Epidemiology and natural history of inflammatory bowel diseases

Association of Healthy Lifestyle Behaviours With Incident Inflammatory Bowel Disease: A Population-Based Prospective Cohort Study

BACKGROUND

The combined effects of some modifiable lifestyle factors on incident inflammatory bowel disease (IBD) are uncertain.

AIMS

To evaluate the combined association between healthy lifestyle behaviours and IBD incidence.

METHODS

This population-based prospective cohort study used data from the UK Biobank. We included 105,715 participants aged 40-70 who had no IBD diagnosis at baseline in the analyses. The five healthy lifestyle behaviours that we studied were never smoking, optimal sleep, high level of vigorous physical activity, high dietary quality, and moderate alcohol intake. The outcome was the overall incidence of IBD and individual incidences of Crohn's disease (CD) and ulcerative colitis (UC). We derived hazard ratios (HR) and 95% confidence intervals (CI) for associations.

RESULTS

The multivariable adjusted HRs (95% CI) associated with having 1, 2 and 3-5 healthy lifestyle behaviours for IBD incidence compared with those with none of these behaviours were 0.75 (0.59-0.97), 0.72 (0.56-0.92), and 0.50 (0.37-0.68), respectively (p for trend < 0.001). We observed similar findings for CD and UC. Only never smoking exhibited significant independent inverse associations with the overall incidence of IBD (HR 0.70, 95% CI 0.58-0.83, p < 0.001) and the incidence of UC (HR 0.58, 95% CI 0.48-0.72, p < 0.001).

CONCLUSIONS

Healthy lifestyle behaviours are significantly associated with lower IBD incidence in middle-aged and elderly individuals, suggesting the potential of lifestyle modifications as a primary prevention strategy for IBD.

Gut Microbiota as a Mediator Between Intestinal Fibrosis and Creeping Fat in Crohn's Disease

Intestinal stricture remains one of the most challenging complications in Crohn's disease, and its underlying mechanisms are poorly understood. Accumulating evidence suggests that gut microbiota is significantly altered in stenotic intestines and may play a key role in the development of fibrogenesis in Crohn's disease. Additionally, the presence of hypertrophic mesenteric adipose tissue, also known as creeping fat, is closely correlated with intestinal stricture and fibrosis. Recent findings have revealed that bacterial translocation to creeping fat might exacerbate colitis and promote intestinal fibrosis. However, there is still a gap in determining whether gut microbiota links the formation of creeping fat to intestinal fibrosis. Hence, this review aims to summarize the known microbial influences on intestinal fibrosis, describes the microbial characteristics of creeping fat in Crohn's disease, and discusses the crosstalk between creeping fat-associated dysbiosis and the development of intestinal fibrosis.

Intestinal fibrosis associated with inflammatory bowel disease: Known and unknown

ABSTRACT

Intestinal fibrosis is a major complication of inflammatory bowel disease (IBD), leading to a high incidence of surgical interventions and significant disability. Despite its clinical relevance, no targeted pharmacological therapies are currently available. This review aims to explore the underlying mechanisms driving intestinal fibrosis and address unresolved scientific questions, offering insights into potential future therapeutic strategies. We conducted a literature review using data from PubMed up to October 2024, focusing on studies related to IBD and fibrosis. Intestinal fibrosis results from a complex network involving stromal cells, immune cells, epithelial cells, and the gut microbiota. Chronic inflammation, driven by factors such as dysbiosis, epithelial injury, and immune activation, leads to the production of cytokines like interleukin (IL)-1β, IL-17, and transforming growth factor (TGF)-β. These mediators activate various stromal cell populations, including fibroblasts, pericytes, and smooth muscle cells. The activated stromal cells secrete excessive extracellular matrix components, thereby promoting fibrosis. Additionally, stromal cells influence the immune microenvironment through cytokine production. Future research would focus on elucidating the temporal and spatial relationships between immune cell-driven inflammation and stromal cell-mediated fibrosis. Additionally, investigations are needed to clarify the differentiation origins of excessive extracellular matrix-producing cells, particularly fibroblast activation protein (FAP) + fibroblasts, in the context of intestinal fibrosis. In conclusion, aberrant stromal cell activation, triggered by upstream immune signals, is a key mechanism underlying intestinal fibrosis. Further investigations into immune-stromal cell interactions and stromal cell activation are essential for the development of therapeutic strategies to prevent, alleviate, and potentially reverse fibrosis.

Cellular and molecular mechanisms in the pathogenesis of pouchitis: more than just the microbiota

Pouchitis, defined as inflammation of the ileal pouch, is the most common complication following restorative proctocolectomy for refractory ulcerative colitis. Antibiotics remain the first line of therapy for pouchitis, but the majority of patients develop subsequent episodes and some are refractory to antibiotic therapy. This highlights the need for more effective treatment options and points to a more complex pathophysiology beyond the role of th pouch microbiome, similar to what is seen in inflammatory bowel disease. In this review, we outline the putative mechanisms of pouchitis, including genetic predisposition, microbiome alterations, dysfunction of the intestinal barrier and the immune system and review the available animal models of pouchitis. In addition, we introduce the concept of pouchitis as a possible transmural disease and discuss the potential role of non-immune cells, including stromal cells, in perpetuating inflammation and intestinal barrier dysfunction. We discuss future directions, implications for novel therapies and propose novel multicellular disease models that can better capture the complexity of pouchitis pathogenesis.

The importance of MUC6 immunohistochemistry staining in the histopathologic examination of Crohn's disease: can we enhance our diagnostic power?

Crohn's disease (CD) is a chronic inflammatory bowel disease characterized by transmural inflammation and histopathologic variability, making diagnosis challenging. Pseudopyloric metaplasia (PPM) is a key histological feature of chronicity in CD. However, its identification on hematoxylin & eosin (H&E)-stained slides is subject to interobserver variability. MUC6 immunohistochemistry (IHC) has been suggested as a useful marker for pyloric glands. This study aims to evaluate the diagnostic utility of MUC6 staining in detecting PPM and to assess interobserver agreement compared to H&E staining. In this retrospective study, 38 terminal ileum biopsies from CD patients were analyzed. H&E-stained and MUC6-stained slides were evaluated independently by four pathologists for the presence and gland count of PPM. Intraobserver and interobserver agreements were assessed using Intraclass Correlation Coefficient (ICC). The mean PPM count was significantly higher with MUC6 staining than by H&E alone. Intraobserver agreement between H&E and MUC6 staining was "moderate" (ICC = 0.577, 0.734, 0.738) for three pathologists and "poor" (ICC = 0.439) for one. Interobserver agreement was classified as "good" for H&E slides (ICC = 0.849) and "excellent" for MUC6-stained slides (ICC = 0.993). PPM is an important finding that is not specific for CD but indicates chronic mucosal damage in the gastrointestinal tract. In our study, MUC6 IHC staining in CD improved the detection of PPM and increased interobserver agreement in the detection of PPM. The increase in the number of detectable metaplastic glands in all observers demonstrates the potential of MUC6 staining as a reliable marker. MUC6 IHC may provide a more standardized and objective evaluation, reducing diagnostic variability.

Definitions, diagnosis, and management of postoperative recurrence in Crohn's disease patients with permanent ileostomy-a systematic review and meta-analysis

BACKGROUND AND AIMS

Over 10% of patients with Crohn's disease require permanent ileostomy. We aimed to summarize the existing data on diagnosis, definitions of recurrence, and management of Crohn's disease patients with permanent ileostomy.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched from inception to February 6, 2024. Randomized controlled trials, cohort and cross-sectional studies, and case series of more than 5 patients reporting on postoperative recurrence or the need for surgery in patients with Crohn's disease and permanent ileostomy were included. Search results were independently screened, and full text of all titles meeting eligibility criteria was obtained. Outcomes of interest included diagnostic techniques, recurrence definitions, and management approaches. We estimated pooled rates (with 95% confidence interval [CI]) of recurrence.

RESULTS

Thirty cohort studies including 2055 Crohn's patients with permanent ileostomy were included (53% female, median age at the time of ileostomy creation 32 years, the most common reason for ileostomy was refractory disease). The postoperative recurrence rate was 27% (95% CI, 21.3-33.3, 26 studies, 451/1805 patients). Modalities for diagnosis of Crohn's disease recurrence were symptoms (15 studies), endoscopy (4 studies), histology from endoscopic biopsies (2 studies), imaging (5 studies), and surgery (22 studies). The reported definitions of recurrence for each modality were heterogeneous.

CONCLUSIONS

There is a lack of standardized monitoring tools and criteria for diagnosing recurrence in patients with Crohn's disease and permanent ileostomy. The results of this systematic review will form the basis of a global expert recommendation exercise focused on developing management standards and trial endpoints for this condition.

The dietary inflammatory potential and its role in the risk and progression of inflammatory bowel disease: A systematic review

BACKGROUND & AIMS

Inflammation is central in inflammatory bowel disease (IBD) pathogenesis. Because of diet's pro- and anti-inflammatory properties, multiple observational studies have explored the link between the dietary inflammatory potential and IBD-related outcomes. We aimed to systematically review the literature and provide a comprehensive overview of the dietary inflammatory potential and its association with the development and progression of IBD.

METHODS

Literature was searched systematically on the 2nd of May 2024 in PubMed, Web of Science, Scopus, Cochrane Library, and Embase to identify the observational studies that explored the link between the dietary inflammatory potential and IBD-related outcomes. A higher dietary inflammatory potential was defined as the ability of a dietary pattern to promote inflammation in the body. Studies were included only if they quantified this using a dietary index, such as the dietary inflammatory index (DII) and the empirical dietary inflammatory pattern (EDIP). Two authors independently performed study selection and data extraction and assessed the risk of bias using the Newcastle-Ottawa scale.

RESULTS

Fourteen of the 165 identified records met the inclusion criteria. Seven investigated the risk of developing IBD, but with mixed results. Nine investigated the progression of IBD, which indicated that a higher dietary inflammatory potential contributed to higher disease activity and associated symptoms.

CONCLUSIONS

The evidence suggested that a higher dietary inflammatory potential worsens the condition of IBD patients, while the link with the risk of developing the disease was less clear. To elucidate this, high-quality intervention studies are needed.

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Exploring diet categorizations and their influence on flare prediction in inflammatory bowel disease, using the Sparse Grouped Least Absolute Shrinkage and Selection Operator method

BACKGROUND & AIMS

Diet is an important environmental factor in inflammatory bowel disease (IBD) onset and disease course, but analyses are hindered by its complexity. We aim to explore the Sparse Grouped Least Absolute Shrinkage and Selection Operator (Sparse Grouped LASSO or SGL) method to study whether different food categorizations, representing different dietary patterns, can predict flares in IBD.

METHODS

Baseline data on habitual dietary intake and longitudinal data on disease course were collected over a 24 month-period in two distinct cohorts. Food items were classified into 22 food groups. These were further classified into three diet categorizations: 1. Plant vs animal vs mixed; 2. Potentially healthy vs potentially unhealthy vs neutral; 3. Ultra-processed vs not ultra-processed. The SGL parameter 'lambda' identifies important groups using a-priori group information, while allowing for only a subset of variables within a group to be important predictors.

RESULTS

Of 724 eligible patients, 427 were in remission at baseline and were included in the SGL analyses. 106 (24.8 %) included patients developed a flare within 11.2 ± 6.6 months (65.1 % female, 34 % ulcerative colitis, mean age 43.3 ± 14.7 years). They had a higher crude food intake of red meat (p = 0.028) and vegetables (p = 0.027) than those who stayed in remission. Prediction models for flare development were moderate with AUC varying between 0.425 and 0.542 for model 1, 0.512 and 0.562 for model 2 and 0.451 and 0.612 for model 3. All models showed red meat, legumes and vegetables as the first selected predicting variables. However, female sex and energy intake had the highest predictive values in all 3 models.

CONCLUSION

Categorization of the same food groups in different ways influences the predictive value of the SGL method. The current exploration of the SGL method shows that food might not be the most important predictor of flares in IBD.

The Durability of Anti-TNF Therapy for Crohn's Disease Is Higher in Anti-TNF Naïve Patients and Increases With Proactive Therapeutic Drug Monitoring

Background

Antitumor necrosis factor (TNF) dose escalation is performed to improve therapeutic response and optimize outcomes in patients with Crohn's disease (CD). We aimed to describe the durability of anti-TNF therapy in patients with CD receiving escalated anti-TNF therapy, along with the overall durability of anti-TNF treatment between patients managed with a proactive versus reactive therapeutic drug monitoring (TDM) approach.

Methods

We undertook a retrospective multicentre cohort study. One center practiced proactive TDM with a weekly virtual TDM clinic, while the other practiced reactive TDM. Patients receiving escalated infliximab or adalimumab therapy for CD from January 2015 to April 2022 were included. Durability was defined as the time from biologic start to cessation for treatment failure.

Results

About 239 patients (45% female, median age 39) meeting criteria for inclusion were identified. About 165 patients were included in the proactive TDM cohort and 74 in the reactive TDM cohort.Anti-TNF naïve patients had significantly higher durability of therapy when compared with the anti-TNF exposed patients for both overall durability (P = .045) and durability postescalation (P = .017). The proactive TDM cohort had significantly higher durability when compared with the reactive cohort for both overall durability (P = .001) and durability postescalation (P = .002).

Conclusions

This multicentre, retrospective cohort study illustrates the importance of dose escalation as a therapeutic strategy in IBD care. The durability of anti-TNF therapy is superior in anti-TNF naïve compared to exposed patients and can be improved further by proactive TDM to guide dose optimization.

Exploring Scopoletin's Therapeutic Efficacy in DSS-Induced Ulcerative Colitis: Insights into Inflammatory Pathways, Immune Modulation, and Microbial Dynamics

This study aimed to investigate the therapeutic potential of scopoletin in ulcerative colitis, with a primary focus on its impact on crucial inflammatory pathways and immune responses. A male mouse model of DSS-induced colitis was employed with six distinct groups: a control group, a group subjected to DSS only, three groups treated with varying scopoletin doses, and the final group treated with dexamethasone. The investigation included an assessment of the effects of scopoletin on colitis symptoms, including alterations in body weight, Disease Activity Index (DAI), and histopathological changes in colonic tissue. Furthermore, this study scrutinized the influence of scopoletin on cytokine production, PPARγ and NF-κB expression, NLRP3 inflammasome, and the composition of intestinal bacteria. Scopoletin treatment yielded noteworthy improvements in DSS-induced colitis in mice, as evidenced by reduced weight loss and colonic shortening (p < 0.05, < 0.01, respectively). It effectively diminished TNF-α, IL-1β, and IL-12 cytokine levels (p < 0.01, p < 0.05), attenuated NLRP3 inflammasome activation and the associated cytokine release (p < 0.05, p < 0.01), and modulated the immune response by elevating PPARγ expression while suppressing NF-κB pathway activation (p < 0.05, p < 0.01). Additionally, scopoletin induced alterations in the gut microbiota composition, augmenting beneficial Lactobacillus and Bifidobacteria while reducing E. coli (p < 0.05). It also enhanced tight junction proteins, signifying an improvement in the intestinal barrier integrity (p < 0.05, < 0.01). Scopoletin is a promising therapeutic agent for managing ulcerative colitis, showing benefits that extend beyond mere anti-inflammatory actions to encompass regulatory effects on gut microbiota and restoration of intestinal integrity.

Enteroscopic Balloon Dilation in Small Bowel Stricturing Crohn's Disease: Long-Term Outcomes and Risk Factors for Surgery in a Single-Center Prospective Observational Study

BACKGROUND AND AIMS

The long-term outcomes of enteroscopic balloon dilation for small bowel strictures in patients with Crohn's disease are not well understood. Although Crohn's strictures can be classified into web-like, ulcerated, and spindle-shaped strictures based on endoscopic findings, the outcomes of enteroscopic balloon dilation according to the shape of Crohn's strictures have not been analyzed. The primary outcome was to evaluate the cumulative surgery-free rate, and the secondary outcome was to evaluate the risk factor for subsequent surgery after enteroscopic balloon dilation.

METHODS

This prospective, longitudinal, observational study enrolled patients with Crohn's disease who underwent enteroscopic balloon dilation for small bowel strictures using single-balloon enteroscopy between 2015 and 2023 at Samsung Medical Center, Seoul, Korea.

RESULTS

A total of 150 consecutive patients who underwent 235 enteroscopic balloon dilations were included in this study with a mean follow-up of 42.4 ± 19.1 months. Thirty-one patients (20.7%) underwent surgery after enteroscopic balloon dilation, and the cumulative 1-, 3-, and 5-year surgery-free rates were 86.7%, 80.4%, and 76.6%, respectively. The cumulative surgery-free rates of enteroscopic balloon dilation for web-like, ulcerated, and spindle-shaped strictures were 96.3%, 91.0%, and 73.3% at 1 year, 96.3%, 84.9%, and 63.0% at 3 years, and 96.3%, 78.3%, and 63.0% at 5 years, respectively (p = 0.001). Multivariate Cox regression analysis identified spindle-shaped stricture (vs. web-like stricture: hazard ratio [HR], 13.33; 95% confidence interval [CI], 1.48-120.24, p = 0.021), ulcerated stricture (vs. web-like stricture: HR, 8.50; 95% CI, 1.05-69.03, p = 0.045), and conventional therapy only (vs. biologic therapy: HR, 2.51; 95% CI, 1.11-5.71; p = 0.028) as risk factors for surgery after enteroscopic balloon dilation. The major complication rate of enteroscopic balloon dilations was 2.7% (4/150) on per-patient analysis and 1.7% (4/235) on per-procedure analysis.

CONCLUSIONS

Enteroscopic balloon dilation for small bowel strictures in patients with Crohn's disease may be an effective and safe alternative to surgery. Enteroscopic balloon dilation for web-like strictures showed favorable outcomes and biologic therapy following enteroscopic balloon dilation may be helpful to avoid surgery.

Altered inflammatory mucosal signatures within their spatial and cellular context during active ileal Crohn's disease

Crohn's disease (CD) involves a complex intestinal microenvironment driven by chronic inflammation. While single-cell RNA sequencing has provided valuable insights into this biology, the spatial context is lost during single-cell preparation of mucosal biopsies. To deepen our understanding of the distinct inflammatory signatures of CD and overcome the limitations of single-cell RNA sequencing, we combined spatial transcriptomics of frozen CD surgical tissue sections with single-cell transcriptomics of ileal CD mucosa. Coexpressed genes and cell-cell communication from single-cell analyses and factorized genes from spatial transcriptomics revealed overlapping pathways affected in inflamed CD, like antigen presentation, phagosome activity, cell adhesion, and extracellular matrix. Within the pathways, early epithelial cells showed evidence of significant changes in gene expression and subtype composition, while spatial mapping revealed the location of the events, particularly antigen presentation from epithelial cells in the base of the crypt. Furthermore, we identified early epithelial cells as a potential mediator of the MHC class II pathway during inflammation, which we validated by spatial transcriptomics cell subtype deconvolution. Therefore, the inflammation from CD appears to change the types of interactions detectable between epithelial cells with immune and mesenchymal cells, likely promoting the conditions for more macrophage infiltration into these inflammatory microdomains.

Increasing Rate of Hospitalization for Inflammatory Bowel Disease Is an Age-Related Effect: A Canadian Population Study

INTRODUCTION

To understand trends in the risk of all-cause hospitalization for individuals with inflammatory bowel disease, we explored age, period, and cohort effects in Canada.

METHODS

Repeated cross-sectional survey data from the 2005-2014 Canadian Community Health Survey linked to the Discharge Abstract Database to capture the all-cause hospitalization within 3 years of entry into the study for eligible individuals. Random-effects 2-level models estimated fixed effects for age and random effects for time periods and birth cohorts on the risk of all-cause hospitalization within 3 years entry into the study.

RESULTS

An estimated 197,000 individuals were eligible for study inclusion. From this, an estimated 70,140 all-cause hospitalizations occurred within 3 years postentry into the study. The risk of hospitalization within 3 years increased with age and across birth cohorts, with older cohorts experiencing greater risks of hospitalization. A small temporal effect was identified for both inflammatory bowel disease groups. Within birth cohorts, the risk of hospitalization increased across ages for Crohn's disease, but in individuals with ulcerative colitis, the risk decreased across ages, except for the 2 oldest birth cohorts.

DISCUSSION

These data support the hypothesis that age effects are primarily responsible for increased risk of hospitalizations. As the prevalence of IBD continues to rise and age distribution of Canadians shifts toward an older-aged population, increasing the allocation of healthcare resources to prevent age-related risks of hospitalizations would be beneficial to reduce hospital burdens.

Preoperative Nutrition Status Predicts Hospital Length of Stay and Unplanned Reoperation Risk in Pediatric Patients With Inflammatory Bowel Disease

INTRODUCTION

Many pediatric inflammatory bowel disease (IBD) patients require surgical intervention during their lifetime. Poor nutrition status correlates with adverse surgical outcomes in the adult population. A paucity of data exists on the association of preoperative nutrition status and postoperative outcomes in the pediatric population. We sought to determine the correlation between nutrition status and perioperative outcomes following a planned operation.

METHODS

A retrospective review was conducted at a tertiary children's hospital from January 2010-December 2022 for all children ≤18 years old, with a diagnosis of IBD, undergoing elective surgery, with preoperative nutrition data. Patients were grouped into none/mild malnutrition and moderate/severe malnutrition based on BMI Z-scores or two-weight differences, and outcomes compared: postoperative complications, hospital length of stay (LOS), and unplanned reoperation. Sarcopenic measures based on cross-sectional imaging were collected.

RESULTS

Ninety-three planned surgical admissions were identified; 70 in the none/mild malnutrition group and 23 in the moderate/severe malnutrition group. There were no significant differences in post-operative complication rates (38.1 % moderate/severe vs. 22.4 % none/mild, p = 0.18). The moderate/severe malnutrition group had a longer LOS (8.6 ± 4.8 days vs. 5.7 ± 2.6 days; p = 0.01) and a higher risk of unplanned reoperation (n = 8, 34.8 % vs. n = 5, 7.1 %, p = 0.03). Psoas index was significantly higher between none/mild and moderate/severe malnutrition groups (6.5 ± 1.9 vs 4.6 ± 2.0, p = 0.01).

CONCLUSIONS

Pediatric IBD patients undergoing elective surgery with moderate/severe malnutrition are at increased risk of a longer hospital LOS and unplanned reoperation. Radiographic sarcopenic measures correlate with malnutrition status based on BMI Z-scores and warrant further investigation for predicting post-operative outcomes in this population.

LEVEL OF EVIDENCE

IV.

Quantitative Magnetic Resonance Imaging (qMRI) of the Small Bowel in Crohn's Disease: State-of-the-Art and Future Directions

Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract in which repeated episodes of acute inflammation may lead to long-term bowel damage. Cross-sectional imaging is used in conjunction with endoscopy to diagnose and monitor disease and detect complications. Magnetic resonance imaging (MRI) has demonstrable utility in evaluating inflammatory activity. However, subjective interpretation of conventional MR sequences is limited in its ability to fully phenotype the underlying histopathological processes in chronic disease. In particular, conventional MRI can be confounded by the presence of mural fibrosis and muscle hypertrophy, which can mask or sometimes mimic inflammation. Quantitative MRI (qMRI) methods provide a means to better differentiate mural inflammation from fibrosis and improve quantification of these processes. qMRI may also provide more objective measures of disease activity and enable better tailoring of treatment. Here, we review quantitative MRI methods for imaging the small bowel in CD and consider the path to their clinical translation. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

In this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Effects of aqueous extract of Waltheria indica (Sterculiaceae) leafy stems on acetic acid-induced ulcerative colitis in rats

Ulcerative colitis is one of the inflammatory bowel diseases that manifest itself by uncontrolled inflammation of colon. The objective of this work was to evaluate the effects of aqueous extract of Waltheria indica on acetic acid-induced ulcerative colitis in rats. Six (6) groups of five (5) rats each, were anesthetized with a ketamine (50 mg/kg)/valium (10 mg/kg) mixture after eighteen (18) fasting hours. Colitis was induced by intrarectal administration of 1 mL of acetic acid (5%) in animals. Five (5) hours later, the normal control (NC) and the colitis control (CC) received distilled water (10 mL/kg bw), the positive control (Pre5) received prednisolone (5 mg/kg) and the other three test groups received the W. indica extract at 50 (Wi50), 100 (Wi100) and 200 (Wi200) mg/kg bw, orally for 7 days. At the end of the treatment, the animals were sacrificed and the blood was collected from the carotid artery, part in the ethylenediaminetetraacetate (EDTA) tube for hematological analyzes and part in dry tubes for biochemical assays. The abdomen was then opened, the colon, liver, spleen, lungs and heart were removed, drained, weighed and the indexes of each organ were determined. The extract at 200 mg/kg reduced myeloperoxidase (MPO) and inhibited the production of interleukin-1 beta (IL-1β) and interleukin-6(IL-6) in the colon and serum. The extract significantly increased the blood platelet level of the colitis rats. Thus, these results suggest that Walthera indica extract may have therapeutic potential for the treatment of inflammatory bowel diseases.

Exhaustion profile on classical monocytes after LPS stimulation on Crohn's disease patients

Crohn's disease is a type of inflammatory bowel disease that leads to symptoms such as diarrhea, abdominal pain, weight loss, and increased risk of developing tumors. The immune system plays a vital role in the gastrointestinal tract by maintaining tolerance to commensal antigens and food. However, in Crohn's disease, this tolerance mechanism is disrupted, resulting in chronic inflammatory responses. The involvement of the immune system is central to Crohn's disease, with a wide range of immune cells including monocytes, being affected. Due to the limited understanding of the role of monocytes in Crohn's disease, our study aimed to clarify the cytokine production and activation profile of monocytes subsets in the context of this condition. We used multiparametric flow cytometry to analyze the status of monocyte, quantified gene expression using qPCR, and created a correlation matrix to connect the flow cytometry data with the qPCR results through a bioinformatics approach. Our findings indicate that patients with Crohn's disease show a reduction in all monocyte subsets. Additionally, classical monocytes exhibit an exhaustion profile characterized by increased CD38 expression and reduced IL-1β production following LPS stimulation in patient groups. These results suggest that monocyte subsets play distinct roles in the disease's pathophysiology of Crohn's disease, potentially contributing to chronic inflammation and impairing the resolution of the immune response.

Association between nutrient intake and inflammatory bowel disease risk: Insights from NHANES data and dose-response analysis

BACKGROUND

The role of dietary and nutritional factors in inflammatory bowel disease (IBD) remains poorly understood, necessitating further investigation. This study aims to explore the association between nutrient intake and the risk of IBD.

METHODS

This cross-sectional study utilized data from the 2009-2010 NHANES cycle, focusing on individuals with complete 24-hour dietary intake records and clinically assessed IBD information. Nutrient intake was assessed through dietary recalls and supplement data. Associations between nutrient intake and IBD risk were analyzed by propensity score matching (PSM) with balanced baseline characteristics and logistic regression. Dose-response relationships were examined by restricted cubic splines (RCS). Statistical significance was set at P < 0.05, and analyses were conducted using R software.

RESULTS

The study included 4,072 participants with clinically assessed IBD and complete nutrient intake data. In adjusted analyses, lower intake of vitamin B3, copper, phosphorus, selenium, sodium, and protein below the recommended dietary allowance may increase the risk of developing IBD. Similarly, reduced intake of vitamin B6, vitamin E, and total PUFA is associated with elevated susceptibility to IBD.

CONCLUSION

This study elucidates the intricate relationship between nutrient intake and the onset of IBD, underscoring the importance of maintaining a balanced diet for gastrointestinal health. These findings emphasize the significance of informed dietary choices in promoting intestinal wellness and potentially reducing the risk of IBD development.

Laboratory Tests in Inflammatory Bowel Disease: An Evidence-Based Approach to Daily Practice

Inflammatory bowel diseases (IBDs) comprise a group of chronic gastrointestinal disorders characterized by periods of relapse and remission. The mainstay of treatment is medical, involving medications such as steroids, immune modulators, monoclonal antibodies (categorized as biologics), and small molecules. These medications can provide profound therapeutic benefits, but they can also cause severe and irreversible toxicities. Clinicians may utilize laboratory tests in the diagnosis and management of IBD including assessment of disease activity, monitoring medication response or toxicity, surveillance of infectious complications, and detection of nutritional deficiencies. Routine use of laboratory tests may help clinicians avoid reactivation of life-threatening infections such as tuberculosis or hepatitis B virus upon initiation of immune suppressive therapy. They can also be used to detect vitamin deficiencies such as B12 deficiency, which has the potential to cause irreversible neurologic damage. While some laboratory tests constitute established practices, the utility of newer tests such therapeutic drug monitoring (TDM) in the era of biologics is an evolving topic. Although clinical assessment with imaging, endoscopic, and histopathological examination is standard practice, laboratory tests serve as valuable adjuncts. We aim to explore the broad range of laboratory tests available to clinicians and to summarize their application in the current management of IBD in daily clinical practice, with special attention to updates in therapeutic drug monitoring.

Classification and identification of risk factors for type 2 diabetes

The risk factors for type 2 diabetes mellitus (T2DM) have been increasingly researched, but the lack of systematic identification and categorization makes it difficult for clinicians to quickly and accurately access and understand all the risk factors, which are categorized in this paper into five categories: Social determinants, lifestyle, checkable/testable risk factors, history of illness and medication, and other factors, which are discussed in a narrative review. Meanwhile, this paper points out the problems of the current research, helps to improve the systematic categorisation and practicality of T2DM risk factors, and provides a professional research basis for clinical practice and industry decision-making.

Integrated Macrogenomics and Metabolomics Analysis of the Effect of Sea Cucumber Ovum Hydrolysates on Dextran Sodium Sulfate-Induced Colitis

Inflammatory bowel disease remains a significant challenge in clinical settings. This study investigated the therapeutic potential of sea cucumber ovum hydrolysates (SCH) in a dextran sulfate sodium (DSS)-induced colitis mouse model. SCH, defined by its elevated stability and solubility, with a molecular weight below 1000 Da, significantly alleviated DSS-induced colitis, as evidenced by enhanced splenic index, reduced colonic damage, and diminished serum pro-inflammatory cytokines. Furthermore, macrogenomic analysis demonstrated that SCH increased beneficial gut microbes and decreased pro-inflammatory bacteria. Furthermore, metabolomic analysis of colonic tissues identified elevated levels of anti-inflammatory metabolites, such as Phenyllactate, 2-Hydroxyglutarate, and L-Aspartic acid, in colitis mice after oral administration of SCH. In conclusion, SCH represents a promising candidate for the treatment of colitis.

Antibiotic usage within the first year of life has a protective effect against ulcerative colitis in South Korea: A nationwide cohort study

BACKGROUND

Antibiotic usage in early life has been proposed as a risk factor for inflammatory bowel disease, especially Crohn's disease. However, most studies were conducted in Western countries.

AIMS

We evaluated the association between antibiotic usage and the incidence of inflammatory bowel disease in the Asian population.

METHODS

This nationwide population-based retrospective cohort study included 2,941,889 South Korean infants born between 2007 and 2015, using the National Health Insurance Service database. We assessed whether antibiotic use was associated with the incidence of inflammatory bowel disease. Additionally, we conducted sensitivity analyses, considering protopathic bias and dietary variables. The Cox proportional hazards model was used.

RESULTS

Among 2,941,889 infants, 2,566,390 (87 %) used antibiotics within a year after birth. Antibiotic usage within a year, number of antibiotic classes, and cumulative days of usage were shown to decrease the risk of ulcerative colitis. This association was particularly prominent with earlier antibiotic exposure. Penicillin was the only antibiotic class related to the reduced risk. The results were robust after adjusting for dietary variables and considering protopathic effect.

CONCLUSIONS

Antibiotic exposure during the first year of life, particularly at a younger age, is linked to a reduced risk of early-onset ulcerative colitis in South Korea.

cGAS-STING DNA-sensing in inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic, incurable pathologies with unknown causes, affecting millions of people. Pediatric-onset IBD, starting before the age of 18 years, are increasing, with more aggressive and extensive features than adult-onset IBD. These differences remain largely unexplained. Intestinal mucosal damage, cell death, DNA release from nuclear, mitochondrial, or microbiota sources, and DNA-sensing activating the cGAS-STING pathway may contribute to disease evolution. Increased colonic cGAS and STING are increasingly reported in experimental and human IBD. However, limited knowledge of the mechanisms involved hinders the development of new therapeutic options. Here, we discuss recent advances and unresolved questions regarding DNA release, DNA sensor activation, and the role and therapeutic potential of the cGAS-STING pathway in inflammatory colitis.

Multidrug resistance Gene-1 polymorphisms (C3435T and G2677T) and the risk of inflammatory bowel disease in Egyptian patients

BACKGROUND AND STUDY AIMS

The multidrug resistance 1 (MDR1) gene is a gene involved in the pathogenesis of inflammatory bowel disease (IBD).The aim of the study is to investigate the association of MDR-1 gene polymorphisms (C2345T and G2677T) and IBD incidence in Egyptian patients, and its relation with disease severity.

PATIENTS AND METHODS

This is a case-control study where genotyping of MDR-1 gene C3435T and G2677T single nucleotide polymorphisms (SNPs) were assayed.

RESULTS

Forty naïve IBD patients, who were composed of 25 UC and 15CD, were compared to 60 healthy controls. They were young aged with significant female predominance, particularly in CD (P = 0.004). UC was mainly (48 %) presented in moderate severity while CD was mainly (53.3 %) presented with mild severity. MDR-1 gene C3435T SNP was not statistically related to IBD, whether in terms of genotypes or alleles, yet its T allele was significantly related to moderate cases of UC (P = 0.014). However, GG genotype of G2677T SNP was significantly low in IBD (P = 0.013), while TT genotype and T allele were significantly related to CD (P = 0.011, and 0.012 respectively). Moreover, G allele proved to be associated significantly with moderate cases of UC (P = 0.001) and mild cases of CD (P = 0.002).

CONCLUSIONS

MDR-I gene G2677T SNP GG genotype proved to be protective against IBD, thus may be considered in diagnostic workup of IBD including its severity.

Epidemiology and temporal trends of adult inflammatory bowel disease in Taiwan: Multicenter study from the TSIBD registration

BACKGROUND

Despite industrialization and advances in healthcare, the prevalence of inflammatory bowel disease (IBD), which encompasses Crohn's disease (CD) and ulcerative colitis (UC), is increasing in Taiwan. Population-based studies can estimate the incidence or prevalence of IBD; however, there is a lack of information regarding the disease phenotype. Therefore, this study was designed to investigate the epidemiologic trends of IBD in Taiwan to gain a more comprehensive understanding.

METHODS

Patient data were reviewed from a prospectively registered study by the Taiwan Society of IBD (TSIBD).

RESULTS

We collected data from 2752 patients with IBD, of whom 881 had CD and 1871 had UC. Their average age was 41.99 ± 15.19 years. The CD group had more male patients than the UC group (67.88% vs. 60.72%; p < .001). The rates of appendectomy, bowel resection, and surgery for perianal disease before IBD diagnosis, along with the increased use of steroids, immunomodulators, and biologics, were higher in the CD group. From 2005 to 2023, the ratio of UC to CD cases in Taiwan decreased, the proportions of patients with colonic and penetrating CD also declined, and the proportion of patients with UC exhibiting ulcerative proctitis increased.

CONCLUSION

In Taiwan, similar to high-income countries, the ratio of UC to CD cases has declined. The reduced of colonic and penetrating CD indicates that diagnostic awareness has improved and colonoscopic examination has become more comprehensive in Taiwan.

Risk factors for inflammatory bowel disease: an umbrella review

Introduction

Inflammatory bowel disease (IBD) represents a cluster of chronic idiopathic inflammatory disorders situated at the nexus of intricate interplays. The primary aim of the present investigation is to perform an umbrella review of metaanalyses, systematically offering a comprehensive overview of the evidence concerning risk factors for IBD.

Methods

To achieve this, we searched reputable databases, including PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews, from inception through April 2023. Two authors independently assessed the methodological quality of each metaanalysis using the AMSTAR tool and adhered to evidence classification criteria.

Results

In total, we extracted 191 unique risk factors in meta-analyses, including 92 significantly associated risk factors. The top ten risk factors were human cytomegalovirus (HCMV) infection, IBD family history, periodontal disease, poliomyelitis, campylobacter species infection, hidradenitis suppurativa, psoriasis, use of proton pump inhibitors, chronic obstructive pulmonary disease, and western dietary pattern.

Discussion

In conclusion, this umbrella review extracted 62 risk factors and 30 protective factors, most of which were related to underlying diseases, personal lifestyle and environmental factors. The findings in this paper help to develop better prevention and treatment measures to reduce the incidence of IBD, delay its progression, and reduce the burden of IBD-related disease worldwide.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023417175.

Therapeutic Agents and Patient Characteristics Affecting Metabolism of Thiopurines in Patients with Inflammatory Bowel Disease

OBJECTIVES

In inflammatory bowel disease therapy, thiopurines have been essential.　However, several reports have investigated factors affecting thiopurine metabolism to date.　This study investigated factors affecting intracellular concentrations of 6-thioguanine nucleotide (6-TGN) and 6-methylmercaptopurine (6-MMP) in a real-world setting.

METHODS

Between May 2013 and October 2021 in one institution, 44 patients (median age 44 years;male 35, female 9;ulcerative colitis 32, Crohn's disease 12) receiving thiopurines were reviewed.　Intracellular 6-TGN/6-MMP concentrations were measured by high-performance liquid chromatography, and the initial measurement in each patient was used for the study.

RESULTS

The 6-TGN level was significantly higher in females, with mild disease activity, absence of NUDT15 polymorphism, and allopurinol administration.　A higher trend was observed with high thiopurine dosage (>50 mg).　6-MMP levels were significantly lower with concomitant use of time-dependent 5-aminosalicylic acid (5-ASA) and allopurinol, and higher with high thiopurine dosage.　On multivariate analysis of variance, logarithmically transformed 6-TGN levels were significantly higher in females, with high thiopurine dosage, and allopurinol administration.　Similarly, logarithmically transformed 6-MMP levels were significantly higher with time-dependent 5-ASA administration and high thiopurine dosage.

CONCLUSIONS

Patients who received allopurinol, a high dose of thiopurine, or were female showed higher 6-TGN levels.

Simultaneous Detection of Hydrogen Sulfide and Peroxynitrite Dysregulation with a Sequentially Activated Fluorescent Probe in Ulcerative Colitis Disease

Ulcerative colitis (UC), often referred to as "green cancer", is a chronic inflammatory bowel disease with an unclear etiology, closely associated with the imbalance of hydrogen sulfide (H2S) and peroxynitrite (ONOO-). H2S exhibits anti-inflammatory effects at physiological levels, but excessive concentrations can compromise the intestinal barrier, while ONOO- aggravates inflammation. To facilitate the molecular-level monitoring of these compounds in UC, we developed a novel fluorescent probe, BCH, capable of simultaneously detecting H2S and ONOO- via distinct fluorescent channels in a cascade mode. BCH features rapid response times (H2S: 6 min; ONOO-: 5 min) with well-separated emission peaks (120 nm), minimizing spectral overlap. The probe demonstrates high selectivity and good detection linearity for H2S (0-500 μM) and ONOO- (0-100 μM), with detection limits of 1.6 μM for H2S and 0.05 μM for ONOO-. BCH has been successfully applied for imaging H2S and ONOO- in living cells and zebrafish, enabling the sensitive detection of their fluctuations in a UC mouse model. These findings indicate that BCH is highly promising for studying the roles of H2S and ONOO- in UC and assessing their biological functions.

Impact of biologics on stoma creation and reversal in Crohn's disease: a retrospective analysis from 2007 to 2021

BACKGROUND

Trends of stoma creation at index surgery for Crohn's disease (CD) in the biologics era has not been thoroughly investigated. This study aimed to assess the impact of increasing biologics use on stoma rates at index surgery of CD, as well as identifying risk factors for the creation and nonreversal of CD-related stoma.

METHODS

In this single-center retrospective analysis, consecutive CD patients who underwent index bowel surgery from 2007 to 2021 were reviewed. The rates of diverting stoma formation and reversal were compared across different time periods, delineated by January 2019, as biologics [anti-tumor necrosis factor (anti-TNF)] were included in national health insurance coverage in China. Logistic regression models and Cox proportional hazards models were utilized to assess factors influencing stoma creation and its reversal, respectively.

RESULTS

Among 1022 CD patients, 27.9% received a diverting stoma during index surgery. Despite increasing preoperative use of biologics, the incidence of stoma creation remained statistically unchanged pre- and post-2019 (29.5% versus 25.2%; P = 0.14). Factors contributing to stoma creation included colonic and perianal involvement, penetrating CD, poorer preoperative conditions, and preoperative steroid usage, but not preoperative biologics. Among diverted patients, 68.8% underwent successful bowel restoration, with the reversal rate significantly increasing from 63.0% before 2019 to 80.2% after 2019 (P < 0.01). Patients with postoperative use of immunomodulators and biologics were more likely to have the stoma closed, with a reversal rate of 90.0% for those receiving biologics compared with 64.0% for those not.

CONCLUSIONS

Increasing prevalence of biologics did not alter the stoma rates in CD patients. Additionally, postoperative biologics were independently associated with a higher probability of stoma reversal.

Resolving Resident Colonic Muscularis Macrophage Diversity and Plasticity During Colitis

BACKGROUND

Immune cell populations in the intestinal muscularis propria during colitis are poorly resolved. Maintaining homeostasis in this niche is critical, highlighted by the poorer prognosis of inflammatory bowel disease associated with muscularis propria inflammation.

METHODS

This study utilizes single-cell RNA sequencing to survey the immune cell populations within the muscularis propria of normal colon and dextran sodium sulfate-induced colitis. Findings are validated by immunohistochemistry, flow cytometry and cell-lineage tracing in vivo, and in vitro assays with muscularis macrophages (MMφ).

RESULTS

In naïve conditions, transcriptional duality is observed in MMφs with 2 major subpopulations: conventional resident Cx3cr1+ MMφs and Lyve1+ MMφs. The Lyve1+ population is phagocytic and expresses several known MMφ markers in mouse and human, confirming their identity as a bona fide MMφ subset. Single-cell transcriptomics indicate that resident MMφs are retained during colitis and exhibit plasticity toward an inflammatory profile. Lyve1+ MMφs, which express anti-inflammatory marker CD163, are absent during colitis, as confirmed by flow cytometry. In contrast, lineage tracing finds that resident Cx3cr1+ MMφs remain during colitis and are not completely replaced by the inflammatory infiltrating monocytes. In vitro studies provide biological evidence of the plasticity of resident Cx3cr1+ MMφs in response to lipopolysaccharide (LPS), mirroring transcriptional observations in vivo of their inflammatory plasticity. Potential markers for colitic MMφs, validated in animal models and in individuals with ulcerative colitis, are identified.

CONCLUSIONS

Our findings contribute to the understanding of the immune system in the muscularis propria niche during colitis by resolving the heterogeneity and origins of colitic MMφs.

Estrogen Receptor β Activation Mitigates Colitis-associated Intestinal Fibrosis via Inhibition of TGF-β/Smad and TLR4/MyD88/NF-κB Signaling Pathways

BACKGROUND

Intestinal fibrosis, a complex complication of colitis, is characterized by excessive extracellular matrix (ECM) deposition. Estrogen receptor (ER) β may play a role in regulating this process.

METHODS

Intestinal tissue samples from stenotic and nonstenotic regions were collected from Crohn's disease (CD) patients. RNA sequencing was conducted on a mouse model to identify differentially expressed mRNAs. Histological, immunohistochemical, and semiquantitative Western blotting analyses were employed to assess ECM deposition and fibrosis. The roles of relevant pathways in fibroblast transdifferentiation, activity, and migration were examined.

RESULTS

Estrogen receptor β expression was found to be downregulated in the stenotic intestinal tissue of CD patients. Histological fibrosis score, collagen deposition, and profibrotic molecules in the colon of an intestinal fibrosis mouse model were significantly decreased after activation of ERβ. In vitro, ERβ activation alleviated transforming growth factor (TGF)-β-induced fibroblast activation and migration, as evidenced by the inhibition of col1α1, fibronectin, α-smooth muscle actin (α-SMA), collagen I, and N-cadherin expression. RNA sequencing showed that ERβ activation affected the expression of genes involved in ECM homeostasis and tissue remodeling. Enrichment analysis of differentially expressed genes highlighted that the downregulated genes were enriched in ECM-receptor interaction, TGF-β signaling, and Toll-like receptor (TLR) signaling. Western blotting confirmed the involvement of TGF-β/Smad and TLR4/MyD88/NF-κB signaling pathways in modulating fibrosis both in vivo and in vitro. The promoter activity of TGF-β1 and TLR4 could be suppressed by ERβ transcription factor.

CONCLUSION

Estrogen receptor β may regulate intestinal fibrosis through modulation of the TGF-β/Smad and TLR4/MyD88/NF-κB signaling pathways. Targeting ERβ activation could be a promising therapeutic strategy for treating intestinal fibrosis.

Disease burden of patients with moderate to severe ulcerative colitis: A French multicenter real-life study (THEFAR)

BACKGROUND

Specific studies on the impact of ulcerative colitis (UC) and bowel urgency (BU) on disability and quality of life (QoL) of patients on advanced therapies are missing.

METHODS

Clinical and therapeutic management data were collected by Gastroenterologists from adult patients with UC treated with advanced therapies. Patients reported outcomes on QoL were collected using patient-reported questionnaires.

RESULTS

Forty-one sites enrolled 293 patients. Median age was 42.0 years, median disease duration was 6.0 years. 38.9 % had active disease (partial Mayo score>1). Median treatment duration was 16.9 months. 166 (57.0 %) patients had BU [median UNRS=2] and 78.3 % had fecal incontinence [median Wexner score=8.0]. Moderate to severe disability (IBD-Disk score≥40) was reported in 37.8 % patients. BU patients had a higher Wexner score [10.0 vs 5.2, p < 0.0001] and moderate to severe disability rate (53.7% vs 16.9 %, p < 0.0001), lower QoL and work productivity than those in BU remission: mean EQ-5D-5 L utility [0.846 vs 0.943, p < 0.0001], VAS for self-rated health [66.2 vs 82.1, p < 0.0001], and overall work impairment [35.7% vs 11.3 %, p < 0.0001].

CONCLUSION

The burden of moderate to severe UC, especially in patients with BU, is high. These findings highlight that BU control remains an unmet medical need in UC patients and underscore the need for new innovative treatments.

Capsule Endoscopy in Inflammatory Bowel Disease: Evolving Role and Recent Advances

Capsule endoscopy has been proven as an efficient and accurate tool in the diagnosing and monitoring patients with inflammatory bowel disease, especially Crohn's disease (CD). The current European Crohn's and Colitis Organization guidelines recommend small bowel disease assessment in newly diagnosed CD, wherein small bowel capsule endoscopy (SBCE) is of prime importance. SBCE plays an essential role in assessing mucosal healing in patients with CD, serving as a monitoring tool in a treat to target strategy, and is capable of identifying high-risk patients for future flares.

Early subclinical stages of the inflammatory bowel diseases: insights from human and animal studies

The inflammatory bowel diseases (IBD) occur in genetically susceptible individuals that mount inappropriate immune responses to their microbiota leading to chronic intestinal inflammation. The natural history of IBD progression begins with early subclinical stages of disease that occur before clinical diagnosis. Improved understanding of those early subclinical stages could lead to new or improved strategies for IBD diagnosis, prognostication, or prevention. Here, we review our current understanding of the early subclinical stages of IBD in humans including studies from first-degree relatives of patients with IBD and members of the general population who go on to develop IBD. We also discuss representative mouse models of IBD that can be used to investigate disease dynamics and host-microbiota relationships during these early stages. In particular, we underscore how mouse models of IBD that develop disease later in life with variable penetrance may present valuable opportunities to discern early subclinical mechanisms of disease before histological inflammation and other severe symptoms become apparent.

Characterization of Inflammatory Bowel Disease in the Elderly According to Age of Onset

Background/Objectives: Elderly populations are under-represented in inflammatory bowel disease (IBD) clinical trials, with limited data on phenotype, treatment patterns, outcomes, and comorbidities. The main objective of this study was to evaluate, in an elderly cohort with IBD, demographic and disease characteristics, comorbidity, polypharmacy, and treatment patterns according to the development of IBD at or before old age. Secondarily, the same analysis was performed based on the type of IBD: ulcerative colitis (UC) or Crohn's disease (CD). Materials and Methods: Observational, single-center, retrospective study including patients diagnosed with IBD and aged 65 years or older seen at the IBD office of the Regional University Hospital of Malaga between September and November 2022. Data were recorded on demographic, disease-related, and IBD treatment-related variables, comorbidities, and polypharmacy. A descriptive and analytical study was undertaken according to the age of IBD onset and type of IBD. Results: Of the patients included, 50.8% were male, 55.1% had CD, and 44.9% UC. IBD onset was before age 65 years in 69.5% and ≥65 years in 30.5%. Elderly with IBD who debuted <65 presented longer disease duration (19.67 ± 9.82 years) and required more IBD-related surgeries (37.8%); elderly with IBD who debuted ≥65 were older (77.69 ± 6.26 years), with no differences in the other variables. According to the type of IBD, elderly UC patients were older (74.55 ± 6.9 years), used more aminosalicylates (77.4%), and had higher rates of polypharmacy (90.6%). Elderly patients with CD had higher IBD activity (moderate/severe in 72.3%), used more biologic drugs (58.5%), and required more IBD-related surgeries (44.6%). Conclusions: Elderly patients who develop IBD before or after the age of 65 years are overall very similar in baseline and disease-related characteristics. Elderly with CD have higher IBD activity and require more biologic drugs and IBD-related surgeries. Elderly with UC are older and have higher rates of polypharmacy and aminosalicylate use.

Patient Preferences for Treatment Attributes in Inflammatory Bowel Disease: Results From a Large Survey Across Seven European Countries Using a Discrete Choice Experiment

BACKGROUND

Inflammatory bowel disease requires long-term treatment; therefore, understanding patient preferences is important in aiding informed treatment decision making. This study explored patients' preferences for treatment attributes of available inflammatory bowel disease therapies.

METHODS

Adult patients from 7 European countries who self-reported previous/current treatment for Crohn's disease (CD) or ulcerative colitis (UC) participated in an online survey via the Carenity platform. In a discrete choice experiment, the relative importance of treatment attributes for CD and UC was estimated using conditional logit models. Latent class analysis was conducted to estimate heterogeneous treatment preferences based on patient profiles. Patients' perspectives and preferences regarding their quality of life were assessed.

RESULTS

Across 686 completed survey responses (CD, n = 360; UC, n = 326), the mean patient age was 48 and 50 years, respectively. Patients with CD ranked route of administration as the most important attribute (attribute importance: 32%), preferring subcutaneous over intravenous treatment (P < .001). Patients with UC ranked route of administration and frequency of serious adverse events as the most important attributes (attribute importance: 31% and 23%, respectively), preferring oral (P < .001) and subcutaneous (P < .001) over intravenous treatment and treatment that minimized the risk of serious adverse events (P < .001) or mild adverse events (P < .01). Latent class analyses confirmed the impact of patients' sociodemographic profile on their preferences. All patients prioritized general well-being, energy level, and daily activities as the most important aspects for improvement through treatment.

CONCLUSIONS

Patient preferences for treatment attributes varied among patients with CD or UC, highlighting the importance of personalized care and shared decision making to maximize treatment benefits.

Immuno-therapeutic and prophylactic potential of Trichinella spiralis antigens for inflammatory bowel diseases

Ulcerative colitis (UC), a severe chronic inflammatory disorder of the colon, is one of the inflammatory bowel diseases (IBD) that affects humans and several domestic animal species, including cats and dogs. Helminth infections and autoimmune diseases are inversely correlated, as explained by the hygiene hypothesis, which suggests that IBD is infrequent in countries where helminth infections are common but more prevalent in developed nations. This study investigated the therapeutic and prophylactic potential of Trichinella spiralis (T. spiralis) antigens in an experimental colitis model for IBD. Mice were divided into eight groups: normal model, colitis model, larval antigen prophylaxis, adult antigen prophylaxis, larval antigen therapeutic, adult antigen therapeutic, larval antigen prophylaxis and therapeutic, and adult antigen prophylaxis and therapeutic. Colitis was induced intrarectally by administering a single dose of 0.2 ml of acetic acid, except in the healthy group, which received PBS (0.2 ml). The mice were euthanized 12 days after colitis induction. The therapeutic and prophylactic potential of T. spiralis antigens were assessed through colitis severity and histopathological, immunological, and immunohistochemical examinations. The results showed a significant reduction in Disease Activity Index (DAI), an increase in goblet cells' acidic mucin levels, reduced iNOS and TNF-α expression, and decreased serum levels of IFN-γ and IL-10 cytokines in Groups IV-VIII compared to the colitis model, particularly in the group that received adult worm antigen both prophylactically and therapeutically. This study demonstrated that T. spiralis antigens, especially from adult worms, had protective and therapeutic effects on experimental colitis, with a superior effect when administered both before and after colitis induction by reducing inflammation and modulating the immune response. Thus, T. spiralis antigens may improve disease outcomes and provide a novel treatment approach for ulcerative colitis.

Relationship Between Quality of Life, Perceived Stress, and Disease Characteristics in Patients With Ulcerative Colitis in Al-Madinah

Background Ulcerative colitis (UC) is a common chronic disease. Perceived stress is one of the risk factors that stimulate UC activity. Long-term clinical suffering negatively alters the health-related quality of life (HRQOL). Aim This study aimed to investigate the relationship between HRQOL, perceived stress, and disease characteristics in patients with UC in Al-Madinah. Methodology Between June 2024 and September 2024, a cross-sectional study was conducted on 122 participants. The test group included 61 UC patients who visited the gastroenterology department of King Fahd Hospital, Al Madinah, Kingdom of Saudi Arabia (KSA). Sixty-one healthy volunteers served as controls. Data were collected from the participants through an anonymous questionnaire after their consent. The questionnaire included demographic data, a 10-item Perceived Stress Scale (PSS), a 36-item Short Form (SF-36) Survey, and UC clinical status data from the UC patients. Results The mean score of PSS was significantly greater in UC patients (19.23±5.28) than in the control group (11.21±6.644), p < 0.001. Patients with UC suffer significantly (p < 0.05) lower health-related quality of life than the control group. Ulcerative colitis patients experienced the lowest scores in the energy/fatigue (56.15±29.15) and emotional well-being domains (66.69±29.26). Sex standardized (β) (-0.308) and time since diagnosis β (0.336) were good predictors (p < 0.05) of physical functioning. Time since diagnosis β (0.401) and partial Mayo score (p Mayo) score β (-0.353) were good predictors (p < 0.05) of role limitations due to physical health. Time since diagnosis β (0.349) was a good predictor (p < 0.05) of role limitations due to emotional health. For social functioning, sex β (-0.348), smoking β (-0.314), time since diagnosis β (0.421), and extraintestinal manifestations β (-0.260) were good predictors (p < 0.05). Extraintestinal manifestations β (-0.386) were good predictors (p < 0.05) of pain. Time since diagnosis β (0.325) and p Mayo score β (-0.278) were good predictors (p < 0.05) of general health. Conclusion Patients with US had lower PSS and HRQOL domains than healthy individuals. Patients with UC experienced the lowest scores in the energy/fatigue and emotional well-being domains. Time since diagnosis, p Mayo score, extraintestinal manifestations, sex, and smoking were good predictors of many domains. This confirms the solidarity of psychological care with medical treatment in those patients.

Exploring Pyroptosis-related Signature Genes and Potential Drugs in Ulcerative Colitis by Transcriptome Data and Animal Experimental Validation

Ulcerative colitis (UC) is an idiopathic, relapsing inflammatory disorder of the colonic mucosa. Pyroptosis contributes significantly to UC. However, the molecular mechanisms of UC remain unexplained. Herein, using transcriptome data and animal experimental validation, we sought to explore pyroptosis-related molecular mechanisms, signature genes, and potential drugs in UC. Gene profiles (GSE48959, GSE59071, GSE53306, and GSE94648) were selected from the Gene Expression Omnibus (GEO) database, which contained samples derived from patients with active and inactive UC, as well as health controls. Gene Set Enrichment Analysis (GSEA), Weighted Gene Co-expression Network Analysis (WGCNA) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed on microarrays to unravel the association between UC and pyroptosis. Then, differential expressed genes (DEGs) and pyroptosis-related DEGs were obtained by differential expression analyses and the public database. Subsequently, pyroptosis-related DEGs and their association with the immune infiltration landscape were analyzed using the CIBERSORT method. Besides, potential signature genes were selected by machine learning (ML) algorithms, and then validated by testing datasets which included samples of colonic mucosal tissue and peripheral blood. More importantly, the potential drug was screened based on this. And these signature genes and the drug effect were finally observed in the animal experiment. GSEA and KEGG enrichment analyses on key module genes derived from WGCNA revealed a close association between UC and pyroptosis. Then, a total of 20 pyroptosis-related DEGs of UC and 27 pyroptosis-related DEGs of active UC were screened. Next, 6 candidate genes (ZBP1, AIM2, IL1β, CASP1, TLR4, CASP11) in UC and 2 candidate genes (TLR4, CASP11) in active UC were respectively identified using the binary logistic regression (BLR), least absolute shrinkage and selection operator (LASSO), random forest (RF) analysis and artificial neural network (ANN), and these genes also showed high diagnostic specificity for UC in testing sets. Specially, TLR4 was elevated in UC and further elevated in active UC. The results of the drug screen revealed that six compounds (quercetin, cyclosporine, resveratrol, cisplatin, paclitaxel, rosiglitazone) could target TLR4, among which the effect of quercetin on intestinal pathology, pyroptosis and the expression of TLR4 in UC and active UC was further determined by the murine model. These findings demonstrated that pyroptosis may promote UC, and especially contributes to the activation of UC. Pyroptosis-related DEGs offer new ideas for the diagnosis of UC. Besides, quercetin was verified as an effective treatment for pyroptosis and intestinal inflammation. This study might enhance our comprehension on the pathogenic mechanism and diagnosis of UC and offer a treatment option for UC.

Mechanism of Resveratrol on LPS/ATP-induced pyroptosis and inflammatory response in HT29 cells

Pyroptosis plays an important role in maintenance of intestinal homeostasis, the abnormal activation of NOD-like receptor thermal protein domain-associated protein 3 (NLRP3) inflammasome can promote the event and development of ulcerative colitis (UC). Its protective effects such as inhibiting pyroptosis in various inflammation-related diseases have been demonstrated, but whether resveratrol (RES) can also alleviate the progression of the disease by inhibiting pyroptosis in UC and the mechanism have rarely been studied. In this study, lipopolysaccharide (LPS) combined with adenosine triphosphate (ATP) was used to induce HT29 human colon cancer cells to construct an intestinal epithelial cell pyroptosis and inflammation model in vitro to investigate the anti-inflammatory effect of RES, reveal the regulatory mechanism of RES on pyroptosis, and provide a new theoretical basis for the treatment of UC. In vitro experiences, HT29 cells were dividing into control group, LPS/ATP group, RES low-dose group, RES high-dose group, NF-κB inhibitor pyrrolidine dithiocarbamate group (PDTC group), and LPS/ATP+PDTC group. The mRNA expressions of pyroptosis-related indicators such as NLRP3, apoptosis-associated speck-like protein containing CARD (ASC), Caspase-1(CASP1), IL-18, IL-1β, and inflammatory factors such as TNF-α and IL-6 were detected by qRT-PCR. The protein expressions of pyroptosis-related indicators NLRP3, ASC, CASP1, IL-18, IL-1β, NF-κB-p65 in the nucleus, and IκBα and p-IκBα in the cytoplasm were detected by Western blot. Immunofluorescence saw the distribution and expression of NLRP3, ASC and NF-κB-p65 protein in each group. The morphology and degree of pyroptosis in each group were observed by transmission electron microscope. The results showed that compared with the control group, the pyroptosis-related proteins including NLRP3, ASC, CASP1, IL-18, IL-1β, and inflammatory factors including TNF-α and IL-6 in the LPS/ATP group were increased, and LPS/ATP activated the activity of NF-κB signaling pathway. Compared with the LPS/ATP group, RES downregulated the expression of pyroptosis-related proteins and inflammatory factors in HT29 cells, and inhibited the activation of the NF-κB signaling pathway in HT29 cells pyroptosis. RES down-regulates the pyroptosis of HT29 cells induced by LPS/ATP and the expression of pyroptosis-related indicators NLRP3, ASC, CASP1, IL-18, IL-1β and inflammatory factors TNF-α and IL-6 in the inflammatory response and inhibits the occurrence of pyroptosis. The mechanism is related to the inhibition of NF-κB pathway activity.

Advanced Techniques in Therapeutic and Inflammatory Bowel Disease Colonoscopy

Colonoscopy is an essential diagnostic and therapeutic tool in the management of colorectal disease. This review explores the recent advances of colonoscopy that have revolutionized patient care in the era of minimally invasive medicine. Key areas of focus include innovations in imaging, advanced endoscopic resection techniques, and nonsurgical management of strictures. Advances in therapeutic endoscopy are especially evident in inflammatory bowel disease. As the landscape of colonoscopy continues to evolve, it will continue to play a central role in modern medicine, shaping the future of patient care, and therapeutic interventions.

Model-Based Dose Selection of a Sphingosine-1-Phosphate Modulator, Etrasimod, in Patients with Various Degrees of Hepatic Impairment

BACKGROUND/OBJECTIVES

Etrasimod is a newly FDA-approved Sphingosine-1-Phosphate modulator indicated for moderate and severe ulcerative colitis. It is extensively metabolized in the liver via the cytochrome P450 system and may accumulate markedly in patients with hepatic dysfunction, exposing them to toxicity. The aim of the current study is to utilize a physiologically-based pharmacokinetic modeling approach to evaluate the impact of hepatic impairment on the pharmacokinetic behavior of etrasimod and to appropriately select dosage regimens for patients with chronic liver disease; Methods: PK-Sim was used to develop the etrasimod PBPK model, which was verified using clinical data from healthy subjects and subsequently adapted to reflect the physiological changes associated with varying degrees of hepatic dysfunction; Results: Simulations indicated that hepatic clearance of etrasimod is clearly reduced in patients with Child-Pugh B and C liver impairment. Based on these findings, dosing adjustments were proposed to achieve therapeutic exposures equivalent to those in individuals with normal liver function. In the Child-Pugh B and C population groups, 75% and 62.5%, respectively, of the standard dose were enough to have comparable exposure to the healthy population. These adjusted dosages aim to mitigate the risk of drug toxicity while maintaining efficacy; Conclusions: The PBPK model provides a robust framework for individualizing drug therapy in patients with hepatic impairment, ensuring safer and more effective treatment outcomes. Further clinical studies are warranted to verify these dosing recommendations and to refine the model for broader clinical applications.

Effects of Vitamin D Supplementation on Serum 25-Hydroxy Cholecalciferol in Inflammatory Bowel Diseases: A Meta-Analysis of Randomized Clinical Trials

Background

Earlier studies about the influence of vitamin D (Vit D) supplementation on patients with inflammatory bowel disease (IBD) reported inconsistent results. Current comprehensive systematic review and meta-analysis was conducted to assess the effect of Vit D supplementation on clinical and subclinical factors in patients with IBD.

Methods

PubMed, Scopus, and Web of Science databases were searched for relevant randomized controlled trials (RCTs) on the effect of Vit D supplementation in IBD patients, published up to March 2023. Data were analyzed by the random-effect model. Heterogeneity was assessed by Cochran's Q test and I-square (I 2) statistic. The mean differences (MDs) were calculated as the summary effect size.

Results

We included nine related articles, and our findings indicated that vitamin D administration increased serum vitamin D levels compared to placebo (weighted mean difference (WMD): 12.08; 95% confidence interval (95% CI): 9.06, 15.09; I 2 = 97.01%; P < 0.001) in IBD patients. However, it had no significant influence on disease activity (standardized mean difference (SMD): 0.27; 95% CI: -0.42, 0.95; I2 = 91.7%; P < 0.001) or serum levels of C-reactive protein (CRP) (WMD: -1.42; 95% CI: -3.90, 1.06; I2 = 41.9%; P = 0.262).

Conclusions

Current meta-analysis showed a significant effect of Vit D supplementation on increasing serum cholecalciferol. However, no significant effects of Vit D supplementation on the disease activity and serum levels of CRP were seen. Further studies are needed to expand current knowledge in this issue and found a significant increment in serum 25-hydroxy cholecalciferol concentrations following Vit D supplementation in IBD patients.

Ulcerative Colitis Patients Are at Increased Risk for Adverse Events Following Total Hip Arthroplasty

BACKGROUND

Patients who have the autoinflammatory bowel disease ulcerative colitis (UC) may become candidates for total hip arthroplasty (THA). Having UC may predispose patients to postoperative adverse events, but it remains unclear if these events are related more to the disease process itself or perhaps related to the medications used to treat the condition.

METHODS

Patients undergoing THA were identified from a large administrative dataset. Those who did not have and those who had UC were matched 4:1 based on patient age, sex, and the Elixhauser Comorbidity Index. Matched THA patients who did not have UC (n = 19,482) and those who had UC (n = 4,874) were identified. The matched groups were compared regarding 90-day adverse and five-year survival. Further analyses were performed based on classes of medications.

RESULTS

Controlling for patient age, sex, and Elixhauser Comorbidity Index, UC patients were at significantly higher odds of 90-day adverse events: any (odds ratio [OR]: 1.59), severe (OR: 1.72), and minor (OR: 1.63) (all P < 0.001). Despite this, no differences in 5-year survival were identified. Relative to those who did not have UC, there were increasing odds of any adverse event based on the potency of related medications: no corticosteroids/immunomodulators/5-aminosalicylic acid (5-ASA) (OR: 1.42), corticosteroids only (OR: 1.58), 5-ASA ± corticosteroids OR (1.72), and immunomodulators ± corticosteroids (OR: 1.74, all P < 0.001).

CONCLUSIONS

Total hip arthroplasty patients who have UC were at higher odds for 90-day postoperative adverse events relative to those who did not have UC, and this risk was even greater for those on defined classes of medications. Total hip arthroplasty patients who have UC bear specific considerations, and surgeons must carefully consider and manage the patient's medication regimen in the perioperative period of the THA.

The Epidemiology of Inflammatory Bowel Disease in Oceania: A Systematic Review and Meta-Analysis of Incidence and Prevalence

BACKGROUND

Past studies have shown high rates of inflammatory bowel disease (IBD) in Australia and New Zealand (NZ). We aimed to describe the epidemiology of IBD in Australia, NZ, and the surrounding region (collectively termed Oceania) by conducting a systematic review and meta-analysis.

METHODS

Electronic databases were searched from inception to April 2023 for studies reporting incidence or prevalence rates of IBD, Crohn's disease (CD), or ulcerative colitis (UC) in Oceania. All study designs were included. A meta-analysis calculated pooled estimates of incidence and prevalence, and a sensitivity analysis compared the pooled population-based studies with the non-population-based studies and the Australian and NZ studies separately.

RESULTS

Nineteen incidence and 11 prevalence studies were included; 2 studies were from the Pacific Islands, with the rest coming from Australia and NZ. Pooled estimates showed high incidence rates of 19.8 (95% confidence interval [CI], 15.8-23.7) for IBD, 8.3 (95% CI, 6.9-9.8) for CD, and 7.4 (95% CI, 5.7-9.1) for CD per 100 000 person-years. CD was more common than UC in most studies. The pooled estimates for the prevalence studies were 303.3 (95% CI, 128.1-478.4) for IBD, 149.8 (95% CI, 71.0-228.5) for CD, and 142.2 (95% CI, 63.1-221.4) for UC per 100 000 persons. Studies using population-based data collection methods showed higher pooled rates for both incidence and prevalence.

CONCLUSIONS

The incidence and prevalence of IBD in Oceania is high. The studies were heterogeneous and there were several geographic areas with no information, highlighting the need for more epidemiological studies of IBD.

Targeted surgery combined with postoperative medical therapy for residual disease for severe and multifocal Crohn disease

BACKGROUND

In patients with multifocal intestinal Crohn disease requiring surgery for complication or uncontrolled disease, resection of all the lesions may lead to diarrhea and malnutrition.

METHODS

This is a single-center retrospective review of all patients undergoing targeted surgery for multifocal Crohn disease with at least one residual Crohn disease location left behind. The primary endpoint was the rate of insufficient control of residual Crohn disease lesions requiring redo-surgery targeting these lesions. The rate of clinical remission defined by Harvey-Bradshaw index <4 was studied over time.

RESULTS

From January 2012 to August 2022, among 320 patients undergoing surgery for intestinal Crohn disease, 30 met all criteria. Before surgery, patients had received a mean of 3 medical treatment lines; 83% (n = 25) had a clinically active Crohn disease (Harvey-Bradshaw index ≥4). Surgery consisted in ileocolonic (n = 14;47%), small bowel (n = 5;17%) or colonic resection (n = 12;40%) and strictureplasty (n = 4;13%). Operative mortality was nil. Overall postoperative and severe morbidity rates were 15 of 30 (50%) and 3 of 30. Residual lesions were in the small bowel (n = 15;50%), the colon (n = 16;53%), and/or the rectum (n = 16;53%). Twenty-five patients (83%) had postoperative medical therapy. Median follow-up was 65. Six patients (20%) required reoperation for insufficient control of residual lesions at index surgery after a mean of 98 ± 8 months. The clinical remission rate increased from 17% before surgery to 59% at 6-12 months and 71% at 24 months.

CONCLUSION

In patients with multifocal Crohn disease, surgery targeted to severe and complicated lesions combined with postoperative medical treatment is a safe and effective strategy.

Exosomes derived from cancer cells relieve inflammatory bowel disease in mice

Exosome therapy has garnered significant attention due to its natural delivery capabilities, low toxicity, high biocompatibility, and potential for personalised treatment through engineering modifications. Recent studies have highlighted the ability of tumour cell-derived exosomes (TDEs) to interact with immune cells or modify the immune microenvironment to suppress host immune responses, as well as their unique homing ability to parental cells. The core question of this study is whether this immunomodulatory property of TDEs can be utilised for the immunotherapy of inflammatory diseases. In our experiments, we prepared exosomes derived from murine colon cancer cells CT26 (CT26 exo) using ultracentrifugation, characterised them, and conducted proteomic analysis. The therapeutic potential of CT26 exo was evaluated in our dextran sulphate sodium salt (DSS)-induced inflammatory bowel disease (IBD) mouse model. Compared to the control and 293 T exo treatment groups, mice treated with CT26 exo showed a reduction in the disease activity index (DAI) and colon shortening rate, with no noticeable weight loss. Haematoxylin and eosin (H&E) staining of colon paraffin sections revealed reduced inflammatory infiltration and increased epithelial goblet cells in the colons of CT26 exo-treated group. Furthermore, we conducted preliminary mechanistic explorations by examining the phenotyping and function of CD4+ T cells and dendritic cells (DCs) in the colonic lamina propria of mice. The results indicated that the ameliorative effect of CT26 exosomes might be due to their inhibition of pro-inflammatory cytokine secretion by colonic DCs and selective suppression of Th17 cell differentiation in the colon. Additionally, CT26 exo exhibited good biosafety. Our findings propose a novel exosome-based therapeutic approach for IBD and suggest the potential application of TDEs in the treatment of inflammatory diseases.