British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Accelerating Earlier Access to Anti-TNF-α Agents with Biosimilar Medicines in the Management of Inflammatory Bowel Disease

Data indicate that earlier initiation of anti-tumor necrosis factor alpha (anti-TNF-α) biologic medicines may prevent progression to irreversible bowel damage and improve outcomes for patients with inflammatory bowel disease (IBD), particularly Crohn's disease. However, the high cost of such therapies may restrict access and prevent timely treatment of IBD. Biosimilar anti-TNF-α medicines may represent a valuable opportunity for cost savings and optimized patient outcomes by improving access to advanced therapies and allowing earlier anti-TNF-α treatment initiation. Biosimilar anti-TNF-α medicines have been shown to offer consistent therapeutic outcomes to their reference medicines, yet despite entering the IBD treatment armamentarium over 10 years ago, their implementation in clinical practice remains suboptimal. Factors limiting the 'real' use of biosimilar anti-TNF-α medicines may include an ongoing lack of understanding and acceptance of biosimilars by both healthcare professionals (HCPs) and patients, as well as systemic factors such as formulary decisions outside of the control of the prescriber. In this review, an expert panel of gastroenterologists discusses HCP-level considerations to improve biosimilar anti-TNF-α utilization in IBD in order to support early anti-TNF-α initiation and maximize patient outcomes.

Small Molecules in the Treatment of Acute Severe Ulcerative Colitis: A Review of Current Evidence

Ulcerative colitis (UC) is an inflammatory bowel disease in which one-quarter of patients are at risk of developing a severe form of the disease known as acute severe UC (ASUC). This condition exposes patients to serious complications, including toxic megacolon, surgical intervention, and even death. The current therapeutic strategy relies on time-dependent, multi-step algorithms that integrate systemic corticosteroids, calcineurin inhibitors, and biologic agents (specifically infliximab) as medical therapy aimed at avoiding colectomy. Despite this approach, a significant proportion of patients fail to respond to either corticosteroids or infliximab and may require alternative therapeutic options if there is no urgent surgical necessity. These alternatives include other biologics or emerging small molecules, although the evidence supporting these treatments remains extremely low, even considering their well-documented and promising efficacy and safety in moderate-to-severe UC. Conversely, it is necessary to investigate whether infliximab can be effectively replaced or surpassed by other approved biological agents and small molecules as first-line therapy after steroid resistance. This review aims to summarise the available evidence on small molecules, specifically Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators.

Health Benefits of Montmorency Tart Cherry Juice Supplementation in Adults with Mild to Moderate Ulcerative Colitis; A Placebo Randomized Controlled Trial

AIMS

Ulcerative colitis (UC) significantly impacts individuals' self-perception, body image, and overall quality of life, while also imposing considerable economic costs. These challenges highlight the necessity for complementary therapeutic strategies with reduced adverse effects to support conventional pharmacological treatments. Among natural interventions, Montmorency tart cherries, noted for their high anthocyanin content have emerged as a natural anti-inflammatory agent for UC. The current trial aimed to investigate the effects of Montmorency tart cherries compared to placebo in patients with mild to moderate UC.

MATERIALS AND METHODS

Thirty-five patients with UC were randomly assigned to receive either placebo or Montmorency tart cherry juice, of which they drank 60 mL per day for 6 weeks. The primary outcomes and health-related quality of life, measured via the Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), and the secondary measures, including other health-related questionnaires, blood biomarkers, and faecal samples, were measured before and after the intervention. Linear mixed-effects models were adopted to contrast the changes from baseline to 6 weeks between trial arms. Effect sizes were calculated using Cohen's d.

RESULTS

There were significantly greater improvements in the IBDQ (22.61 (95% CI = 5.24 to 39.99) d = 0.90) and simple clinical colitis activity index (-3.98 (95% CI = -6.69 to -1.28) d = -1.01) in the tart cherry trial arm compared to placebo. In addition, reductions in faecal calprotectin levels were significantly greater in the tart cherry trial arm compared to placebo (-136.17 µg/g (95% CI = -258.06 to -4.28) d = -1.14). Loss to follow-up (N = 1) and adverse events (N = 1) were low and compliance was very high in the tart cherry (95.8%) trial arm.

CONCLUSIONS

Given the profoundly negative effects of UC on health-related quality of life and its fiscal implications for global healthcare systems, this trial indicates that twice-daily tart cherry supplementation can improve IBD-related quality of life as well as the severity of symptoms and therefore may be important in the management of UC.

Gut microbiota in Crohn's disease pathogenesis

Inflammatory bowel diseases (IBDs) are classified into two distinct types based on the area and severity of inflammation: Crohn's disease (CD) and ulcerative colitis. In CD, gut bacteria can infiltrate mesenteric fat, causing expansion known as creeping fat, which may limit bacterial spread and inflammation but can promote fibrosis. The gut bacteria composition varies depending on whether the colon or ileum is affected. Fecal microbiota transplantation (FMT) transfers feces from a healthy donor to restore gut microbiota balance, often used in IBD patients to reduce inflammation and promote mucosal repair. The use of FMT for CD remains uncertain, with insufficient evidence to fully endorse it as a definitive treatment. While some studies suggest it may improve symptoms, questions about the duration of these improvements and the need for repeated treatments persist. There is a pressing need for methods that provide long-term benefits, as highlighted by Wu et al's research.

Inappropriate use of antibiotics in the management of diarrhoea in children under five years admitted with acute diarrhoea in four provinces of Mozambique 2014-2019

BACKGROUND

Even with a great reduction in the last years, diarrhoea continues to be one of the leading causes of hospital admission and mortality in children less than five years of age globally. The success of diarrhoeal disease management relies on the rapid recognition of the symptoms and adequate treatment, with World Health Organization (WHO) guidelines, limiting the use of antibiotics for all diarrhoea cases being reserved to specific circumstances. Therefore, this study aimed to evaluate the frequency of antibiotics use in diarrhoea management in children aged 0-59 months admitted with acute diarrhoea in four provinces of Mozambique, from 2014 to 2019.

METHODS

A cross-sectional hospital-based surveillance was conducted from January 2014 to December 2019 in six sentinel sites located in four provinces. Socio-demographic, epidemiological and clinical data were obtained by interviewing the child's caregivers and by accessing the child's medical records and children's vaccination card. Data collected through National Surveillance of Diarrhoea (ViNaDia) was double-entered in Epi InfoTM3.5.1. (Centers for Disease Control and Prevention, Atlanta 2008), followed by data comparison. IBM SPSS software was used to conduct the data analysis.

RESULTS

During the study period 2014-2019 a total of 2382 children presenting at one of the designated health facilities were enrolled via ViNaDia surveillance. Of these 85.1% (2028/2382) provided data of antibiotics (ATB) usage and thus included in the present analysis. The majority was male with 59.3% (1203/2028), with infants aged 0-11 months composing the largest age group with 49.4% (1002/2028). Nutritional assessment revealed that 28.8% (585/2028) were underweight and 15.2% (308/2028) faced wasting. The comorbidities included human immunodeficiency virus (HIV) 7.8% (159/2028), malaria 7.0% (141/2028), and pneumonia 2.1% (42/2028). The rates of bloody diarrhoea and "rice-water" were reported in 1.5% (10/1664) and 2% (29/1664) respectively. Antibiotics use was reported in 93.2% of the children [95% CI: 92.0-94.2; 1890/2028], with s 49.1% [95% CI: 47.0-51.5; 930/1890] received more than one ATB. The most prescribed antibiotics were Ampicillin (46.2%), Gentamicin (38.4%) and Cotrimoxazole (30.5%).

CONCLUSIONS

The results of this study indicate inappropriate use of antibiotics in the management of acute diarrhoea in children attended in four provinces of Mozambique. The study suggests the drawing of a local guideline for the efficient management of acute diarrhoea, and the need for education on adherence of WHO recommendations on antibiotics use in acute diarrhoea.

Gut microbiota dysfunction in Crohn's disease

Introduction

Crohn's disease (CD) results from alterations in the gut microbiota and the immune system. However, the exact metabolic dysfunctions of the gut microbiota during CD are still unclear. Here, we investigated metagenomic functions using PICRUSt2 during the course of CD to better understand microbiota-related disease mechanisms and provide new insights for novel therapeutic strategies.

Methods

We performed 16S rRNA-based microbial profiling of 567 faecal samples collected from a cohort of 383 CD patients, including 291 remissions (CR), 177 mild-moderate (CM) and 99 severe (CS) disease states. Gene and pathway composition was assessed using PICRUSt2 analyses of 16S data.

Results

As expected, changes in alpha and beta diversity, in interaction networks and increases in Proteobacteria abundance were associated with disease severity. However, microbial function was more consistently disrupted than composition from CR, to CM and then to CS. Major shifts in oxidative stress pathways and reduced carbohydrate and amino acid metabolism in favour of nutrient transport were identified in CS compared to CR. Virulence factors involved in host invasion, host evasion and inflammation were also increased in CS.

Conclusions

This functional metagenomic information provides new insights into community-wide microbial processes and pathways associated with CD pathogenesis. This study paves the way for new advanced strategies to rebalance gut microbiota and/or eliminate oxidative stress, and biofilm to downregulate gut inflammation.

Cumulative experience meets modern science: Remarkable effects of TongXieYaoFang formula on facilitating intestinal mucosal healing and secretory function

ETHNOPHARMACOLOGICAL RELEVANCE

TongXieYaoFang (TXYF), a classical formula used in Traditional Chinese Medicine, is renowned for its efficacy in treating chronic abdominal pain and diarrhoea. Modern research suggests that fundamental relief from these symptoms depends on complete intestinal mucosal healing, which normalises gut secretory functions. Consensus between traditional and modern medical theories indicates that TXYF is particularly suitable for treating the remission phase of ulcerative colitis (UC). Unfortunately, its potential in the remission phase has not received sufficient attention, and its use has been largely limited to a supportive role during the acute phase.

AIM OF THE STUDY

This study aimed to elucidate the efficacy of TXYF in promoting intestinal mucosal healing and enhancing gut secretory function during the non-acute damage phase, as well as to identify the underlying mechanisms contributing to its effects.

METHODS

A mouse model of dextran sulphate sodium salt (DSS)-induced colitis was optimised to specifically evaluate the effects of TXYF on mucosal healing during the repair phase. The effects of TXYF on murine colon function were assessed by measuring faecal pellet count and water content, and further evaluated through immunohistochemical analyses. The underlying mechanisms of action of TXYF were elucidated using mouse intestinal organoid cultures, intestinal stem cell (ISCs) transplantation, immunofluorescence, and western blotting. Active components of TXYF were identified via LC-MS/MS analysis and integrated with network pharmacology for bioinformatics assessment.

RESULTS

TXYF significantly promoted mucosal healing, as reflected by reduced disease activity scores, increased colon length, enhanced epithelial proliferation, and decreased histological damage. Furthermore, TXYF enhanced the recovery of critical intestinal functions, including barrier integrity, absorption, secretion, and motility. Notably, the improvement in the secretory function was particularly pronounced. Mechanistically, these therapeutic effects were mediated by the upregulation of the Atonal homolog 1/SAM pointed domain containing ETS transcription factor/Mucin 2 pathway, which facilitates the differentiation and maturation of ISCs into goblet cells, thereby contributing to both mucosal repair and enhanced secretory function.

CONCLUSIONS

Our study demonstrated that TXYF significantly promotes intestinal mucosal healing and enhances secretory function. These findings offer a solid basis for exploring the potential applications of TXYF in UC management during the remission phase.

The Effect of Colesevelam on the Microbiome in Postoperative Crohn's Disease

BACKGROUND

While surgery plays a pivotal role in the management of ileal Crohn's disease, the risk of endoscopic recurrence following an ileocaecal resection can be greater than 65% within 12 months of surgery. More than 90% of patients with Crohn's disease have a concomitant diagnosis of bile acid diarrhea following an ileal resection. This pilot study aimed to assess whether the use of bile acid sequestrants in patients with Crohn's disease who have undergone a primary terminal ileal resection with concomitant bile acid diarrhea can alter the microbiome and prevent disease recurrence.

METHODS

Patients with Crohn's disease who underwent a primary terminal ileal resection and had symptoms of diarrhea within 1-3 months of surgery underwent 75SeHCAT testing for bile acid diarrhea. If positive (75SeHCAT ≤ 15%), patients were treated with colesevelam and stool samples were collected at 4 weeks, 8 weeks, and 6-12 months posttreatment. If negative (75SeHCAT > 15%), treatment was not given and were reviewed in the clinic as per local guidelines. All patients underwent a 6-12 month postoperative colonoscopy where further stool samples and mucosal biopsies were taken. Disease activity was established using the endoscopic Rutgeert's score, with disease remission defined as Rutgeert's score

RESULTS

A total of 14 patients who completed the study, 10 of whom had a 75SeHCAT positive diagnosis of bile acid diarrhea and were started on treatment with colesevelam. Four patients did not require treatment as 3 were asymptomatic and 1 had a negative 75SeHCAT scan. Three of the fourteen patients had disease recurrence at their 6-12 month postoperative colonoscopy assessment, of which 1 patient was taking colesevelam and 2 patients were not taking colesevelam. A total of 44 fecal samples and 44 mucosal biopsies underwent 16S ribosomal RNA gene analysis to assess α/β-diversity and microbial composition. In the colesevelam treated patients there was no significant difference in α/β-diversity pre- and posttreatment. Pretreatment, the 3 most abundant bacterial classes in all patients were Bacteroidia, Clostridia, and Gammaproteobacteria. Following 6-12 months of treatment, out of the 9 patients on colesevelam, 5/9 (55.6%) had a reduction in Bacteroidia, 9/9 (100%) had an increase in Clostridia, and 7/9 (77.8%) had a reduction in Gammaproteobacteria. Of the 2 patients not given colesevelam, one showed a reduction in Bacteroidia, increase in Clostridia and a reduction in Gammaproteobacteria.

CONCLUSIONS

This small pilot study demonstrated that patients who were given colesevelam, were more likely to be in disease remission at their 6-12 months colonoscopy review compared with those not treated. Furthermore, treatment with colesevelam may have a role in altering the microbiome to help maintain remission states in postoperative Crohn's disease. Larger mechanistic studies are now needed to confirm these findings and demonstrate statistical significance as well as investigate whether this benefit may be present even in those patients with 75SeHCAT negative disease.

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Key Words

• Crohn’s disease
• bile acid diarrhoea
• bile acid sequestrants
• colesevelam
• microbiome
• terminal ileal resection

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MESH Headings

• Humans
• Crohn Disease/surgery
• Crohn Disease/microbiology
• Crohn Disease/drug therapy
• Female
• Male
• Adult
• Pilot Projects
• Gastrointestinal Microbiome/drug effects
• Colesevelam Hydrochloride/therapeutic use
• Middle Aged
• Diarrhea/drug therapy
• Diarrhea/etiology
• Diarrhea/microbiology
• Bile Acids and Salts/metabolism
• Postoperative Complications/drug therapy
• Postoperative Complications/microbiology
• Feces/microbiology
• Colonoscopy
• Ileum/surgery
• Follow-Up Studies
• Recurrence
• Young Adult
• RNA, Ribosomal, 16S/genetics

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Grants

• Bowel and Cancer Research

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Affiliation(s)

Aditi Kumar Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
Mohammed Nabil Quraishi University of Birmingham Microbiome Treatment Centre, Birmingham, UK Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Hafid O Al-Hassi Research Institute in Healthcare Science, University of Wolverhampton, Wolverhampton, UK
Mohammed Elasrag Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham, UK
Jonathan P Segal Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia
Manushri Jain Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
Helen Steed Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK School of Medicine and Clinical Practice, Faculty of Sciences and Engineering, University of Wolverhampton, Wolverhampton, UK
Jeffrey Butterworth Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
Adam Farmer Division of Gastroenterology & Hepatology, St Louis University Hospital, St Louis, MO, USA
John Mclaughlin Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK Department of Gastroenterology, Salford Royal Foundation Trust, Stott Lane, UK
Andrew D Beggs University of Birmingham Microbiome Treatment Centre, Birmingham, UK Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
Matthew J Brookes Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK School of Medicine and Clinical Practice, Faculty of Sciences and Engineering, University of Wolverhampton, Wolverhampton, UK

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3D-printed cannabidiol hollow suppositories for treatment of epilepsy

Cannabidiol (CBD) is widely used to alleviate the syndromes of epilepsy. However, the marketed oral CBD formulation has the prominent first-pass effect. Here, a cannabidiol-loaded hollow suppository (CHS) was developed using three-dimensional (3D) printing technology. CHS was assembled with an inner supporting spring and an outer CBD-loaded curved hollow shell. The spring was prepared using fused deposition modeling 3D printing with thermoplastic urethane filaments followed by splitting. The shell was prepared with a 3D-printed metal mold filled with the mixture of CBD, polyvinyl alcohol, and polyethylene glycol. CHS slowly in vitro released CBD for 5 h and achieved the systemic delivery of CBD. The high in vitro and in vivo safety of CHS was demonstrated. Epilepsy rat models were established by lithium-pilocarpine dosing. Locally administered CHS greatly alleviated the damage to brains and reduced inflammation. Moreover, CBD obviously improved the abundance and composition of gut microbiota and the abundance of beneficial bacteria, including Lachnoclostridium and Akkermansia. Personalized CHS is a promising medication for the treatment of epilepsy.

Ocrelizumab-induced colitis-critical review and case series from a Romanian cohort of MS patients

Background

Widespread use of ocrelizumab, an anti-CD20 monoclonal antibody, for treating patients with multiple sclerosis (MS), has led to an increase in reported adverse events following real-world observation. Among these, drug-induced colitis is a rare, but severe side effect, prompting a recent FDA statement regarding this safety concern. Objectives: We analyzed a cohort of ocrelizumab treated patients in our MS center to evaluate the incidence of drug-induced colitis.

Methods

We present a critical review of the available literature on diagnosis and management of anti-CD20 induced colitis and display a case series of 3 suspected patients in our cohort.

Results

Two patients met the full criteria for ocrelizumab-induced colitis, while a third partially met the criteria. Following symptomatic treatment and discontinuation of ocrelizumab, the patients showed favorable outcomes.

Conclusion

Ocrelizumab-induced colitis is a rare, but severe adverse event. Its incidence may be higher than expected, reaching 1,95% in our cohort of MS patients. Further reporting of such cases is essential to broaden our understanding of this side effect.

Differences in the Adverse Event Burden of Corticosteroid Use in Inflammatory Bowel Disease as Reported Between Adverse Event Reporting Systems and a Patient Questionnaire

BACKGROUND AND AIMS

Corticosteroids are widely used in managing inflammatory bowel disease (IBD). While adverse events (AEs) of corticosteroids are well recognized, current understanding of corticosteroid-related AE burden in IBD remains incomplete.

METHODS

AE reports for prednisone/prednisolone and budesonide were extracted from the Food and Drug Administration Adverse Event Reporting System (FAERS) and VigiBase databases. Total and frequently reported AEs were tabulated, and AEs of special interest were compared with reports for all drugs using proportional reporting ratio criteria. Database reports were compared with AEs reported in a patient survey capturing corticosteroid exposure and AE recall.

RESULTS

In FAERS and VigiBase, 344 140 and 42 836 AEs were reported, respectively, in patients with IBD; among these, 10 157 (3.0%) and 11 391 (26.6%), respectively, were related to prednisone/prednisolone or budesonide. AEs associated with corticosteroid use in IBD increased over time. Adrenal insufficiency, Cushingoid complications, osteonecrosis, osteoporosis, diabetes, and pancreatitis were disproportionately reported for corticosteroids. Among 9229 patients who responded to the survey, 6434 (69.7%) reported corticosteroid exposure. AEs were more frequently recalled by patients exposed to prednisone (61.9%) vs budesonide (27.4%; p = 0.0001). The most commonly recalled AEs differed from those reported in the pharmacovigilance databases and included weight gain, sleep problems, mood disturbance, and skin changes. Younger patients and those with mental health disorders were more likely to recall suicidal thoughts/attempts.

CONCLUSIONS

Adverse events associated with IBD-related corticosteroid use were frequent. Patients reported AEs affecting quality of life, while clinicians disproportionately reported AEs based on objective diagnostic criteria.

Machine learning and metabolomics identify biomarkers associated with the disease extent of ulcerative colitis

BACKGROUND AND AIMS

Ulcerative colitis (UC) is a metabolism-related chronic intestinal inflammatory disease. Disease extent is a key parameter of UC. Using serum metabolic profiling to identify noninvasive biomarkers of disease extent may inform therapeutic decisions and risk stratification.

METHODS

The orthogonal partial least squares-discriminant analysis (OPLS-DA) was performed to identify the metabolites. Least absolute shrinkage and selection operator regression, random forest-recursive feature elimination, and support vector machine-recursive feature elimination algorithms were used to screen metabolites. Five machine learning algorithms (eXtreme Gradient Boosting, K-NearestNeighbor, Naive Bayes, random forest [RF], and SVM) were used to construct the prediction model.

RESULTS

A total of 220 differential metabolites between the patients with UC and healthy controls (HCs) were confirmed by the OPLS-DA model. Machine learning screened 8 essential metabolites for distinguishing patients with UC from HCs. A total of 23, 6, and 6 differential metabolites were obtained through machine learning between groups E1 and E2, E1 and E3, and E2 and E3. The RF model had a prediction accuracy of up to 100% in all 3 training sets. The serum levels of tridecanoic acid were significantly lower, and pelargonic acid was significantly higher in patients with extensive colitis than in the other groups. The serum level of asparaginyl valine in patients with rectal UC was significantly lower than that in the E2 and E3 groups.

CONCLUSIONS

Our findings revealed the metabolic landscape of UC and identified biomarkers for different disease extents, confirming the value of metabolites in predicting the occurrence and progression of UC.

Effects of GLPG3970 on Sulfasalazine and Methotrexate Pharmacokinetics in Healthy Adults: Two Open-Label, Phase I, Drug-Drug Interaction Studies

GLPG3970 is a selective salt-inducible kinase 2/3 inhibitor intended for the treatment of inflammatory diseases. In vitro studies suggest GLPG3970 strongly inhibits breast cancer resistance protein (BCRP), indicating a possible interaction with BCRP substrates such as sulfasalazine (SSZ; a probe substrate for intestinal BCRP inhibition) and methotrexate (MTX), both inflammatory disease medications. Two open-label, nonrandomized, phase I, drug-drug interaction (DDI) studies assessed the pharmacokinetics of SSZ 1,000 mg (NCT04720183) and MTX 7.5 mg (EudraCT: 2020-000391-37) with and without GLPG3970 350 mg. Healthy participants aged 18-55 years with wild-type homozygous BCRP genotype (c421C/C) received: SSZ on day (D)1, GLPG3970 + SSZ on D5, and GLPG3970 2 hours after SSZ on D9 (N = 8; SSZ/GLPG3970 DDI study); MTX on D1, GLPG3970 + MTX on D5, and GLPG3970 on D6-8 (N = 15; MTX/GLPG3970 DDI study). Primary end points were AUC and Cmax ("exposure") of SSZ and its metabolite (sulfapyridine [SPD]), SPD:SSZ AUC ratio (SSZ/GLPG3970 study), and AUC and Cmax ("exposure") of MTX (MTX/GLPG3970 study). DDIs were evaluated using the geometric mean ratio of each end point; a > 2-fold increase in SSZ or MTX exposure was deemed clinically relevant. GLPG3970 demonstrated mild inhibition of intestinal BCRP in vivo: GLPG3970 + SSZ increased SSZ exposure ~1.7-1.8-fold and decreased SPD:SSZ ratio ~ 2-fold vs. SSZ alone. GLPG3970 administered 2 hours after SSZ did not change the magnitude of the interaction. GLPG3970 + MTX had no relevant effect on MTX pharmacokinetics vs. MTX alone. Therefore, the strong in vitro BCRP inhibition was not confirmed in vivo. No safety concerns were observed when GLPG3970 was coadministered with SSZ or MTX.

Association of Race and Postoperative Outcomes in Patients with Inflammatory Bowel Disease

BACKGROUND

Previous literature suggests that rates of postoperative complications following inflammatory bowel disease (IBD) surgery differ based on race.

AIMS

The purpose of this study was to examine the association between race and adverse events and wound complications in patients with IBD.

METHODS

This was a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program Inflammatory Bowel Disease Collaborative from 2017 to 2022. The data was collected from 15 high-volume IBD centers across the United States. The data was analyzed using crude and multivariable logistic regressions.

RESULTS

4284 patients were included in the study. Overall rates of adverse events and wound complications were 20.3% and 11.3%, respectively, and did not differ based on race on bivariate analysis. Rates of adverse events were 20.0% vs 24.6% vs 22.1%, p = 0.13 for white, black and other minority subjects, respectively. The adjusted odds of adverse events were higher for black subjects (1.46 [95%CI 1.0-2.1], p = 0.03) compared to white subjects. No difference in adverse events was found between other minority subjects and either black or white subjects (1.29 [0.7-2.3], p = 0.58). Race was not associated with likelihood of wound complications in the final analysis.

CONCLUSIONS

We found that a subset of black patients with IBD continue to experience more adverse events compared to white patients, primarily driven by a higher need for postoperative blood transfusion. Nonetheless, known risk factors, including comorbid conditions, decreased BMI, open surgery, and emergency surgery have a stronger association with postoperative complications than race alone.

Linking dietary fiber to human malady through cumulative profiling of microbiota disturbance

Dietary fiber influences the composition and metabolic activity of microbial communities, impacting disease development. Current understanding of the intricate fiber-microbe-disease tripartite relationship remains fragmented and elusive, urging a systematic investigation. Here, we focused on microbiota disturbance as a robust index to mitigate various confounding factors and developed the Bio-taxonomic Hierarchy Weighted Aggregation (BHWA) algorithm to integrate multi-taxonomy microbiota disturbance data, thereby illuminating the complex relationships among dietary fiber, microbiota, and disease. By leveraging microbiota disturbance similarities, we (1) classified 32 types of dietary fibers into six functional subgroups, revealing correlations with fiber solubility; (2) established associations among 161 diseases, uncovering shared microbiota disturbance patterns that explain disease co-occurrence (e.g., type II diabetes and kidney diseases) and distinct microbiota patterns that discern symptomatically similar diseases (e.g., inflammatory bowel disease and irritable bowel syndrome); (3) designed a body-site-specific microbiota disturbance scoring scheme, computing a disturbance score (DS) for each disease and highlighting the pronounced capacity of Crohn's disease to disturb gut microbiota (DS = 14.01) in contrast with food allergy's minimal capacity (DS = 0.74); (4) identified 1659 fiber-disease associations, predicting the potential of dietary fiber to modulate specific microbiota changes associated with diseases of interest; (5) established murine models of inflammatory bowel disease to validate the preventive and therapeutic effects of arabinoxylan that notably perturbed the Bacteroidetes and Firmicutes phyla, as well as the Bacteroidetes and Lactobacillus genera, aligning with our model predictions. To enhance data accessibility and facilitate targeted dietary intervention development, we launched an interactive webtool-mDiFiBank at https://mdifibank.org.cn/.

A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions

PURPOSE

Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions.

METHODS

A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted.

RESULTS

The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials.

CONCLUSION

This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.

CT-based body composition parameters predict the loss of response to infliximab in patients with Crohn's disease

OBJECTIVE

Infliximab is a first-line biologic agent for the treatment of Crohn's disease (CD), in which loss of response (LOR) remains a challenge in the treatment of patients with CD. The study aimed to explore the association between body composition parameters and LOR to infliximab in CD patients.

METHODS

118 patients with CD admitted to the First Affiliated Hospital of Wenzhou Medical University and treated with infliximab from June 2015 to December 2021 were retrospectively enrolled. The body composition of patients was analyzed by computed tomography (CT). The primary outcome measure was the one-year LOR. Patients were divided into the Remission group and the LOR group to analyze the association between body composition parameters and the LOR to infliximab.

RESULTS

The rate of sarcopenia in the LOR group was higher than in the Remission group (83.7% vs. 60.0%, P=0.008). Multivariate analysis showed that females had a lower risk of sarcopenia than males (OR=0.30, 95% CI 0.11-0.81, P =0.017); BMI was significantly associated with sarcopenia (OR=0.68, 95% CI 0.56-0.83, P <0.001); L1 CD and L2 CD had a lower risk of sarcopenia than L3 CD (OR=0.29, 95% CI 0.10-0.83, P =0.021; OR=0.25, 95% CI 0.07-0.87, P=0.028).

CONCLUSIONS

Sarcopenia was identified as a risk factor for developing LOR in infliximab-treated patients.

Comparison of 1-Year Clinical Course in Patients With Newly Diagnosed Inflammatory Bowel Disease Between Vietnam and Korea: A Multinational, Multicenter Retrospective Cohort Study

Background/Aims

The differences in the clinical course of Crohn's disease (CD) and ulcerative colitis (UC) among Asian countries remain unknown. Thus, we compared the clinical characteristics, treatment, and one-year outcomes of newly diagnosed inflammatory bowel disease (IBD) patients between Vietnam and Korea.

Methods

A retrospective cohort study was conducted at seven tertiary hospitals in these countries between January 2020 and January 2021. Data on demographics, diseases, treatment, and outcomes during 1 year after diagnosis were collected.

Results

Among 225 patients (60 from Vietnam and 165 from Korea), 140 and 85 were diagnosed with UC and CD, respectively. Severe activity (p < 0.01) and extensive colitis (p < 0.01) in UC, along with complicated behavior in CD (p < 0.01), were more frequently observed in Vietnamese patients compared to Korean patients. The proportion of UC patients using corticosteroids (p < 0.01), immunomodulators (p < 0.01), and biologics (p = 0.026) was significantly higher in Vietnam. In contrast, the proportion of UC patients using topical mesalamine (p < 0.01) was significantly higher in Korea. The intervals from CD diagnosis to biologic therapy initiation (p = 0.04), as well as from UC diagnosis to corticosteroid (p < 0.01), immunomodulator (p < 0.01), and biologic therapy (p < 0.01) commencement, were significantly shorter in Vietnamese patients compared to Korean patients. However, the proportions of endoscopic healing and complications at 1-year follow-up did not significantly differ between the countries (p > 0.05).

Conclusions

Although Vietnamese IBD patients had higher baseline clinical and phenotypic severity than their Korean counterparts, no significant differences in short-term outcomes were observed, potentially reflecting the impact of the higher rate and early biologic usage in Vietnamese patients.

Antimicrobial peptide DP7 alleviates dextran sulfate sodium (DSS)-induced colitis via modifying gut microbiota and regulating intestinal barrier function

Inflammatory bowel diseases (IBDs), such as Crohn's disease (CD) and ulcerative colitis (UC), represent a growing global health concern. Restoring the balance of the gut microbiota, a crucial factor in intestinal health, offers potential for treating IBD. DP7, a novel antimicrobial peptide with potent antibacterial activity, was investigated for its anti-inflammatory effects in a dextran sulfate sodium (DSS)-induced UC mouse model. DP7 significantly ameliorated key disease parameters, including disease activity index, weight loss, and shortened colon length, while preserving colonic epithelial integrity and reducing inflammatory infiltration. Further analysis revealed potential targets of DP7, highlighting the significant role of Muribaculaceae bacteria during inflammatory states. To further explore the role of the gut microbiota in DP7's efficacy, fecal microbiota transplantation (FMT) was performed using feces from DP7-treated mice. FMT successfully ameliorated colitis in recipient mice, providing further evidence for the crucial role of the gut microbiome in IBD treatment and DP7's ability to modulate the gut microbiota for therapeutic benefit. Moreover, our findings suggest that DP7's modulation of the immune system is intricately linked to the complex microbial environment. Our findings demonstrate that DP7 effectively mitigates inflammation, attenuates barrier dysfunction, and shapes the gut microbiota, suggesting its potential as a therapeutic agent for UC.

Evaluation of intestinal biopsy tissue preservation methods to facilitate large-scale mucosal microbiota research

BACKGROUND

Large-scale multicentre studies are needed to understand complex relationships between the gut microbiota, health and disease. Interrogating the mucosal microbiota may identify important biology not captured by stool analysis. Gold standard tissue cryopreservation ('flash freezing') limits large-scale study feasibility. We aimed to compare gut microbiota in gold standard and pragmatic mucosal biopsy storage conditions.

METHODS

We collected endoscopic recto-sigmoid biopsies from 20 adults with inflammatory bowel disease. Biopsies were preserved using three methods: (i) flash freezing (most proximal and distal biopsy sites); (ii) nucleic acid preservative reagents (QIAGEN Allprotect®, Invitrogen RNAlater™, and Zymo DNA/RNA Shield™); and (iii) formalin fixation with paraffin embedding (FFPE), which is used to preserve tissue for clinical histopathology within healthcare settings. Microbiota were sequenced on the MiSeq platform (V4 region, 16S rRNA gene).

FINDINGS

Tissue microbiota were consistent between most proximal and distal tissue suggesting any within-patient variation observed reflected storage condition, not biopsy location. There was no significant difference in alpha-diversity or microbial community profiles of reagent-preserved versus gold standard tissue. FFPE community structure was significantly dissimilar to other tissue samples, driven by differential relative abundance of obligate gut anaerobes; Faecalibacterium, Anaerostipes and Lachnospiraceae. Despite these differences, tissue microbiota grouped by participant regardless of preservation and storage conditions.

INTERPRETATION

Preservative reagents offer a convenient alternative to flash freezing tissue in prospective large-scale mucosal microbiota studies. Whilst less comparable, FFPE provides potential for retrospective microbiota studies using historical samples.

FUNDING

Medical Research Council (MR/T032162/1) and The Leona M. and Harry B. Helmsley Charitable Trust (G-2002-04255).

Endoscopic diagnosis and management of adult inflammatory bowel disease: a consensus document from the American Society for Gastrointestinal Endoscopy IBD Endoscopy Consensus Panel

Endoscopy plays a key role in diagnosis, monitoring of disease activity, assessment of treatment response, dysplasia surveillance, postoperative evaluation, and interventional therapy for patients with inflammatory bowel disease (IBD). Clinical practice patterns in the endoscopic management of IBD vary. A panel of experts consisting of IBD specialists, endoscopists, and GI pathologists participated in virtual conferences and developed this modified Delphi-based consensus document to address endoscopic aspects of IBD management.

Prognostic value of magnetic resonance enterography for children with Crohn's disease: A multicenter, multireader study

BACKGROUND

Paediatric Inflammatory Crohn's MRE Index (PICMI) is a multi-point index of intestinal inflammation (mucosal and transmural) for children with CD. The present study aims to assess whether PICMI at diagnosis may predict the course of CD and to test the inter-reader agreement.

METHODS

CD children with a ≥ 1-year follow-up were retrospectively enrolled. Three radiologists calculated PICMI at diagnosis and association between PICMI and Paediatric Crohn's Disease Activity Index (PCDAI) and CD Endoscopic Index of Severity (CDEIS) was tested.

RESULTS

68 children (median age 13 years IQR: 11-14) with CD with PICMI at diagnosis: remission 6 (8.8 %), mild 29 (42.6 %), moderate 24 (35.3 %), severe 9 (13.2 %), were enrolled. PICMI score significantly correlated with PCDAI at diagnosis (p: 0.036). Steroid-free remission at 1, 3 and 5 years was comparable between PICMI groups (p: 0.606). Higher PICMI at diagnosis was associated with higher biologic introduction at 1 year: incidence rate ratio IRR: 2.17 (1.09-4.42); p = 0.019, 3-year IRR: 2.12 (1.15-3.96); p = 0.011, and 5 years: 2.21 (1.20-4.08); p = 0.007.

CONCLUSIONS

PICMI score is a reliable and almost reproducible index to score activity in children with CD. Children with higher PICMI scores of disease activity at diagnosis required more biologic treatment to achieve comparable rates of steroid-free remission if compared with lower PICMI scores.

Incidence and Risk Factors for Nonreversal of Stoma in Patients With Crohn's Disease: A Single-Center Study

BACKGROUND

Even in the biological era, permanent stoma is not uncommon in patients with Crohn's Disease.

OBJECTIVE

This study aimed to investigate the incidence and risk factors of permanent stoma in Crohn's disease patients and provide clinical evidence for reducing this disabling outcome.

DESIGN

Consecutive patients with Crohn's disease who underwent ostomies in the past decade were reviewed.

SETTINGS

The study was conducted in a tertiary referral hospital.

PATIENTS

Four hundred fifty-seven patients with Crohn's disease were divided into temporary stoma and permanent stoma groups based on stoma reversal or not. A permanent stoma was defined as a stoma that had not been reversed or closed for at least 2 years.

MAIN OUTCOME MEASURES

The incidence, risk factors, and long-term outcomes of permanent stomas were reported.

RESULTS

The rate of permanent stoma was 4.0% in our surgical cohort. The mean age at the time of permanent stoma creation was 36.0 (28.0-45.0) years. The annual incidence of permanent stoma had declined significantly in the past 10 years (p = 0.033). Our study showed that the independent risk factors for permanent stoma formation included female sex, previous operation for Crohn's disease, the presence of rectal disease, subtotal colectomy, and rectal resection. Interestingly, long-term follow-up found that the active distal colorectal lesion was independently associated with the requirement of subsequent surgery.

LIMITATIONS

The study was limited by its retrospective nature.

CONCLUSIONS

Although the incidence of permanent stoma in patients with Crohn's disease showed a downward trend in the past 10 years, effective treatments based on relevant risk factors should be used to prevent permanent stoma and control subsequent surgical recurrence. See Video Abstract.

INCIDENCIA Y FACTORES DE RIESGO DE NO REVERSIN DEL ESTOMA EN PACIENTES CON ENFERMEDAD DE CROHN ESTUDIO DE UN SOLO CENTRO

ANTECEDENTES:Incluso en la era biológica, el estoma permanente no es poco común en pacientes con enfermedad de Crohn.OBJETIVO:Este estudio tuvo como objetivo investigar la incidencia y los factores de riesgo del estoma permanente en pacientes con enfermedad de Crohn y proporcionar evidencia clínica para reducir este resultado discapacitante.DISEÑO:Se revisaron pacientes consecutivos con enfermedad de Crohn que se sometieron a ostomías en la última década.ESCENARIO:El estudio se realizó en un hospital de referencia terciario.PACIENTES:457 pacientes con enfermedad de Crohn se dividieron en los grupos de estoma temporal y estoma permanente según si se había revertido o no el estoma. Un estoma permanente se definió como un estoma que no se había revertido o cerrado durante al menos dos años.PRINCIPALES MEDIDAS DE RESULTADOS:Se informó la incidencia, los factores de riesgo y los resultados a largo plazo de los estomas permanentes.RESULTADOS:La tasa de estoma permanente fue del 4,0 % en nuestra cohorte quirúrgica. La edad media en el momento de la creación del estoma permanente fue de 36,0 (28,0-45,0) años. La incidencia anual de estomas permanentes había disminuido significativamente en los últimos 10 años (p = 0,033). Nuestro estudio mostró que los factores de riesgo independientes para la formación de estomas permanentes incluían el sexo femenino, la cirugía previa para la enfermedad de Crohn, la presencia de enfermedad rectal, la colectomía subtotal y la resección rectal. Curiosamente, el seguimiento a largo plazo encontró que la enfermedad colorrectal distal activa se asoció de forma independiente con la necesidad de una cirugía posterior.LIMITACIONES:El estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES:Aunque la incidencia de estomas permanentes en pacientes con enfermedad de Crohn mostró una tendencia descendente en los últimos 10 años, se deben utilizar tratamientos efectivos basados en factores de riesgo relevantes para prevenir el estoma permanente y controlar la recurrencia quirúrgica posterior. (Traducción-Dr. Felipe Bellolio).

Understanding the therapeutic toolkit for inflammatory bowel disease

Inflammatory bowel disease (IBD), encompassing ulcerative colitis and Crohn's disease, is a group of chronic, immune-mediated disorders of the gastrointestinal tract that present substantial clinical challenges owing to their complex pathophysiology and tendency to relapse. A treat-to-target approach is recommended, involving iterative treatment adjustments to achieve clinical response, reduce inflammatory markers and achieve long-term goals such as mucosal healing. Lifelong medication is often necessary to manage the disease, maintain remission and prevent complications. The therapeutic landscape for IBD has evolved substantially; however, a ceiling on therapeutic efficacy remains and surgery is sometimes required (owing to uncontrolled disease activity or complications). Effective IBD management involves comprehensive care, including medication adherence and a collaborative clinician-patient relationship. This Review discusses current therapeutic options for IBD, detailing mechanisms of action, efficacy, safety profiles and guidelines for use of each drug class. We also explore emerging therapies and the role of surgery. Additionally, the importance of a multidisciplinary team and personalized care in managing IBD is emphasized, advocating for patient empowerment and involvement in treatment decisions. By synthesizing current knowledge and emerging trends, this Review aims to equip healthcare professionals with a thorough understanding of therapeutic options for IBD, enhancing informed, evidence-based decisions in clinical practice.

Placebo-Controlled Trials in the Management of Crohn's Disease: An Umbrella Review of Meta-Analyses

INTRODUCTION

Crohn's disease is a chronic inflammatory bowel disease characterized by abdominal pain, diarrhea, and other symptoms. It can lead to significant complications and impact patients' quality of life. Therefore, effective management strategies are essential for improving outcomes.

METHODS

To assess the efficacy of the treatments for Crohn's disease, this umbrella review systematically addresses systematic reviews and meta-analyses on Crohn's disease management published between 2013 and 2023. The quality of the included studies was assessed using the National Institutes of Health's quality assessment tool.

RESULTS

Sixteen studies were included, evaluating various interventions for the induction and maintenance of remission. These included biologic agents (anti-TNF agents, anti-IL-12/23p40 antibodies, and integrin receptor antagonists), antimetabolites, and corticosteroids.

CONCLUSIONS

The findings suggest that biologic agents may be promising options for both the induction and maintenance of remission in Crohn's disease. Antimetabolites and corticosteroids may be effective in certain cases, but their efficacy and safety profiles require further investigation. The included studies varied in quality and sample size. More research is needed to confirm the findings and establish optimal treatment strategies. Moreover, while biologic agents show promise, the optimal management of Crohn's disease requires further research. A personalized approach considering patient factors and disease characteristics is crucial for optimizing outcomes.

From Evidence to Practice: A Narrative Framework for Integrating the Mediterranean Diet into Inflammatory Bowel Disease Management

Emerging evidence underscores the pivotal role of diet in preventing and managing inflammatory bowel disease (IBD). As our comprehension of the microbiome's role in IBD expands, dietary modifications are increasingly recognized as potential adjuncts or primary therapeutic strategies. Key components of the Mediterranean diet (MD)-including microbiota-accessible carbohydrates, omega-3 fatty acids, polyphenols, and antioxidants-have demonstrated promise in enhancing gut microbiota diversity and reducing intestinal inflammation, making it a practical approach for managing IBD. Moreover, the MD offers additional benefits considering the rising prevalence of comorbid chronic inflammatory conditions such as diabetes, cardiovascular disease, and obesity in IBD patients. The purpose of this narrative review was to provide an overview of the feasibility and clinical outcomes of the MD and offer evidence-based guidance for researchers and practitioners on how to adapt the MD to patients with IBD. According to several cross-sectional and interventional studies, the MD is feasible for patients with IBD and confers several benefits, such as reduced inflammation, improved disease activity, and enhanced quality of life, with a strong adherence rate and minimal adverse effects. To facilitate knowledge translation, we provide a practical framework for integrating the MD as a nutritional therapy for IBD, including specific recommendations and messaging that researchers, practitioners, and patients can use. By synthesizing current evidence and offering actionable insights, the aim is to facilitate the integration of the MD into IBD management, with the potential to improve patient outcomes.

Mesalazine-Induced Acute Pancreatitis in Inflammatory Bowel Disease Patients: A Systematic Review

Objective

Mesalazine is a widely used medication for treating mild to moderate inflammatory bowel disease (IBD). First identified as a potential cause of acute pancreatitis (AP) in 1989, the link between mesalazine and AP has primarily been established through case reports and a limited number of retrospective studies. This study aims to explore the characteristics of mesalazine-induced AP.

Methods

The databases of CNKI, Wanfang Data, VIP, PubMed and Web of Science were searched (up to March, 2024), and the case reports of mesalazine-related AP in IBD patients were collected and descriptively analyzed.

Results

Thirty-four reports were included, describing 42 patients (22 males, 16 females, 4 unspecified) with mesalazine-related AP. The onset of pancreatitis occurred a median of 14 days (range 1-730 days) after starting mesalazine. Common symptoms included abdominal pain (100%), vomiting (38.1%), fever (21.4%), and nausea (21.4%). Most patients had elevated serum amylase and lipase levels, with some showing raised C-reactive protein and erythrocyte sedimentation rate. Imaging tests, such as computed tomography and B-scan ultrasonography, revealed edematous infiltration and inflammation. Discontinuation of mesalazine led to symptom resolution in all patients, with 93.3% improving within a week. Alternative treatments or switching to other forms of 5-aminosalicylic acid may be considered for ongoing management. Rechallenge with mesalazine led to recurrence of AP in 21 cases, with a shorter median time to symptom onset.

Conclusion

Mesalazine-induced AP is a rare but significant adverse reaction, not related to drug dosage, and can occur at any point during treatment, typically within two weeks. The reaction can recur upon rechallenge. Discontinuation of mesalazine and symptomatic treatment typically resolves the condition.

Monitoring for 5-aminosalicylate nephrotoxicity in adults with inflammatory bowel disease: prognostic model development and validation using data from the Clinical Practice Research Datalink

OBJECTIVE

To develop and validate a prognostic model for risk-stratified monitoring of 5-aminosalicylate nephrotoxicity.

METHODS

This UK retrospective cohort study used data from the Clinical Practice Research Datalink Aurum and Gold for model development and validation respectively. It included adults newly diagnosed with inflammatory bowel disease and established on 5-aminosalicylic acid (5-ASA) treatment between 1 January 2007 and 31 December 2019. Drug discontinuation associated with 5-ASA nephrotoxicity defined as a prescription gap of ≥90 days with decline in kidney function was the outcome. Patients prescribed 5-ASAs for ≥6 months were followed-up for up to 5 years. Penalised Cox regression was used to develop the risk equation with bootstrapping for internal validation and optimism adjustment. Model performance was assessed in terms of calibration and discrimination.

RESULTS

13 728 and 7318 participants who contributed 40 378 and 20 679 person-years follow-up formed the development and validation cohorts with 170 (1.2%) and 98 (1.3%) outcome events respectively. Nine predictors were included in the final model, including chronic kidney disease stage 3 and hazardous alcohol use as strong predictors. Age and Body Mass Index were weak predictors. The optimism-adjusted calibration slope, C and D statistics in the development and validation data were 0.90, 0.64 and 0.98, and 1.01, 0.66 and 0.94 respectively.

CONCLUSION

This prognostic model used information from routine clinical care and performed well in an independent validation cohort. It can be used to risk-stratify blood test monitoring during established 5-ASA treatment. A key limitation is that the decline in kidney function could have been due to factors other than 5-ASA nephrotoxicity.

Frequency and Risk Factors of Advanced Neoplasia in Korean Inflammatory Bowel Disease Patients with Low-grade Dysplasia

BACKGROUND/AIMS

Studies on the clinical outcomes after detecting low-grade dysplasia (LGD) in patients with inflammatory bowel disease (IBD) are insufficient. This study evaluated the clinical features, frequency, and risk factors for advanced neoplasia in patients with IBD after an LGD diagnosis.

METHODS

The medical records of 166 patients with IBD from six university hospitals in Korea from 2010 to 2019 were reviewed retrospectively. LGD was diagnosed in all patients during surveillance. The frequency and risk factors for advanced neoplasia were evaluated, and the clinical features of patients with and without advanced neoplasia were compared.

RESULTS

Advanced neoplasia developed in 12 patients (six with large LGD, three with tubulovillous adenoma, and three with high-grade dysplasia), and all cases developed from UC. Patients with advanced neoplasia had significantly higher Mayo scores, and colitis-associated dysplasia was more common than sporadic lesions (83.3% vs. 29.9%; p<0.001). Multivariate analysis showed that colitis-associated LGD significantly increased the risk of developing advanced neoplasia (odds ratio [OR], 10.516; 95% confidence interval [CI], 2.064-53.577). Among patients with colitis-associated lesions, a significant risk factor for advanced neoplasia was a prior history of LGD (OR, 9.429; 95% CI, 1.330-66.863).

CONCLUSIONS

Advanced neoplasia developed in 7.2% of patients with IBD and LGD. Most advanced neoplasms developed from colitis-associated lesions, and the risk was higher in patients with a history of LGD before index colonoscopy.

Molecular Mechanisms and Clinical Aspects of Colitis-Associated Cancer in Ulcerative Colitis

Inflammatory bowel diseases have long been recognized as entities with a higher risk of colorectal cancer. An increasing amount of information has been published regarding ulcerative colitis-associated colorectal cancer and its unique mechanisms in recent decades, as ulcerative colitis constitutes a chronic process characterized by cycles of activity and remission of unpredictable durations and intensities; cumulative genomic alterations occur during active disease and mucosal healing, resulting in a special sequence of events different to the events associated with sporadic colorectal cancer. The recognition of the core differences between sporadic colorectal cancer and colitis-associated cancer is of great importance to understand and guide the directions in which new research could be performed, and how it could be applied to current clinical scenarios. A DSS/AOM murine model has allowed for a better understanding of the pathogenic mechanisms in colitis-associated cancer, as it is currently the closest model to this unique scenario. In this review, we provide a summary of the main molecular mechanisms and the clinical aspects of colitis-associated cancer in ulcerative colitis.

Prevalence and predictors of small intestinal bacterial overgrowth in inflammatory bowel disease: a meta-analysis

Background

Small intestinal bacterial overgrowth (SIBO) has been reported to be very common among individuals with inflammatory bowel disease (IBD), and the prevalence of SIBO is highly variable. We conducted this study to calculate the prevalence and identify predictors of SIBO in IBD.

Methods

PubMed, Cochrane Library, and EMBASE from inception to March 2024 were searched for studies evaluating the prevalence of SIBO in IBD. We calculated the pooled prevalence of SIBO among IBD patients and the odds ratio (OR) of SIBO in IBD compared with healthy controls. Besides, we also evaluated predictors of SIBO in IBD patients.

Results

Twenty-nine studies (3,250 IBD, 708 controls) were included in our study. The pooled prevalence of SIBO in IBD was 31.0% (95% CI 25.2-37.1), and the prevalence of SIBO was higher in IBD compared with healthy controls (OR 5.25, 95% CI 2.96-9.32). The pooled prevalence of SIBO was higher among CD patients (32.2, 95% CI 25.9-38.8) compared with UC patients (27.8, 95% CI 18.5-38.1). The odds of lower BMI (mean difference = -1.04; 95% CI -1.86 to -0.23), bloating (OR = 3.02, 95% CI 1.22-7.5), flatulence (OR = 4.70, 95% CI 1.44-15.35), history of abdominal surgery (OR = 2.05, 95% CI 1.35-3.11), and stricturing/penetrating disease behavior (OR = 3.51, 95% CI 1.67-7.40) increased significantly in IBD patients with SIBO compared to those without SIBO. Antibiotic treatment may be effective for SIBO in IBD patients.

Conclusion

Nearly one-third of IBD patients present with SIBO positive, and the odds of SIBO in IBD was increased by 5.25-fold compared with healthy controls. Lower BMI, bloating, flatulence, history of abdominal surgery, and stricturing/penetrating disease behavior were predictors of SIBO in IBD patients.

A Treat-to-Target Approach in IBD: Contemporary Real-World Perspectives from an International Survey

Background/Objectives: The management of inflammatory bowel disease (IBD) varies due to differences in healthcare systems, treatment costs, access to diagnostics, and diverse clinical practices between specialists. Despite the frequent advocacy of a treat-to-target (T2T) approach, there is insufficient clarity on how clinicians implement T2T in real-world settings. We aim to conduct a large, global survey among IBD experts to identify current practices in management. Methods: A prospective, cross-sectional study was conducted using a 16-item survey divided into two sections-for ulcerative colitis (UC) and Crohn's disease (CD)-and distributed to practicing IBD clinicians. Results: A total of 261 respondents from 88 countries participated in the survey, with the majority (253/261) being physicians and eight being IBD nurse specialists. Despite global guidance, only a quarter of the respondents routinely perform an endoscopy to assess the response after starting an advanced therapy (28.4% in UC vs. 23.5% in CD). Moreover, despite an increasing academic focus on intestinal ultrasound (IUS), 171 (66%) of respondents in UC and 132 (51%) in CD reported that they do not routinely undertake IUS to guide treatment decisions. Faecal calprotectin for monitoring treatment response was routinely used by 87% (90% in UC and 84% in CD) of the respondents. Forty-five percent reported use of therapeutic drug monitoring (TDM) both proactively and reactively and 35% reported only using TDM reactively. Conclusions: Our study shows considerable variation in IBD management across different countries and interpretation of the T2T approach. This highlights the need for standardised and pragmatic guidelines to help improve outcomes for patients with IBD globally.

Anti-Inflammatory Effects of Algae-Derived Biomolecules in Gut Health: A Review

Under physiological conditions, the inflammatory response acts as a biological defense against tissue damage or infection, and is rapidly resolved once the infection is cleared. However, chronic inflammatory diseases, including inflammatory bowel disease (IBD), have become increasingly widespread in the last decades, placing a burden on the quality of life of affected people and on healthcare systems worldwide. Available drug therapies are often ineffective due to the chronic nature of these diseases, and prolonged administration of drugs can result in severe side effects for the patient or a lack of efficacy. In addition, there is the growing problem of bacterial resistance to synthetic antibiotics. Together, these factors have led to a strong research focus on the discovery of natural products capable of treating IBD. Recently, there has been a growing interest in compounds derived from marine sources, mainly algae, due to their bioactive secondary metabolites with anti-inflammatory properties well known in the literature. Based on this evidence, this review aimed to evaluate the anti-inflammatory potential of algae-derived biomolecules in IBD. In particular, interesting species from green algae (e.g., Chlorella vulgaris and Ulva pertusa), brown algae (e.g., Macrocystis pyrifera and Ecklonia cava) and red algae (e.g., Porphyra tenera and Grateloupia turuturu) are included in this review due to their proven anti-inflammatory properties. For this purpose, an extensive literature search was conducted using several databases. The results suggest that both macroalgae and microalgae have remarkable potential for IBD therapy due to the anti-inflammatory and antioxidant activities of their bioactive compounds. However, while the preclinical evidence is encouraging, further and long-term clinical studies are needed to better understand their mechanisms of action in order to determine the true efficacy of marine algae in the treatment of IBD.

Evaluation of variations in predominant gut microbiota members in inflammatory bowel disease using real-time PCR

Inflammatory Bowel Disease (IBD) is a persistent ailment that impacts many individuals worldwide. The interaction between the immune system and gut microbiome is thought to influence IBD development. This study aimed to assess some microbiota in IBD patients compared to healthy individuals. The investigation involved a selected group of twenty patients suffering from IBD and an equal number of healthy participants. Stool specimens were obtained and analyzed for Lactobacillus, Bifidobacterium, Bacteroides, Clostridium leptum, Akkermansia muciniphila, Fusobacterium and Enterobacteriaceae using real-time PCR. The findings indicated significantly higher levels of Bifidobacterium in IBD patients (Pv = 0.009) and lower levels of A. muciniphila (Pv = 0.003) healthy individuals. Other bacteria tested did not show significant differences. The study suggests that the progression of IBD patients could be influenced by the rising of Bifidobacterium and the declining of A. muciniphila. Targeting these bacteria could lead to improved treatments and quality of life for those with IBD.

Selected Use of Complementary and Alternative Medicine (CAM) Agents in IBD

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) can cause significant psychological, physical, and economic burdens on patients and healthcare systems. Studies show over one-fifth of patients will seek nontraditional methods of treatment for managing their symptoms. Understanding the benefits - and potential harms - of these therapies is important to provide holistic and evidence-based care to our IBD patients.

RECENT FINDINGS

In this review, we present several studied herbal therapies for the management of both Crohn's disease and ulcerative colitis. These include cannabinoids, Tripterygium wilfordii, Chios mastic gum, Boswellia serrata, Indigo Naturalis, curcumin, resveratrol, and Zingiber officinale. While these herbal remedies have been shown to have anti-inflammatory effects and positive outcomes in IBD patients, larger scale studies are lacking and the use may be limited by bioavailability, lack of standardization of formulations, and adverse reactions. In reviewing the literature, we discuss the current data available including benefits, adverse reactions, and considerations for use surrounding several of the more common herbal remedies used for IBD.

Top-down infliximab plus azathioprine versus azathioprine alone in patients with acute severe ulcerative colitis responsive to intravenous steroids: a parallel, open-label randomised controlled trial, the ACTIVE trial

BACKGROUND

It is unknown which maintenance therapy is the most effective option for patients admitted for an acute severe ulcerative colitis (ASUC) episode responding to intravenous steroids.

METHODS

We conducted a multicentre, parallel-group, open-label randomised controlled trial among 23 French centres in thiopurine and biologics-naïve adults admitted for ASUC responding to intravenous steroids. Eligible patients were randomly assigned to receive infliximab (IFX) and azathioprine (AZA) with a 7-day steroid tapering scheme (IFX+AZA arm) or AZA and conventional standardised steroid tapering regimen (AZA arm). The primary composite endpoint was treatment failure at week 52, defined as the absence of steroid-free clinical remission, the absence of endoscopic response, the use of a prohibited treatment for relapse, severe adverse event leading to treatment interruption, colectomy or death. Multiple imputation for missing data was performed.

FINDINGS

Among the 64 patients randomised (Lichtiger score 13.5±2.0; median age of 34.5 (P25-P75 26.3-50.3) years, median C reactive protein of 29.0 (12.8-96.8) mg/L at baseline): 32 were assigned to the IFX+AZA arm and 32 to the AZA arm. In the ITT population, treatment failure at week 52 was observed in 22/27 (81.5%) in the AZA arm and 16/30 (53.3%) in the IFX+AZA arm (risk ratio 3.85, 95% CI (1.15 to 12.88), p=0.03). 29 adverse events were severe, including 13 disease exacerbations, 6 severe infections without any difference between both arms.

INTERPRETATION

Combination therapy with IFX+AZA was more effective at 1 year than AZA alone to avoid treatment failure in patients with ASUC responding to intravenous steroids.

TRIAL REGISTRATION NUMBER

NCT02425852.

Refining the clinical and therapeutic spectrum of granulomatous myositis from a large cohort of patients

OBJECTIVES

Granulomatous myositis (GM) is a rare entity whose precise clinical features and therapeutic outcomes have not yet been well defined. Given the limited evidence, data from a large cohort of patients is needed to aid in the recognition and management of this condition.

METHODS

We retrospectively analyzed our institutional databases to identify patients who had myositis and non-caseating granuloma on muscle biopsy (GM). We collected data on clinical and diagnostic features, management, and outcomes of these cases and compared them with inclusion body myositis (IBM) controls.

RESULTS

22 GM patients were identified and subdivided into 3 main groups: 13 patients with GM and sarcoidosis (6 of whom subsequently developed suspected or confirmed IBM), 7 patients with idiopathic isolated GM (2 of whom subsequently developed confirmed IBM), 2 patients with GM and Crohn's disease. Patients with GM and sarcoidosis without IBM, as well as patients with isolated GM, exhibited variable clinical presentation ranging from myalgia to mostly symmetrical proximo-distal weakness, with most showing complete or at least partial response to therapies. Patients with GM associated with Crohn's disease had only mild clinical impairment and good therapeutic outcomes. Conversely, patients with GM and IBM presented more severe asymmetric proximo-distal muscle weakness, increased occurrence of dysphagia and poor treatment response, similar to IBM controls.

CONCLUSIONS

A frequent association of GM with IBM and/or sarcoidosis was demonstrated in our cohort. When associated with IBM, GM led to treatment refractoriness and more severe clinical impairment, unlike the other GM groups which showed satisfactory outcomes in most cases.

The fate of the rectum in ulcerative colitis at index surgery and beyond-a contemporary cohort

PURPOSE

Proctectomy is frequently deferred at index colectomy for ulcerative colitis due to acuity or immunosuppressive treatments. The retained rectum remains symptomatic in over 50% with associated cancer risk. Management options include index or delayed proctectomy with or without restoration of continuity or surveillance. Comparative studies of perioperative outcomes and reasons for retaining the rectum are lacking.

METHODS

This 13-year retrospective cohort assesses the fate of the rectum in 168 ulcerative colitis patients by analysing index proctectomy, staged proctectomy and retained rectal remnant determinants and outcomes. The primary outcome was the fate of the rectum. Secondary analysis included perioperative morbidity, length of stay and decision-making determinants.

RESULTS

Proctectomy was performed in 69% of patients, with 16.1% at index surgery. Restorative surgery rate was 44%. Index proctectomy patients were older (54 vs 37 years, p < 0.01), more co-morbid (59.3% vs 38.2%, p = 0.04) and likely to have elective surgery (81.5% vs 21.3%, p < 0.01) or neoplasia (33.3% vs 1.1%, p < 0.01). Outcomes after staged proctectomy were comparable, with age influencing restoration of continuity (33.5 vs 46 years, p < 0.01). Younger patients were indecisive on proctectomy, while those opting for endoscopic surveillance were older (median 65 years, p < 0.01), had more complications (64.3%, p = 0.23) and prolonged hospitalisation (median 15 days, p = 0.02) at colectomy.

CONCLUSIONS

Index proctocolectomy for ulcerative colitis is infrequently performed. Perioperative outcomes of restorative and non-restorative staged proctectomy are comparable. Perioperative experience at colectomy may influence patient decisions regarding future management of their rectum.

Oral colon-targeted responsive chitosan/pectin-based nanoparticles propels the application of tofacitinib in colitis therapy

Tofacitinib (Tof), a commercially available pan-Janus kinases inhibitor, is approved for the treatment of moderate to severe ulcerative colitis. However, its clinical application is limited due to dose-dependent systemic side effects. The present study aims to develop an efficient oral colon-targeted drug delivery systems using prebiotic pectin (Pcn) and chitosan (Csn) polysaccharides as a shell, with Tof loaded into a Bovine Serum Albumin (BSA) core, and improving it with chondroitin sulfate (Chs), thus constructing Tof@BSA-Chs-CP nanoparticles (NPs). Our results suggest that the pH-sensitive characteristics of the Pcn/Csn shell contribute to its capacity for attenuating absorption and systemic diffusion in the gastrointestinal tract, and exhibiting targeted localization at inflamed colonic sites in mice. Additionally, the gut microbiota-secreted polysaccharide-degrading enzyme acts as the triggering agent for Pcn/Csn shell degradation. In mice colitis models, we demonstrated that oral administration of Tof@BSA-Chs-CP NPs effectively ameliorated colitis and expedited its resolution by modulating the expression of pro-inflammatory cytokines and immune regulatory factors. Collectively, our synthetic NPs demonstrate the promising potential of Tof for the therapy of UC.

Assessment tools for transition readiness in adolescents with inflammatory bowel disease: A scoping review

BACKGROUND

Assessing the level of transition readiness in adolescents with inflammatory bowel disease is crucial; however, standardized research tools are lacking. This study aimed to map transition readiness assessment tools for adolescents with inflammatory bowel disease and determine their suitability.

METHODS

A literature review following the Arksey and O'Malley scoping review methodology was conducted. By using appropriate key terms, literature on transition readiness assessment tool searches were conducted in the CNKI, WanFang, SinoMed, Pubmed, Cochrane Library, Web of Science, and CINAHL databases, with a reference search. The retrieval period was from the establishment of the databases to January 2024.

RESULTS

A total of 2561 studies were obtained through a preliminary search, and 5 references were obtained as retrospective references. Finally, 21 studies were selected for this review. In total, 20 transition readiness assessment tools were identified. Qualitative findings were grouped into five thematic areas: descriptive characteristics of reviewed articles, development procedures, design, psychometric properties, and cohort characteristics for validity testing of transition readiness assessment tools.

CONCLUSIONS

The most appropriate way to assess the transition readiness of adolescents with inflammatory bowel disease is to select an assessment tool that is most suitable for individual needs, accompanied by a comprehensive patient evaluation. Despite some flaws in the methodology, TRM is currently the most suitable assessment tool, and more population studies are needed to validate it.

Healthy Lifestyle Is a Protective Factor from Moderate and Severe Relapses and Steroid Use in Inflammatory Bowel Disease: A Prospective Cohort Study

BACKGROUND

A healthy lifestyle, including good adherence to a Mediterranean diet (MD) and regular physical exercise, may be an important factor during the course of inflammatory bowel disease (IBD). Our aim is to determine whether adherence to MD, physical activity, and the combination of both can impact on IBD course.

METHODS

This prospective cohort study includes 693 IBD outpatients who were in remission with a median follow-up time of 27 months (interquartile range 22-29 months). Each patient completed a survey to assess their adherence to the MD and physical activity. Healthy lifestyle was considered to be a proper adherence to both MD and an active lifestyle. Relapse during follow-up, severity of relapses, need for systemic steroids, and therapy changes were recorded.

RESULTS

During the follow-up period, 188 patients (27.1%) experienced relapse, of which 56.1% were moderate or severe. Among patients with relapse, 85 (45%) required treatment with corticosteroids, and 15 (7.9%) were hospitalized. Patients with ulcerative colitis (CU) were more adherent to healthy lifestyle than patients with Crohn's disease (P = .011). Healthy lifestyle was associated with lower risk of moderate and severe relapses (adjusted Hazard ratio [aHR], 0.250; 95% confidence interval [CI], 0.093-0.670) and steroids use (aHR 0.292; 95% CI, 0.103-0.828) in IBD patients and with lower risk of moderate and severe relapses (aHR 0.270; 95% CI, 0.093-0.789) in UC patients.

CONCLUSIONS

Healthy lifestyle has a favorable influence on promoting a milder disease course, and thus should be a crucial part of clinical management of patients with IBD.

Volumetric measurement of terminal ileal Crohn's disease by magnetic resonance enterography: a feasibility study

OBJECTIVES

Magnetic resonance enterography (MRE) interpretation of Crohn's disease (CD) is subjective and uses 2D analysis. We evaluated the feasibility of volumetric measurement of terminal ileal CD on MRE compared to endoscopy and sMARIA, and the responsiveness of volumetric changes to biologics.

METHODS

CD patients with MRE and contemporaneous CD endoscopic index of severity-scored ileocolonoscopy were included. A centreline was placed through the terminal ileum (TI) lumen defining the diseased bowel length on the T2-weighted non-fat saturated sequence, used by two radiologists to independently segment the bowel wall to measure volume (phase 1). In phase 2, we measured disease volume in patients treated with biologics, who had undergone pre- and post-treatment MRE, with treatment response classified via global physician assessment.

RESULTS

Phase 1 comprised 30 patients (median age 29 (IQR 24, 34) years). Phase 2 included 12 patients (25 years (22, 38)). In phase 1, the mean of the radiologist-measured volumes was used for analysis. The median disease volume in those with endoscopically active CD was 20.9 cm3 (IQR 11.3, 44.0) compared to 5.7 cm3 (2.9, 9.8) with normal endoscopy. The mean difference in disease volume between the radiologists was 3.0 cm3 (limits of agreement -21.8, 15.9). The median disease volume of patients with active CD by sMARIA was 15.0 cm3 (8.7, 44.0) compared to 2.85 cm3 (2.6, 3.1) for those with inactive CD. Pre- and post-treatment median disease volumes were 28.5 cm3 (26.4, 31.2), 11 cm3 (4.8, 16.6), respectively in biological responders, vs 26.8 cm3 (12.3, 48.7), 40.1 cm3 (10, 56.7) in non-responders.

CONCLUSION

Volumetric measurement of terminal ileal CD by MRE is feasible, related to endoscopy and sMARIA activity, and responsive to biologics.

CLINICAL RELEVANCE STATEMENT

Measuring the whole volume of diseased bowel on MRE in CD is feasible, related to how biologically active the disease is when assessed by endoscopy and by existing MRE activity scores, and is sensitive to treatment response.

KEY POINTS

MRE reporting for CD is subjective and uses 2D images rather than assessing the full disease volume. Volumetric measurement of CD relates to endoscopic activity and shows reduced disease volumes in treatment responders. This technique is an objective biomarker that can assess disease activity and treatment response, warranting validation.

Advanced Endoscopic Imaging for Detection of Dysplasia in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) patients are at an increased risk of developing colorectal cancer. Dysplasia is often found in flat, subtle mucosal abnormalities; therefore, early detection is essential. Innovative enhanced endoscopy imaging techniques are increasingly available for endoscopists managing IBD, allowing an in-depth, close to histology evaluation of mucosal pattern and vascular architecture. These new tools enable an earlier and more accurate detection and assessment of dysplasia, leading to improved patientoutcomes. This review provides an exhaustive overview of these techniques and their applicability in the clinical practice.

Improving access to inflammatory bowel disease care in Canada: The patient experience

OBJECTIVES

Canada has one of the highest age-adjusted incidence and prevalence rates of inflammatory bowel disease (IBD). Large patient volumes and limited resources have created challenges concerning the quality of IBD care, but little is known about patients' experiences. This paper aimed to better understand patient-perceived barriers to IBD care.

METHODS

An exploratory qualitative approach was used for this study. Fourteen focus groups (with 63 total participants) were co-facilitated by a researcher and patient research partner across eight Canadian provinces in 2018. Patients diagnosed with IBD (>18 years of age) and their caregivers were purposefully recruited through Crohn's and Colitis Canada, gastroenterology clinics and communities, and national social media campaigns. Focus group sessions were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Most participants self-identified as being white and women. The analysis generated four key themes regarding patient-perceived barriers and gaps in access to IBD care: (1) gatekeepers and their lack of IBD knowledge, (2) expenses and time, (3) lack of holistic care, and (4) care that is not patient-centered. An additional four themes were generated on the topic of patient-perceived areas of health system improvement for IBD care: (1) direct access to care, (2) good care providers, (3) electronic records and passports, and (4) multidisciplinary care or an 'IBD dream team'.

CONCLUSIONS

This research contributes to the limited global knowledge on patients' experiences accessing IBD care. It is valuable for the development of care plans and policies to target gaps in care. Patients have identified system-level barriers and ideas for improvement, which should be taken into consideration when implementing system redesign and policy change.

Suboptimal disease control and contributing factors in Italian IBD patients: The IBD-PODCAST Study

BACKGROUND AND AIM

Suboptimal disease control (SDC) and its contributing factors in IBD according to STRIDE-II criteria is unclear. IBD-PODCAST was a non-interventional, international, multicenter real-world study to assess this.

METHODS

Data from the Italian IBD cohort (N=220) are presented here. Participants aged ≥19 with confirmed IBD diagnosis of ≥1 year were consecutively enrolled. A retrospective chart review and cross-sectional assessment by physicians and patients within the past 12 months were performed. SDC or optimal disease control was assessed using adapted STRIDE-II criteria.

RESULTS

At the index date, 53.4 % of 116 CD patients and 49.0 % of 104 UC patients had SDC, mainly attributed to a Short Inflammatory Bowel Disease Questionnaire score <50, failure to achieve endoscopic remission, and the presence of active extra-intestinal manifestations in both diseases. Disease monitoring with imaging and/or endoscopy during the previous year was conducted in ∼50 % of patients, with endoscopy performed in ∼40 %. Potential therapeutic adjustments were reported for half of the patients.

CONCLUSIONS

This study highlights SDC in a significant portion of IBD Italian patients. These results emphasize the need for more proactive management strategies in both CD and UC patients.

Cardiovascular disease: extraintestinal manifestation of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a spectrum of diseases characterized by the interplay of the aberrant immune system, genetic factors, environmental factors, and intestinal microbiota, resulting in relapsing inflammation of the gastrointestinal tract. Underlying pro-inflammatory state and immune dysregulation act as a catalyst for increasing the likelihood of developing extraintestinal manifestations, including cardiovascular diseases (CVD) like atherosclerosis, pericarditis, myocarditis, venous and arterial thromboembolism, arrhythmias, despite a lower prevalence of classic CVD risk factors, like high body mass index or dyslipidemia compared to the general population. Chronic inflammation damages endothelium resulting in the recruitment of inflammatory cells, which induce cytotoxicity, lipoprotein oxidation, and matrix degradation, which increases the risk of atherosclerosis. Additionally, intestinal dysbiosis disrupts the intestinal mucosal barrier, releasing endotoxins and lipopolysaccharides into circulation, further exaggerating the atherosclerotic process. Abnormal collagen metabolism and alteration of nitric oxide-mediated vasodilation lead to blood pressure dysregulation in patients with IBD. Therefore, it is essential to make lifestyle modifications like smoking cessation, dietary changes, and increasing physical activity with adherence to medication to mitigate the risk of developing CVD in patients with IBD. This article reviews the potential links between IBD and the increased risk of CVD in such individuals.

Optimizing 5-aminosalicylate for moderate ulcerative colitis: expert recommendations from the Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition

The lack of clear definition and classification for "moderate ulcerative colitis (UC)" creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

Artificial intelligence-aided colonoscopic differential diagnosis between Crohn's disease and gastrointestinal tuberculosis

BACKGROUND AND AIM

Differentiating between Crohn's disease (CD) and gastrointestinal tuberculosis (GITB) is challenging. We aimed to evaluate the clinical applicability of an artificial intelligence (AI) model for this purpose.

METHODS

The AI model was developed and assessed using an internal dataset comprising 1,132 colonoscopy images of CD and 1,045 colonoscopy images of GITB at a tertiary referral center. Its stand-alone performance was further evaluated in an external dataset comprising 67 colonoscopy images of 17 CD patients and 63 colonoscopy images of 14 GITB patients from other institutions. Additionally, a crossover trial involving three expert endoscopists and three trainee endoscopists compared AI-assisted and unassisted human interpretations.

RESULTS

In the internal dataset, the sensitivity, specificity, and accuracy of the AI model in distinguishing between CD and GITB were 95.3%, 100.0%, and 97.7%, respectively, with an area under the ROC curve of 0.997. In the external dataset, the AI model exhibited a sensitivity, specificity, and accuracy of 77.8%, 85.1%, and 81.5%, respectively, with an area under the ROC curve of 0.877. In the human endoscopist trial, AI assistance increased the pooled accuracy of the six endoscopists from 86.2% to 88.8% (P = 0.010). While AI did not significantly enhance diagnostic accuracy for the experts (96.7% with AI vs 95.6% without, P = 0.360), it significantly improved accuracy for the trainees (81.0% vs 76.7%, P = 0.002).

CONCLUSIONS

This AI model shows potential in aiding the accurate differential diagnosis between CD and GITB, particularly benefiting less experienced endoscopists.