isn't super concerned about the MCHC count. (3.06 where normal is 3.1-3.7)

My GI explained to me that while I'm in "clinical remission" I have not reached "mucosal remission" which is. . . not exactly sure, but it includes ending these tiny invisible ulcers. He said that while other doctors might start putting me on biologics at this point to try to achieve mucosal remission, he was wary to start changing things up since I've been feeling so well for 3 years, after 11 years of the flareup/prednisone/remission cycle.

What have you guys heard about this? Should I be more concerned or do anything differently if I am feeling great, even if I have tiny ulcers in my colon that you only notice with a colonoscopy?

Ah yes "remission" the word with many different qualifiers, definitions, and various interpretations. Everyone seems to have their own inclusions, exclusions, etc.

Our best prognosis (outcome) is when there are no (zero) signs of active inflammation from UC, as studies have shown that when we are in a complete/deep/quiescent remission that we have the longest remissions, least frequent and more moderate flares. If there's any signs at all of inflammation including microscopic-ulcers from inflammation as you describe, then you are not in that ideal state.

Should you jump to a class of much stronger medications because of microscopic-ulcers with no UC symptoms? No, probably not.

You could add mild medications to your current regiment to heal the very last bit that is very mild in severity. You could add rowasa/mesalamine retention enemas to your daily meds if those ulcers where in the rectum, sigmoid colon, or left-side. And/or you could up your generic Lialda to 4 pills a day to achieve the recommended 4,800mgs a day (2 pills a day is 2,400mgs).

You could wait and do nothing. The thing is you can very well continue to heal over the coming months into a complete/deep/quiescent remission without any intervention at all. Your colonoscopy was a snapshot in time, things can change for the better or worse going forward.