The combination of fecal calprotectin with ESR, CRP and albumin discriminates more accurately children with Crohn's disease

Identification of circadian rhythm-related biomarkers and development of diagnostic models for Crohn's disease using machine learning algorithms

The global rise in Crohn's Disease (CD) incidence has intensified diagnostic challenges. This study identified circadian rhythm-related biomarkers for CD using datasets from the GEO database. Differentially expressed genes underwent Weighted Gene Co-Expression Network Analysis, with 49 hub genes intersected from GeneCards data. Diagnostic models were constructed using machine learning algorithms, and biologic therapy efficacy was predicted with advanced regression techniques. Single-cell sequencing showed high gene expression in stem cells, immune, and endothelial cells, with validation confirming significant differences between CD patients and controls. These findings suggest circadian rhythm-related genes as promising diagnostic biomarkers for CD.

Platelet/Albumin ratio and plateletcrit levels are potential new biomarkers for assessing endoscopic inflammatory bowel disease severity

BACKGROUND

Endoscopy is currently recognized as the gold standard for assessing inflammatory bowel disease (IBD) severity. However, because the procedure is costly and invasive, endoscopy is not suitable for frequently monitoring intestinal inflammation. In this study, our aim was to identify noninvasive, low cost, and convenient biomarkers for identifying endoscopic IBD activity.

METHODS

In total, 246 patients with IBD (131 with Ulcerative colitis (UC) and 115 with Crohn's disease (CD)) and 369 healthy controls were recruited for this retrospective study. IBD activity was evaluated using endoscopic and clinical examinations. The potential of several inflammatory biomarkers, including platelets (PLT), plateletcrit (PCT), albumin (ALB), highly sensitive C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), and platelet-to-albumin ratio (PLT/ALB) to assess endoscopic IBD activity was evaluated using receiver operating characteristic (ROC) analyses.

RESULTS

PLT/ALB ratio, PLT, ALB, and hs-CRP levels were correlated with Mayo scores in UC patients, while PCT, PLT, fibrinogen (FIB), PLT/ALB ratio, hs-CRP, and ESR levels were correlated with Simple Endoscopic Scores for CD (SES-CD) in CD patients. ROC analyses showed that the area under the curve (AUC) value for the PLT/ALB ratio (0.705) was greater than hs-CRP (0.607) and ESR (0.552) values in UC patients. The AUC value for PCT (0.779) was greater than hs-CRP (0.698) and ESR (0.746) values in CD patients.

CONCLUSION

PLT/ALB ratio and PCT biomarkers were the most appropriate of all tested inflammatory biomarkers for assessing endoscopic IBD activity in UC and CD patients, respectively.

Nutritional Risk and Sarcopenia Features in Patients with Crohn's Disease: Relation to Body Composition, Physical Performance, Nutritional Questionnaires and Biomarkers

Patients with Crohn's disease (CD) face malnutrition risk, which, combined with inflammation, can lead to sarcopenia, associated with a worse prognosis. The purpose of the present study was to assess malnutrition and sarcopenia in patients with CD. Fifty-three patients (26 women) participated (38.1 ± 10.9 years, 79% in remission). Body composition, physical performance, nutritional questionnaires, and biomarkers were performed. Malnutrition was screened with the Mini Nutritional Assessment (MNA) and the Malnutrition Inflammation Risk Tool (MIRT) and was assessed with the Global Leadership Initiative on Malnutrition (GLIM) tool using etiologic along with three different phenotypic criteria: low Body Mass Index (BMI), low Calf Circumference (CC), and low Fat-Free Mass Index (FFMI). To find cases and evaluate sarcopenia, the Sarcopenia Questionnaire (SARC-F) and European Working Group on Sarcopenia2 (EWGSOP2) criteria were used. Malnutrition rates were 11.3% (n = 6), 7.5% (n = 4), and 5.6% (n = 3) based on low FFMI, CC, and BMI, correspondingly. Four (7%) patients had low Hand-Grip Strength (HGS), n = 8 (14.8%) had low Appendicular Lean Mass (ALM), and n = 3 (5.6%) had low gait speed. No-one had sarcopenia. A high albumin and triceps skinfold pattern, identified by principal component analysis, was related to reduced C-Reactive Protein (CRP) levels (B = -0.180, SE = 0.085, p = 0.045). In conclusion, based on the studied anthropometric, nutritional, and functional variables, CD patients were not diagnosed with sarcopenia in the present study. Body composition patterns were related to the inflammatory burden, underlying the interplay of inflammation and malnutrition, even in remission states. Further studies on older populations and during disease exacerbation are necessary to explore the potential link between CD, inflammation, and sarcopenia.

Oligoelements in serum and intestinal tissue of pediatric IBD patients

INTRODUCTION

Inflammatory bowel disease (IBD) develops through complex interplay of genetic, microbial, immune, and environmental factors. Trace elements alterations are commonly present in IBD and may have influence on IBD development. Heavy metal pollution is one of the major environmental issues nowadays and IBD incidence is rising in countries where industry starts to develop. Metals are implicated in processes that are connected to IBD pathogenesis.

AIM

The aim of this study was to investigate toxic and trace element levels in pediatric population of IBD patients both in serum and intestinal mucosa.

MATERIALS AND METHODS

This prospective study enrolled children newly diagnosed with IBD in University children's hospital in Belgrade. Concentrations of thirteen elements: Al, As, Ca, Cd, Cr, Cu, Fe, K, Mg, Mn, Na, Se and Zn in serum and intestinal mucosa of 17 newly diagnosed children with IBD (10 Crohn's disease (CD) and 7ulcerative colitis (UC)) and 10 controls were assessed using inductively coupled plasma mass spectrometry (ICP-MS). Intestinal mucosa samples were taken from terminal ileum and six different colon segments (cecum, ascending colon, colon transversum, descending and sigmoid colon and rectum).

RESULTS

The results demonstrated significant alterations in serum and intestinal mucosa concentrations of investigated elements. Serum iron was significantly decreased in IBD and CD group, compared to controls while serum Cu significantly differed between three investigated groups with highest concentration observed in CD children. Serum manganese was the highest in the UC subgroup. Terminal ileums of IBD patients contained significantly lower amount of Cu, Mg, Mn and Zn with Mn being significantly decreased also in CD patients compared to control. IBD patients' caecum contained significantly less Mg and Cu while colon transversum tissue samples from IBD and Crohn's patients contained significantly more chromium than controls. Moreover, sigmoid colon of IBD patients were poorer in Mg than controls (p < 0.05). Colon Al, As and Cd were significantly reduced in IBD, and UC children compared to control. Correlations of investigated elements in CD and UC groups were different from controls. Biochemical and clinical parameters showed correlation with element concentrations in intestines.

CONCLUSION

Sera of CD, UC and control children significantly differ in Fe, Cu and Mn levels. Serum manganese was the highest in the UC subgroup creating the most prominent and only significant difference between UC and CD subgroups. Terminal ileum of IBD patients contained significantly lower amount of majority of investigated essential trace elements and toxic elements were significantly reduced in colon of IBD and UC patients. Investigation of macro- and microelement alterations in children and adults has potential to further elucidate IBD pathogenesis.

Serum Calprotectin and B-cell activating factor are potential biomarkers for Helicobacter pylori infection

Humans always mount a robust immune response to the bacterial infection caused by Helicobacter pylori, which causes various gastrointestinal tract infections. Calprotectin (CALP) and B-Cell Activating Factor (BAFF) are inflammatory biomarkers having a role in the gastrointestinal neutrophilic response to bacterial infection. The study was designed to assess serum CALP and BAFF as inflammatory biomarkers in H. pylori infection and peptic ulcer patients. The current study comprised 112 people, including 62 H. pylori-infected patients (34 men and 28 women) who were clinically diagnosed with H. pylori infection via testing positive for the H. pylori stool antigen test; they were compared to a control group of 50 healthy people (34 men and 16 women) who were age and gender-matched to H. pylori-infected patients. The serum level of CALP and BAFF were assayed using the ELISA technique. The biochemical parameters were statistically compared between patients and controls by unpaired Man-Whitney U t-test and Receiver Operating Characteristic (ROC) curve analysis. There was a significant elevation of serum CALP in H. pylori-infected patients [116.4(120.7), p=0.0132] in comparison to healthy controls [99.50(115.8)]. Similarly, there was a significant elevation of serum BAFF concentration in H. pylori-infected patients [485.7(367.1), p=0.0014] in comparison to healthy controls [444.5(513.0)]. The ROC curve analysis suggests serum CALP and BAFF as reasonable inflammatory biomarkers for H. pylori infection with statistically significant (p=0.0135, p=0.0015) area under the ROC curve of (0.6361, 0.6748), respectively. CALP and BAFF are potent inflammatory biomarkers involved in the development and etiology of H. pylori infection. Serum CALP and BAFF levels could be used as biomarkers for chronic inflammation induced by H. pylori. CALP and BAFF biomarkers can be combined to diagnose and predict the prognosis of H. pylori infection.

Evaluation of Fecal Calprotectin, Serum C-Reactive Protein, Erythrocyte Sedimentation Rate, Seromucoid and Procalcitonin in the Diagnostics and Monitoring of Crohn's Disease in Children

Background: The development of diagnostic and monitoring algorithms for Crohn’s disease based on non-invasive methods is of particular importance in children and is the subject of many studies. Objectives: Evaluate the usefulness of fecal calprotectin, serum C-reactive protein, erythrocyte sedimentation rate, seromucoid and procalcitonin in the differential diagnosis of non-inflammatory gastrointestinal tract diseases and Crohn’s disease in children and their usefulness in determining the phenotype of Crohn’s disease. Material and methods: Forty-seven children with non-inflammatory gastrointestinal tract diseases and fifty-four with Crohn’s disease were enrolled. Clinical and endoscopic activity was evaluated based on the Pediatric Crohn’s Disease Activity Index (PCDAI) and the Simple Endoscopic Score for Crohn’s Disease (SES-CD). Results: Fecal calprotectin, C-reactive protein, erythrocyte sedimentation rate and seromucoid were significantly higher in children with Crohn’s disease than in controls (p < 0.001). Fecal calprotectin correlated with clinical and endoscopic activity according to the Pediatric Crohn’s Disease Activity Index (r = 0.338; p = 0.012) and the Simple Endoscopic Score for Crohn’s Disease (r = 0.428; p = 0.001). Non-invasive biomarkers did not correlate with the location and clinical manifestation of Crohn’s disease. Conclusions: Fecal calprotectin, C-reactive protein, erythrocyte sedimentation rate and seromucoid are useful in the differentiation of Crohn’s disease from non-inflammatory gastrointestinal tract diseases in children and in monitoring the clinical course of Crohn’s disease, but not in evaluating activity and phenotype of the disease.

Differentiation of Isolated Small Bowel Crohn’s Disease from Other Small Bowel Ulcerative Diseases: Clinical Features and Double-Balloon Enteroscopy Characteristics

Background. The diagnosis of isolated small bowel Crohn’s disease (ISBCD) has always been challenging. Aims. This study is aimed at comparing the clinical features and double-balloon enteroscopy (DBE) characteristics of ISBCD with those of other small bowel ulcerative diseases (OSBUD). Methods. Patients with coexisting colonic and/or ileal valve lesions ( $n=45$ ) or whose final diagnosis was not determined ( $n=29$ ) were excluded. One hundred thirty-nine patients with ISBCD and 62 patients with OSBUD found by DBE were retrospectively analyzed. Results. The age of ISBCD onset was lower than that of OSBUD (OR 0.957, 95% CI 0.938-0.977, $p<0.001$ ). Abdominal pain was more common in ISBCD (OR 4.986, 95% CI 2.539-9.792, $p<0.001$ ). Elevated fibrinogen levels (OR 1.431, 95% CI 1.022-2.003, $p=0.037$ ) and lower levels of D-dimer (OR 0.999, 95% CI 0.999-1.000, $p=0.017$ ) were also more supportive of the diagnosis of ISBCD. Nonsteroidal anti-inflammatory drugs (NSAIDs) used for more than two weeks decreased the probability of a diagnosis of ISBCD (OR 0.173, 95% CI 0.043-0.695, $p=0.013$ ). Abdominal computed tomography revealed a higher proportion of skip lesions in ISBCD than in OSBUD (OR 9.728, 95% CI 3.676-25.742, $p<0.001$ ). The ulcers of ISBCD were more distributed in the ileum (111 (79.9%) vs. 29 (46.8%), $p<0.001$ ), and their main morphology differed in different intestinal segments. Longitudinal ulcers (OR 14.293, 95% CI 4.920-41.518, $p<0.001$ ) and large ulcer (OR 0.128, 95% CI 0.044-0.374, $p<0.001$ ) contributed to the differentiation of ISBCD from OSBUD. We constructed a diagnostic model, ISBCD index ( $\text{AUROC}=0.877$ , 95% CI: 0.830-0.925), using multifactorial binary logistic regression to help distinguish between these two groups of diseases. Conclusion. Clinical features, laboratory tests, abdominal computed tomography, DBE characteristics, and pathology help to distinguish ISBCD from OSBUD.

Combination of serological biomarkers and clinical features to predict mucosal healing in Crohn's disease: a multicenter cohort study

PURPOSE

Mucosal healing (MH) has become the treatment goal of patients with Crohn's disease (CD). This study aims to develop a noninvasive and reliable clinical tool for individual evaluation of mucosal healing in patients with Crohn's disease.

METHODS

A multicenter retrospective cohort was established. Clinical and serological variables were collected. Separate risk factors were incorporated into a binary logistic regression model. A primary model and a simple model were established, respectively. The model performance was evaluated with C-index, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Internal validation was performed in patients with small intestinal lesions.

RESULTS

A total of 348 consecutive patients diagnosed with CD who underwent endoscopic examination and review after treatment from January 2010 to June 2021 were composed in the derivation cohort, and 112 patients with small intestinal lesions were included in the validation cohort. The following variables were independently associated with the MH and were subsequently included into the primary prediction model: PLR (platelet to lymphocyte ratio), CAR (C-reactive protein to albumin ratio), ESR (erythrocyte sedimentation rate), HBI (Harvey-Bradshaw Index) score and infliximab treatment. The simple model only included factors of PLR, CAR and ESR. The primary model performed better than the simple one in C-index (87.5% vs. 83.0%, p = 0.004). There was no statistical significance between these two models in sensitivity (70.43% vs. 62.61%, p = 0.467), specificity (87.12% vs. 80.69%, p = 0.448), PPV (72.97% vs. 61.54%, p = 0.292), NPV (85.65% vs. 81.39%, p = 0.614), and accuracy (81.61% vs. 74.71%, p = 0.303). The primary model had good calibration and high levels of explained variation and discrimination in validation cohort.

CONCLUSIONS

This model can be used to predict MH in post-treatment patients with CD. It can also be used as an indication of endoscopic surveillance to evaluate mucosal healing in patients with CD after treatment.

Are Matrix Metalloproteinase-9 and Tissue Inhibitor of Metalloproteinase-1 Useful as Markers in Diagnostic Management of Children with Newly Diagnosed Ulcerative Colitis?

Matrix Metaloproteinase-9 (MMP-9) and Tissue Inhibitor of Metaloproteinase-1 (TIMP-1), enzymes involved in tissue remodelling, have been previously reported to be overexpressed in the colonic mucosa of patients with Ulcerative colitis (UC). The aim of this study was to determine the relation of MMP-9 and TIMP-1 with UC phenotypes, the disease activity index and routinely tested inflammatory markers in newly diagnosed paediatric patients. The study group comprised 35 children diagnosed with UC and 20 control groups. Serum and faecal concentrations of MMP-9 and TIMP-1 were estimated using enzyme-like immunosorbent assay kits and correlated to the disease activity index (Paediatric Ulcerative Colitis Activity Index, PUCAI), UC phenotype (Paris Classification), inflammatory markers and endoscopic score (Mayo score). Children with UC presented with significantly higher serum and faecal concentrations of studied markers compared to the control group. Both serums, MMP-9 and TIMP-1, were higher in children with more extended and severe lesions in the colon. Furthermore, serum MMP-9 correlated with the Mayo score, Paris classification and C-reactive protein (CRP) levels. Serum TIMP-1 showed correlation with PUCAI, Paris Classification, CRP levels and the erythrocyte sedimentation rate. Serum and faecal levels of MMP-9 and TIMP-1 are useful in discriminating UC patients and non-invasive assessments of disease phenotypes. It seemed that simultaneous measurement of these proteins in combination with other common markers of inflammation could be applied in clinical practice.

Early Change in Fecal Calprotectin Predicts One-Year Outcome in Children Newly Diagnosed With Ulcerative Colitis

INTRODUCTION

While fecal calprotectin (FC) is used to assess disease activity in ulcerative colitis (UC) there are little data concerning the role of serial FC levels at diagnosis in predicting clinical course. We sought to determine whether FC at diagnosis or early change following therapy predicts clinical outcomes in pediatric UC.Methods: Children with newly diagnosed UC were treated with standardized regimens of mesalamine or corticosteroids (CS). CS tapering and escalation to additional therapy or colectomy were by protocol. Patients with baseline or week 4 or week 12 FC levels were included in the analysis. Our primary outcome was CS-free remission on mesalamine at week 52. We compared the prognostic value of a baseline FC as well as a change in FC by week 4 or week 12 in predicting clinical outcomes.

RESULTS

The study included 352 children (113 initial mesalamine, 239 initial CS, mean age 12.6 years) with UC. At Week 52, 135 (38.3%), 84 (23.8%), and 19 (5.4%) children achieved CS-free remission, needed anti-tumor necrosis factor therapy or had colectomy respectively. Baseline FC was not associated with CS-free remission at week 52. However, both week 4 (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.901.00) and week 12 FC levels (OR 0.91, 95% CI 0.87-0.96) were associated with outcomes, with the latter having a stronger association with CS-free remission. Patients with a >75% decrease by 12 weeks, had a 3-fold increased likelihood of CS-free remission at 1 year.

DISCUSSION

Longitudinal changes in FC may predict 1 year outcomes better than values at diagnosis in children with a new diagnosis of UC.

Predictive value of fibrinogen in identifying inflammatory bowel disease in active stage

Background

We aimed to externally validate for the first time the diagnostic ability of fibrinogen to identify active inflammatory bowel disease (IBD).

Methods

The research totally involved 788 patients with IBD, consisted of 245 ulcerative colitis (UC) and 543 Crohn’ s disease (CD). The Mayo score and Crohn disease activity index (CDAI) assessed disease activity of UC and CD respectively. The independent association between fibrinogen and disease activity of patients with UC or CD was investigated by multivariate logistic regression analyses. Area under the receiver operating characteristic curve (AUROC) assessed the performance of various biomarkers in discriminating disease states.

Results

The fibrinogen levels in active patients with IBD significantly increased compared with those in remission stage (P < 0.001). Fibrinogen was an independent predictor to distinguish disease activity of UC (odds ratio: 2.247, 95% confidence interval: 1.428–3.537, P < 0.001) and CD (odds ratio: 2.124, 95% confidence interval: 1.433–3.148, P < 0.001). Fibrinogen was positively correlated with the Mayo score (r = 0.529, P < 0.001) and CDAI (r = 0.625, P < 0.001). Fibrinogen had a high discriminative capacity for both active UC (AUROC: 0.806, 95% confidence interval: 0.751–0.861) and CD (AUROC: 0.869, 95% confidence interval: 0.839–0.899). The optimum cut-off values of fibrinogen 3.22 was 70% sensitive and 77% specific for active UC, and 3.87 was 77% sensitive and 81% specific for active CD respectively.

Conclusions

Fibrinogen is a convenient and practical biomarker to identify active IBD.

Serum matrix metalloproteinase-9 concentration as a marker of disease activity in patients with inflammatory bowel disease

BACKGROUND AND AIM

Diagnosing inflammatory bowel disease (IBD), determining the appropriate treatment and follow-up of patients rely mainly on endoscopy and biopsy. Finding a sensitive, specific, cost-effective and less-invasive biomarker is the focus of much of the current research in this field. The aim was to investigate the relation between serum matrix metalloproteinase-9 (MMP-9) levels and disease activity in patients with IBD, correlating with clinical and endoscopic indices of disease activity and with treatment received.

PATIENTS AND METHODS

Sixty patients (30 with ulcerative colitis, 30 with Crohn's disease) and 20 controls were included. Serum MMP-9 levels were measured for all patients and controls by ELISA. Clinical activity was determined by partial Mayo score for patients with ulcerative colitis and Crohn's Disease Activity Index for patients with Crohn's disease, and endoscopic activity was assessed using Ulcerative Colitis Endoscopic Index of Severity for patients with ulcerative colitis and Simple Endoscopic Score of Crohn's disease for patients with Crohn's disease.

RESULTS

Serum MMP-9 was higher in patients with active ulcerative colitis than in patients with inactive disease and the control group. Serum MMP-9 was also higher in patients with active Crohn's disease than in patients with inactive disease and the control group. In both ulcerative colitis and Crohn's disease groups, there was a significant difference between serum MMP-9 levels in patients receiving conventional treatment and those on biological treatment, with lower levels of the marker detected in the sera of patients subgroups receiving biologics.

CONCLUSION

Serum MMP-9 can be used to differentiate between active and inactive IBD (including both ulcerative colitis and Crohn's disease).

The assessment of plasma fatty acid profiles in newly diagnosed treatment-naive paediatric Crohn's disease

Fatty acid (FA) profiles as potentially relevant components of Crohn's disease (CD) have been insufficiently analysed. We sought to explore the plasma profiles of n-3 and n-6 polyunsa-turated fatty acids (PUFAs) in newly diagnosed untreated active CD. We included 26 consecutive CD pediatric patients (<19 years) and 14 healthy controls (HCs). Disease characteristics, including inflammatory markers, dietary histories, and the Pediatric Crohn's Disease Activity Index (PCDAI), were obtained. The profiles of plasma FAs in plasma lipid classes were analysed by gas chromatography with FID detection of methyl esters. The erythrocyte sedimentation rate, C-reactive protein level and fecal calprotectin level (all p<0.001) were significantly higher in CD patients than in HCs. Most changes were observed in plasma phospholipids (PLs), such as a higher content of n-3 and changes in n-6 long-chain PUFAs in the CD group. The CD group had a lower ratio of n-6/n-3 PUFAs in PLs (p<0.001) and triacylglycerols (TAGs) (p<0.01). Correlations of the FA content in plasma PLs with disease activity scores of CD were also observed, which were positive for the sum of monounsaturated fatty acids (MUFAs) as well as oleic acid (18:1n-9) (both p<0.05). The metabolism of PUFAs is significantly altered even in treatment-naive newly diagnosed active pediatric CD, and the content of major FAs in PLs correlates with disease activity and inflammatory markers, thus probably contributing to the still unclear early disease pathogenesis.

Liver Pathology in Children with Diagnosed Inflammatory Bowel Disease-A Single Center Experience

BACKGROUND

Inflammatory bowel disease (IBD) in children is frequently associated with liver pathology manifested as transient elevation of liver enzymes or specified liver diseases. The aim of the study was to evaluate the prevalence and the type of liver pathology in children with IBD within 2 years' follow-up after the IBD diagnosis.

METHODS

We retrospectively reviewed records of children with IBD. Liver pathology was defined as elevated activity of liver enzymes (alanine transaminase (ALT) and/or gamma-glutamyl transpeptidase (GGT)) and bilirubin concentration in serum and/or as pathological changes of the organ on imaging tests (abdominal ultrasound and/or magnetic resonance cholangiopancreatography) or on liver histology performed when indicated.

RESULTS

Liver pathology was detected in 21 from 119 children (18%), including 7 (17%) with Crohn's disease (CD) and 14 (18%) with ulcerative colitis (UC). Specified diagnosis for liver abnormality was found in 14 of 21 children (67%), including primary sclerosing cholangitis (PSC, 19%), non-alcoholic fatty liver disease (NAFLD, 19%), autoimmune sclerosing cholangitis (ASC, 5%), autoimmune hepatitis (AIH, 5%), cholelithiasis (5%), drug-induced liver disease (9%) and viral infection (herpes simplex virus, 5%). Most patients manifested mild IBD or were in clinical remission at the time of liver pathology diagnosis. 14% of patients with liver disease (including only cases with PSC) were diagnosed before IBD, 33% at the same time, and 52% in the later period. Patients with the specified diagnosis of liver pathology were younger, had higher ALT activity and more often demonstrated liver abnormalities on imaging tests. UC patients with idiopathic elevation of liver enzymes had higher pediatric ulcerative colitis activity index scores compared to children with specified liver disease.

CONCLUSIONS

Liver pathology was observed in a significant percentage of children with IBD in our study. The majority of cases of hepatobiliary abnormalities were detected after diagnosis of IBD; therefore, children with IBD should undergo routine monitoring of liver enzymes.

Neutrophil-T cell crosstalk in inflammatory bowel disease

Neutrophils are the most abundant leucocytes in human blood, promptly recruited to the site of tissue injury, where they orchestrate inflammation and tissue repair. The multifaceted functions of neutrophils have been more appreciated during the recent decade, and these cells are now recognized as sophisticated and essential players in infection, cancer and chronic inflammatory diseases. Consequently, our understanding of the role of neutrophils in inflammatory bowel disease (IBD), their immune responses and their ability to shape adaptive immunity in the gut have been recognized. Here, current knowledge on neutrophil responses in IBD and their capacity to influence T cells are summarized with an emphasis on the role of these cells in human disease.

Pancreatic Disorders in Children with Inflammatory Bowel Disease

Background and Objectives: Inflammatory bowel disease (IBD) is a chronic condition and mainly affects the intestines, however, the involvement of the other organs of the gastrointestinal tract (upper part, pancreas, and liver) have been observed. The coexistence of IBD with pancreatic pathology is rare, however, it has been diagnosed more frequently during recent years in the pediatric population. This article reviews the current literature on the most common pancreatic diseases associated with IBD in the pediatric population and their relationship with IBD activity and treatment. Materials and Methods: We performed a systematic review of data from published studies on pancreatic disorders, also reported as extraintestinal manifestations (EIMs), among children with IBD. We searched PubMed and Web of Science to identify eligible studies published prior to 25 April 2020. Results: Forty-four papers were chosen for analysis after a detailed inspection, which aimed to keep only the research studies (case control studies and cohort studies) or case reports on children and only those which were written in English. The manifestations of IBD-associated pancreatic disorders range from asymptomatic increase in pancreatic enzymes activity to severe disease such as acute pancreatitis. Acute pancreatitis (AP) induced by drugs, mainly thiopurine, seems to be the most- often-reported pancreatic disease associated with IBD in children. AP associated with other than drug etiologies, and chronic pancreatitis (CP), are rarely observed in the course of pediatric IBD. The pancreatic involvement can be strictly related to the activity of IBD and can also precede the diagnosis of IBD in some pediatric patients. The course of AP is mild in most cases and may occasionally lead to the development of CP, mainly in cases with a genetic predisposition. Conclusions: The involvement of the pancreas in the course of IBD may be considered as an EIM or a separate co-morbid disease, but it can also be a side effect of IBD therapy, therefore a differential diagnosis should always be performed. As the number of IBD incidences with concomitant pancreatic diseases is constantly increasing in the pediatric population, it is important to include pancreatic enzymes level measurement in the workup of IBD.

STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD

BACKGROUND

The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) has proposed treatment targets in 2015 for adult patients with inflammatory bowel disease (IBD). We aimed to update the original STRIDE statements for incorporating treatment targets in both adult and pediatric IBD.

METHODS

Based on a systematic review of the literature and iterative surveys of 89 IOIBD members, recommendations were drafted and modified in 2 surveys and 2 voting rounds. Consensus was reached if ≥75% of participants scored the recommendation as 7 to 10 on a 10-point rating scale.

RESULTS

In the systematic review, 11,278 manuscripts were screened, of which 435 were included. The first IOIBD survey identified the following targets as most important: clinical response and remission, endoscopic healing, and normalization of C-reactive protein/erythrocyte sedimentation rate and calprotectin. Fifteen recommendations were identified, of which 13 were endorsed. STRIDE-II confirmed STRIDE-I long-term targets of clinical remission and endoscopic healing and added absence of disability, restoration of quality of life, and normal growth in children. Symptomatic relief and normalization of serum and fecal markers have been determined as short-term targets. Transmural healing in Crohn's disease and histological healing in ulcerative colitis are not formal targets but should be assessed as measures of the remission depth.

CONCLUSIONS

STRIDE-II encompasses evidence- and consensus-based recommendations for treat-to-target strategies in adults and children with IBD. This frameworkshould be adapted to individual patients and local resources to improve outcomes.

Cathelicidin - A Novel Potential Marker of Pediatric Inflammatory Bowel Disease

INTRODUCTION

Cathelicidin is a multifunctional host defense peptide which may also exert pro-inflammatory signals and contribute to the development of autoimmune disorders. We aimed to assess serum concentration of cathelicidin in children with inflammatory bowel disease (IBD) compared to healthy controls and to evaluate its relationship with disease activity and phenotype.

PATIENTS AND METHODS

The study group included 68 children with IBD. The control group comprised 20 children with functional abdominal pain. All patients and controls were tested for complete blood count, C-reactive protein, erythrocyte sedimentation rate and cathelicidin. Stool samples were collected to assess calprotectin.

RESULTS

Cathelicidin was significantly increased in patients with ulcerative colitis (1073.39±214.52 ng/mL) and Crohn's disease (1057.63±176.03 ng/mL) patients compared to controls (890.56±129.37 ng/mL) (H=16.28; p=0.0003). Cathelicidin was significantly elevated in children with active IBD (1044.90±176.17 ng/mL) and IBD remission (1098.10±227.87 ng/mL) compared to controls (Z=3.21; p=0.001; Z=-4.12; p<0.0001, respectively). Negative correlation between cathelicidin and calprotectin in children with ulcerative colitis was found (R=-0.39; p=0.02). Cathelicidin exhibited AUC of 0.815 for differentiation children with ulcerative colitis from the control group.

CONCLUSION

Serum cathelicidin is increased in children with Crohn's disease and ulcerative colitis regardless of clinical activity of the disease suggesting that it may be a potential biomarker of IBD. Inverse correlation between cathelicidin and fecal calprotectin may imply a disparate role of these molecules in the pathophysiology of pediatric ulcerative colitis.

Eosinophil-Derived Neurotoxin, Tumor Necrosis Factor Alpha, and Calprotectin as Non-Invasive Biomarkers of Food Protein-Induced Allergic Proctocolitis in Infants

Diagnosis of non-IgE mediated food allergy presents a special challenge due to lack of a single, non-invasive diagnostic method. We selected three fecal biomarkers of allergic inflammation of gastrointestinal origin in order to improve the diagnostic process. Twenty-seven infants with symptoms of hematochezia were prospectively enrolled into this study. All patients underwent a complete differential diagnosis of rectal bleeding. Non-IgE mediated food allergy was confirmed by an open, oral food challenge. The control group included twenty-five infants with functional gastrointestinal disorders. Eosinophil-derived neurotoxin (EDN), tumor necrosis factor alpha (TNFα), and calprotectin concentration were measured in stools of all children by enzyme-linked immunosorbent assays (ELISA) using commercial kits. Median eosinophil-derived neurotoxin and calprotectin fecal levels were significantly higher in the study group than in the control group (p < 0.05). The difference of fecal tumor necrosis factor alpha concentration between both groups was not statistically significant (p > 0.05). The best diagnostic performance was reached in a combination of fecal calprotectin (fCal) and EDN i.e., 88.9% and 84%, respectively. Fecal EDN and fCAl are reliable tools in differentiating between food protein-induced allergic proctocolitis and gastrointestinal functional disorders in infants.

Correlation between biomarkers (calprotectin, seromucoid, metalloproteinase-3 and CRP) and clinical and endoscopic activity of ulcerative colitis in children

PURPOSE

The aim of the study was to compare the clinical activity and inflammatory markers with the endoscopic activity of ulcerative colitis (UC) and mucosal healing.

PATIENTS AND METHODS

The study included 50 children aged 2-18 years (27 girls, 23 boys) diagnosed with UC at various stages of the disease; 8 children were assessed twice. In 20 children, colonoscopy revealed pancolitis, in 24 - left-sided colitis, and in 6 - ulcerative proctitis. The clinical activity of UC was assessed according to the Pediatric Ulcerative Colitis Activity Index (PUCAI). Endoscopic index of the colon inflammation was assessed according to the Rachmilewitz scoring. We assessed the clinical activity of UC, the concentration of fecal calprotectin (FC), seromucoid, metalloproteinase-3 (MMP-3) and C-reactive protein (CRP).

RESULTS

The study demonstrated significant decrease in the clinical activity, FC, seromucoid and MMP-3 in endoscopic remission. We found a strong positive correlation between PUCAI, FC, serum seromucoid and serum MMP-3 with the endoscopic activity. However, we found no relationship between the concentration of CRP and the endoscopic activity of the disease. Among the studied markers, seromucoid exhibited the best performance in distinguishing between patients with endoscopic remission and endoscopically active disease.

CONCLUSIONS

The examined inflammatory markers such as FC, as well as serum seromucoid and MMP-3 levels may be helpful in the assessment of large intestine mucosal healing.

Usefulness of metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 in clinical characterisation of children with newly diagnosed Crohn's disease

AIM

The aim of this study was to determine the relation of non-invasive markers representing gut mucosal damage (metalloproteinase-9 (MMP-9)) and remodelling (tissue inhibitor of metalloproteinase-1 (TIMP-1)) with Crohn's disease (CD) phenotype, disease activity scores (clinical and endoscopic) and radiological evaluation of the ileum in newly diagnosed children.

METHODS

Serum and faecal MMP-9 and TIMP-1 concentrations were determined with the sandwich enzyme-linked immunoassay technique. The performance of each marker with reference to the Paris classification, disease activity scores and magnetic resonance enterography results was assessed using non-parametric tests.

RESULTS

A total of 32 children with CD demonstrated higher levels of serum and faecal MMP-9 and TIMP-1 compared with a control group including children without gastrointestinal inflammatory disease (all P < 0.05). Only the serum MMP-9 concentration was significantly higher in children with L3 (ileocolonic) compared with children with L1 (distal ileum). The serum TIMP-1 level was significantly higher in patients with an magnetic resonance enterography-detected ileum involvement longer than 51 mm and in children with severe disease activity compared with other patients. The serum MMP-9 level was lower in patients with stenosis combined with prestenotic dilation compared with children without stenosis.

CONCLUSION

Increased serum and faecal MMP-9 and TIMP-1 concentrations are some reliable markers of inflammation in newly diagnosed children with CD, but without facilitating clear phenotyping of the disease.

Sphingolipid Analysis Indicate Lactosylceramide as a Potential Biomarker of Inflammatory Bowel Disease in Children

An altered ceramide composition in patients with inflammatory bowel disease (IBD) has been reported recently. The aim of this study was to evaluate the concentrations of sphingolipids in the serum of treatment-naive children with newly diagnosed IBD and to determine the diagnostic value of the tested lipids in pediatric IBD. The concentrations of sphingolipids in serum samples were evaluated using a quantitative method, an ultra-high-performance liquid chromatography-tandem mass spectrometry in children with Crohn’s disease (CD) (n=34), ulcerative colitis (UC) (n = 39), and controls (Ctr) (n = 24). Among the study groups, the most significant differences in concentrations were noted for C16:0-LacCer, especially in children with CD compared to Ctr or even to UC. Additionally, the relevant increase in C20:0-Cer and C18:1-Cer concentrations were detected in both IBD groups compared to Ctr. The enhanced C24:0-Cer level was observed only in UC, while C18:0-Cer only in the CD group. The highest area under the curve (AUC), specificity, and sensitivity were determined for C16:0-LacCer in CD diagnosis. Our results suggest that the serum LacC16-Cer may be a potential biomarker that distinguishes children with IBD from healthy controls and differentiates IBD subtypes. In addition, C20:0-Cer and C18:0-Cer levels also seem to be closely connected with IBD.

The Relationship between C-Reactive Protein/Albumin Ratio and Disease Activity in Patients with Inflammatory Bowel Disease

Objectives

The aims of this study were to evaluate the C-reactive protein/albumin ratio (CRP/ALB), inflammatory markers, and parameters from the complete blood count (CBC) in patients with inflammatory bowel disease (IBD) and their associations with disease activity.

Methods

A total of 876 IBD patients, composed of 275 patients with ulcerative colitis (UC) and 601 patients with Crohn's disease (CD), were included in this retrospective study, and the serum C-reactive protein (CRP), albumin (ALB), erythrocyte sedimentation rate (ESR), and CBC parameters were measured. To explore the disease activity, the Mayo score and Crohn disease activity index were used to assess UC and CD patients, respectively.

Results

The CRP/ALB ratio, CRP, ESR, platelet to lymphocyte ratio (PLR), red blood cell distribution width (RDW), and neutrophil to lymphocyte ratio (NLR) levels in active IBD patients were significantly higher than those in inactive IBD patients, whereas ALB and lymphocyte to monocyte ratio (LMR) levels were significantly decreased (P < 0.001). The receiver operating characteristic analysis showed that the optimum cut-off values of the CRP/ALB ratio for active UC and CD were 0.18 and 0.43, with sensitivities of 67.8% and 75.8% and specificities of 86.7% and 92.0%, respectively. Multivariable logistic analysis revealed that after adjusting for these inflammatory markers (ESR, NLR, PLR, and LMR), the CRP/ALB ratio was a statistically significant parameter capable of differentiating the disease activity of UC and CD.

Conclusions

This study indicated that the CRP/ALB ratio was closely related to the IBD disease activity. Compared with CBC parameters, the CRP/ALB ratio had a higher discriminative capacity for active IBD.

Body composition in children with chronic inflammatory diseases: A systematic review

BACKGROUND & AIMS

Aberrations in body composition are expected in children suffering from chronic inflammatory conditions. The objective is to examine whether children with inflammatory bowel disease (IBD: Crohn's disease and ulcerative colitis), coeliac disease, asthma and juvenile idiopathic arthritis (JIA) have an altered body composition as compared to healthy children.

METHODS

A systematic review, registered in Prospero (registration number: CRD42018107645), was conducted according to PRISMA guidelines. We conducted a search of three databases, Pubmed, Cochrane and Scopus. An assessment of the quality of the study was performed.

RESULTS

Data from 50 studies, 32 with IBD, 8 with coeliac disease, 2 with asthma and 8 with JIA, involving 2399 children were selected for review after applying the eligibility criteria. In all but 4 studies, children with Crohn's disease exhibited decreased amounts of fat mass and fat free mass. Reductions in fat mass were also evident in studies in children with coeliac disease. It is uncertain whether body composition is altered in children with asthma or JIA.

CONCLUSIONS

Children with Crohn's disease manifest with lowered adiposity and lean mass and therefore are likely to be at risk for suffering malnutrition-related clinical complications. Apart from Crohn's disease, data examining body composition in children with chronic inflammatory conditions are scarce and there is a paucity of reports examining the relationship between inflammation and body composition. Interpretation of the current study results is hampered by the low quality of the studies and due to the fact that the analyses have been habitually secondary outcomes.

Development and Validation of the Mucosal Inflammation Noninvasive Index For Pediatric Crohn's Disease

BACKGROUND & AIMS

Mucosal healing (MH) has become a goal of therapy for Crohn's disease (CD), but frequent endoscopies are not feasible. We aimed to develop and validate a non-invasive index to assess mucosal inflammation in children with CD.

METHODS

We collected data from the multi-center prospective ImageKids study, in which children with CD underwent ileocolonoscopy with magnetic resonance enterography. We investigated the association of pediatric CD activity index (PCDAI) items and laboratory test results with the simple endoscopic score for CD (SESCD). We used these data in a blended mathematical judgmental clinimetric approach to develop a weighted categorized index to identify children with CD who have MH, which we called the MINI index. We validated the index using data from 3 independent patient cohorts. The derivation and validation cohorts included 154 and 168 children, respectively (age 14.1 ± 2.5 years and 14.2 ± 3.9 years), of whom 16% and 36% had MH (defined as SESCD<3).

RESULTS

In multivariable models, the stooling item of the PCDAI, erythrocyte sedimentation rate, and level of fecal calprotectin were associated with SESCD (all P < .05). We added data on level of C-reactive protein to develop the MINI index. MINI scores below 8 identified children with MH with 88% sensitivity and 85% specificity in the derivation cohort and with 84% sensitivity and 87% specificity in the validation cohorts. Ninety percent of the patients in the validation cohort with scores of 8 or more had active mucosal inflammation, yet 78% of patients with scores below 8 had MH. Scores below 6 increase the positive predictive value to 86%.

CONCLUSIONS

We developed an index to non-invasively assess mucosal inflammation in children with CD. This index, identifies children with MH with high sensitivity and specificity. The added benefit of MINI over measurement of fecal calprotectin was small but significant, especially for patients with concentrations of fecal calprotectin from 100 to 599 μg/g. ClinicalTrials.gov no: NCT01881490.

Fecal Calprotectin in Combination With Standard Blood Tests in the Diagnosis of Inflammatory Bowel Disease in Children

Introduction: Fecal calprotectin (FC) is a useful non-invasive screening test but elevated levels are not specific to inflammatory bowel disease (IBD). The study aimed to evaluate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of FC alone or FC in combination with other standard blood tests in the diagnosis of IBD. Methods: Children aged <17 years who had FC (normal range <50 μg/g) measured and underwent endoscopy over 33 months in Christchurch, New Zealand were identified retrospectively (consecutive sampling). Medical records were reviewed for patient final diagnoses. Results: One hundred and two children were included; mean age was 12.3 years and 53 were male. Fifty-eight (57%) of the 102 children were diagnosed with IBD: 49 with Crohn's disease, eight with ulcerative colitis and one with IBD-unclassified. FC of 50 μg/g threshold provided a sensitivity of 96.6% [95% confident interval (CI) 88.3-99.4%] and PPV of 72.7% (95% CI 61.9-81.4%) in diagnosing IBD. Two children with IBD however were found to have FC <50 μg/g. Sensitivity in diagnosing IBD was further improved to 98.3% (95% CI 90.7-99.1%) when including FC >50 μg/g or elevated platelet count. Furthermore, PPVs in diagnosing IBD improved when FC at various thresholds was combined with either low albumin or high platelet count. Conclusion: Although FC alone is a useful screening test for IBD, a normal FC alone does not exclude IBD. Extending FC to include albumin or platelet count may improve sensitivity, specificity, PPV and NPV in diagnosing IBD. However, prospective studies are required to validate this conclusion.

Untargeted Metabolomics and Inflammatory Markers Profiling in Children With Crohn's Disease and Ulcerative Colitis-A Preliminary Study

BACKGROUND

Metabolic profiling might be used to identify disease biomarkers. The aim of our study was to determine the usefulness of untargeted metabolomics analysis to detect differences in serum metabolites between newly diagnosed and untreated pediatric patients with Crohn's disease (CD) or ulcerative colitis (UC) in comparison with a control group (Ctr). Moreover, we investigated the potential of profiling metabolomics and inflammatory markers to improve the noninvasive diagnosis of CD and UC in children.

METHODS

Metabolic fingerprinting of serum samples was estimated with liquid chromatography coupled with mass spectrometry in children with CD (n = 9; median age, 14 years), UC (n = 10; median age, 13.5 years), and controls (n = 10; median age, 12.5 years).

RESULTS

The majority of chemically annotated metabolites belonged to phospholipids and were downregulated in CD and UC compared with the Ctr. Only 1 metabolite, lactosylceramide 18:1/16:0 (LacCer 18:1/16:0), significantly discriminated CD from UC patients. Interestingly, combining LacCer 18:1/16:0 with other inflammatory markers resulted in a significant increase in the area under the curve with the highest specificity and sensitivity.

CONCLUSIONS

Using serum untargeted metabolomics, we have shown that LacCer 18:1/16:0 is a very unique metabolite for CD patients.