ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications

Microbiota-derived IPA alleviates intestinal mucosal inflammation through upregulating Th1/Th17 cell apoptosis in inflammatory bowel disease

The gut microbiota-derived metabolite indole-3-propionic acid (IPA) plays an important role in maintaining intestinal mucosal homeostasis, while the molecular mechanisms underlying IPA regulation on mucosal CD4+ T cell functions in inflammatory bowel disease (IBD) remain elusive. Here we investigated the roles of IPA in modulating mucosal CD4+ T cells and its therapeutic potential in treatment of human IBD. Leveraging metabolomics and microbial community analyses, we observed that the levels of IPA-producing microbiota (e.g. Peptostreptococcus, Clostridium, and Fournierella) and IPA were decreased, while the IPA-consuming microbiota (e.g. Parabacteroides, Erysipelatoclostridium, and Lachnoclostridium) were increased in the feces of IBD patients than those in healthy donors. Dextran sulfate sodium (DSS)-induced acute colitis and CD45RBhighCD4+ T cell transfer-induced chronic colitis models were then established in mice and treated orally with IPA to study its role in intestinal mucosal inflammation in vivo. We found that oral administration of IPA attenuated mucosal inflammation in both acute and chronic colitis models in mice, as characterized by increased body weight, and reduced levels of pro-inflammatory cytokines (e.g. TNF-α, IFN-γ, and IL-17A) and histological scores in the colon. We further utilized RNA sequencing, molecular docking simulations, and surface plasmon resonance analyses and identified that IPA exerts its biological effects by interacting with heat shock protein 70 (HSP70), leading to inducing Th1/Th17 cell apoptosis. Consistently, ectopic expression of HSP70 in CD4+ T cells conferred resistance to IPA-induced Th1/Th17 cell apoptosis. Therefore, these findings identify a previously unrecognized pathway by which IPA modulates intestinal inflammation and provide a promising avenue for the treatment of IBD.

Colonic strictures in Crohn's disease: a non-surgical survival

BACKGROUND

Colonic stenosis in Crohn's disease (CD) is uncommon, and data on surgery-free survival are limited. This study aimed to determine surgery-free survival rates and identify associated factors.

PATIENTS AND METHODS

A retrospective study was conducted from 2003 to 2022, including patients with CD complicated by colonic stenosis. Patients with uncertain diagnoses or follow-up periods of less than six months were excluded.

RESULTS

Fifty-six patients were included (median age 44 years [range 14-65], male-to-female ratio = 0.93). Surgery-free survival rates were 58.9% at 6 months, 43.7% at 2 years, and 31.7% at 5 years, with an average surgery-free survival of 46.7 months. Univariate analysis showed that joint manifestations (p = 0.01), corticosteroids (p = 0.02), anti-TNF alpha (p = 0.02), salicylates (p = 0.02), and azathioprine (p = 0.01) increased surgery-free survival. Complications such as collections or internal fistulas (p = 0.03), parietal ulceration on imaging (p = 0.01), and acute intestinal obstruction (p = 0.01) were associated with reduced surgery-free survival. In multivariate analysis, biologic therapy was the only independent protective factor against surgery (p = 0.001, OR = 0.19).

CONCLUSION

The early introduction of biologic therapy is crucial for increasing surgery-free survival in patients with colonic stenosis in CD, given the limited effectiveness of conventional treatments.

A British Society of Gastrointestinal and Abdominal Radiology multi-centre audit of imaging investigations in inflammatory bowel disease

OBJECTIVES

To evaluate current UK practice for inflammatory bowel disease (IBD) imaging against recommendations from published international literature.

METHODS

A retrospective multi-centre audit was undertaken evaluating imaging modalities, protocols, and pathways used to investigate IBD both in outpatient and inpatient settings during January-December 2022. Reporting practices and training provisions were also recorded.

RESULTS

Forty-one centres contributed: 35 centres provided complete data, whereas 6 centres provided incomplete data. Magnetic resonance enterography (MRE) was the most common modality for small bowel imaging across UK centres, comprising 13 099/18 784 (69.7%) investigations. There was regional variability in other modalities used, with 5 centres performing 81% of all intestinal ultrasound and 3 centres performing 65% of all small bowel follow-through. Compared with outpatients, inpatients with suspected IBD were significantly more likely to be imaged with techniques imparting ionising radiation whether scanned either in-hours (p = 0.005) or out-of-hours (p < 0.001). Non-ionising radiation imaging modalities were significantly less available out-of-hours (p < 0.0001). Sequences included in MRE protocols were variable. Disparity in imaging follow-up for patients prescribed biologic therapies was observed.

CONCLUSIONS

Considerable variation in UK IBD imaging practice has been identified. Improvements must be made to reduce the regional inequality of patient access to different imaging modalities and decrease reliance on ionising radiation for inpatients. Further research to standardise and optimise imaging pathways should be undertaken to improve uniformity, with emphasis placed on training and education.

ADVANCES IN KNOWLEDGE

This multi-centre audit showed considerable IBD imaging practice variation between UK centres, particularly for imaging modalities used between inpatient and outpatient groups and in-hours versus out-of-hours.

Small bowel ultrasound: friend or foe?

PURPOSE OF REVIEW

Crohn's disease (CD), requires accurate diagnosis and regular monitoring to manage disease activity, prevent complications, and improve outcomes. Intestinal ultrasound (IUS) has emerged as a noninvasive, real-time imaging modality, offering a valuable alternative to traditional diagnostic techniques such as magnetic resonance enterography (MRE), endoscopy and capsule endoscopy (CE). This review examines recent advances in IUS for the diagnosis and monitoring of small bowel CD, with a focus on its applications, benefits, and limitations.

RECENT FINDINGS

Recent studies have demonstrated that IUS provides high sensitivity and specificity in detecting key markers of disease activity, including bowel wall thickness (BWT), bowel wall flow (BWF), and bowel wall stratification (BWS). Advances in IUS techniques, such as elastography and contrast-enhanced ultrasound (CEUS), have expanded its diagnostic and prognostic capabilities, potentially enabling differentiation between inflammation and fibrosis. However, challenges remain, including operator dependency, variability in scoring systems, and reduced sensitivity for superficial mucosal abnormalities. Efforts to standardize parameters and improve training have shown promise in addressing these limitations.

SUMMARY

IUS is a critical complementary tool for assessing disease activity, transmural healing, and postoperative recurrence in small bowel CD. Its noninvasiveness, cost-effectiveness, and real time assessment make it well suited for routine clinical use. Nonetheless, further multicentre studies are needed to validate scoring systems, optimize integration with other modalities, and improve consistency across clinical settings. IUS holds significant potential for advancing personalized care in small bowel CD, though ongoing research is required to refine its applications and maximize its clinical utility.

The Power of Antibodies: Advancing Biomarker-Based Disease Detection and Surveillance

BACKGROUND

Antibodies have long served as fundamental tools in disease diagnosis and surveillance. Their utility as biomarkers has expanded beyond infectious diseases to encompass a wide range of health conditions.

OBJECTIVES

This review aims to explore recent advancements in antibody biomarker discovery and their applications in diagnosing and monitoring diverse health conditions. It also examines the role of antibody surveillance in public health and epidemiological studies.

METHODS

A comprehensive analysis of recent literature was conducted, focusing on studies that identify and characterize disease-specific antibodies. Particular attention was given to their relevance in autoimmune diseases, infections, cancers, and neurological disorders.

CONTENT

The review highlights disease-specific antibody biomarkers and their clinical significance. It also discusses the utility and challenges of antibody-based surveillance in assessing disease prevalence, tracking immunity trends, and supporting One Health strategies.

CONCLUSIONS

Recent advancements in antibody biomarker discovery demonstrate significant potential in improving early diagnosis, personalized treatment, and population-level health management. Antibody surveillance continues to play a pivotal role in guiding public health responses and understanding disease dynamics.

Elevated fecal calprotectin: Does capsule endoscopy have a role in the diagnostic algorithm?

INTRODUCTION

The purpose of this study was to examine the utility of small bowel capsule endoscopy (SBCE) in the diagnostic pathway of patients that had elevated fecal calprotectin (FC) and normal colonoscopy.

METHODS

Patients with elevated FC and normal colonoscopy that underwent SBCE in the last 4 years were included. Patients were divided into 3 groups: group 1: patients with isolated small bowel Crohn's disease (SBCD) on SBCE; group 2: patients with elevated FC but normal SBCE; and group 3: patients with isolated terminal ileitis.

RESULTS

The study included 320 patients (group 1: 254 patients, group 2: 50 patients, and group 3: 16 patients). The median age was 42.5 years (IQR 26) across the three groups and 52.4% of the patients had a new diagnosis of SBCD. In group 1, active disease was identified distally in 247 patients (77.2%), proximal involvement in 90 patients (28.1%), and extensive SBCD in 68 patients (21.3%). Magnetic resonance enterography (MRE) was carried out in 229 (90.1%) patients in group 1 and was negative in 42 patients with SBCD. The diagnostic yield of SBCE was higher than that of MRE (p < 0.0001). In group 2, the final diagnoses included Helicobacter pylori infection (n = 2), NSAID use (n = 3), celiac disease (n = 2), and microscopic colitis (n = 1). The final diagnoses in group 3 were idiopathic terminal ileitis (n = 11), inflammatory bowel disease (n = 3), and infective terminal ileitis (n = 2).

CONCLUSION

SBCE influences the patient pathway even when negative/normal. It is better at identifying early SBCD, when compared with MRE.

Current practice and innovations in diagnosing perianal fistulizing Crohn's disease (pfCD): a narrative review

Perianal fistulizing Crohn's disease (pfCD) represents a severe manifestation of Crohn's disease (CD) that often leads to significant morbidity. Clinical examination alone of perianal fistulae is unlikely to be sufficient in the context of complex pfCD, as patients are likely to have complex disease and are more likely to experience complications, treatment failure, and recurrent disease. Furthermore, the relapsing-remitting nature of Crohn's disease and our limited understanding of the pathogenesis of this potentially destructive disease necessitate regular examination and radiological assessment, often in the form of magnetic resonance imaging (MRI). Recent advancements in diagnostic techniques have enhanced the accuracy and timeliness of pfCD diagnosis, facilitating better patient outcomes. A growing appreciation of isolated perianal Crohn's disease has prompted a recent attempt to develop consensus recommendations on diagnosing and treating this group of patients who would previously not have been offered CD medications. This narrative review aims to summarize current practice and the latest developments in the diagnosis of pfCD, highlighting: 1. Clinical examination and assessment tools 2. Current imaging practices 3. Innovations in imaging and biomarkers 4. The diagnosis of isolated perianal Crohn's disease.

The Effect of Etrasimod on Fecal Calprotectin and High-sensitivity C-reactive Protein: Results From the ELEVATE UC Clinical Program

BACKGROUND

Biomarkers offer potential alternatives to endoscopies in monitoring ulcerative colitis (UC) progression and therapeutic response. This post hoc analysis of the ELEVATE UC clinical program assessed potential predictive values of fecal calprotectin (fCAL) and high-sensitivity C-reactive protein (hsCRP) as biomarkers and associated responses to etrasimod, an oral, once-daily, selective sphingosine 1-phosphate (S1P)1,4,5 receptor modulator for the treatment of moderately to severely active UC, in 2 phase 3 clinical trials.

METHODS

In ELEVATE UC 52 and ELEVATE UC 12, patients were randomized 2:1 to 2 mg of etrasimod once daily or placebo for 52 or 12 weeks, respectively. Fecal calprotectin/hsCRP differences between responders and nonresponders for efficacy end points (clinical remission, clinical response, endoscopic improvement-histologic remission [EIHR]) were assessed by Wilcoxon P-values. Sensitivity and specificity were presented as receiver operating characteristics (ROC) curves with area under the curve (AUC).

RESULTS

In ELEVATE UC 52 and ELEVATE UC 12, 289 and 238 patients received etrasimod and 144 and 116 received placebo, respectively. Baseline fCAL/hsCRP concentrations were generally balanced. Both trials had lower week-12 median fCAL levels in week-12 responders vs nonresponders receiving etrasimod for clinical remission, clinical response, and EIHR (all P < .001), with similar trends for hsCRP levels (all P < .01). For etrasimod, AUCs for fCAL/hsCRP and EIHR were 0.85/0.74 (week 12; ELEVATE UC 52), 0.83/0.69 (week 52; ELEVATE UC 52), and 0.80/0.65 (week 12; ELEVATE UC 12).

CONCLUSIONS

Fecal calprotectin/hsCRP levels decreased with etrasimod treatment; ROC analyses indicated a prognostic correlation between fCAL changes during induction and short-/long-term treatment response.

Increased Colonic Levels of CD8+ Cytotoxic T lymphocyte-Associated Mediators in Patients With Microscopic Colitis

BACKGROUND

For unidentified reasons, possibly due to increased immune surveillance, patients with collagenous colitis (CC) and lymphocytic colitis (LC), both forms of microscopic colitis (MC), have lower risk of colorectal cancer than controls and ulcerative colitis (UC) patients. Levels of secreted and cell-bound mediators in MC patients with active disease and in histological remission (HR) compared to UC patients and controls were investigated.

METHODS

Median fluorescence intensity of 54 analytes in colonic biopsies from patients with active CC (n = 21), LC (n = 11), and UC (n = 19); CC-HR (n = 6), LC-HR (n = 9), UC in remission (n = 19), non-diarrhea controls (n = 48), and diarrhea controls (n = 25) was measured using Luminex.

RESULTS

Granzyme B and CCL5 levels were higher in active CC than in UC, whereas CCL4 and CD163 levels were similar in CC and UC, and both groups had higher levels of matrix metalloproteinase (MMP)-1, MMP-3, and tumor necrosis factor receptor II than both control groups. APRIL, BAFF, BCMA, CCL20, CXCL8, chitinase 3-like 1, pentraxin-3, Fas, and IL-33 were higher in UC than MC. Increases in 4-1BB and perforin in MC compared to controls were lower than in UC. Levels of gp130 and IL-6Rα were decreased in MC but increased in UC compared to controls.

CONCLUSIONS

Microscopic colitis patients exhibit increased levels of several analytes, including some associated with CD8+ T lymphocytes, suggesting a different pathogenesis of MC compared to UC. Higher levels of MMP-1 and MMP-3 in CC than LC indicate separate disease entities.

Akkermansia muciniphila Protects Against Trinitrobenzene Sulfonic Acid Induced Colitis by Inhibiting IL6/STAT3 Pathway

BACKGROUND

Inflammatory bowel disease is a long-standing inflammatory disorder that influences the intestinal tract. The intent of this research is to explore whether the relative abundance of Akkermansia muciniphila is related to the IL6/STAT3 pathway and the fundamental molecular mechanisms of A. muciniphila on a trinitrobenzene sulfonic acid (TNBS)-induced enteritis mouse model, including the expression of inflammatory cytokines and proteins in the IL6/STAT3 signaling pathway.

METHODS

The association between the A. muciniphila and IL6/STAT3 was investigated by using mucosal biopsies and fecal samples. TNBS-induced colitis mouse models were performed to elucidate the underlying mechanisms. The alteration of intestinal microbiota was organized by 16s rRNA sequencing.

RESULTS

In Crohn's disease patients, the level of STAT3 and IL-6 presented a negative relationship with A. muciniphila. The expression of IL-6, p-STAT3, and STAT3 was downregulated in A.m+TNBS group, indicating A. muciniphila may inhibit the IL6/STAT3 pathway in TNBS-induced enteritis in vivo. To investigate the potential defensive role of A. muciniphila supplementation in vivo with TNBS-induced enteritis, 16S rRNA sequencing was performed to analyze changes in the intestinal microbiota composition. The results revealed a marked increase in microbial diversity and abundance within the A. muciniphila-treated group, suggesting a beneficial modulation of the gut microbiome associated with the supplementation.

CONCLUSIONS

Our findings declared that A. muciniphila supplementation alleviates gastrointestinal inflammation through IL-6/STAT3 signaling pathway. This protective effect was mediated by the downregulation of the IL-6 and STAT3, highlighting a potential mechanism by which A. muciniphila modulates inflammatory responses. This work disclosed that A. muciniphila demonstrates a defensive influence against TNBS-induced enteritis in vivo, proposing it qualified as a unique therapeutic focusing on modulating IL-6, STAT3, or p-STAT3 in the treatment of colitis.

Fatigue in Patients with Inflammatory Bowel Disease in Remission One Year After Diagnosis (the IBSEN III Study)

BACKGROUND AND AIMS

Fatigue is commonly observed in Crohn's disease (CD) and ulcerative colitis (UC) but its association to achieving remission is not clearly established. In this study, we describe the odds for fatigue in patients with CD/UC 1 year after diagnosis based on different definitions of remission and identified factors associated with chronic fatigue (CF) among patients in endoscopic/radiological remission.

METHODS

Patients ≥ 18 years old with CD/UC were recruited from the IBSEN III cohort. Using the Fatigue Questionnaire, and dichotomizing the score, CF was defined as the presence of substantial fatigue (SF) for ≥6 months. Remission was divided into symptomatic (CD: Harvey-Bradshaw Index score < 5/UC: SCCAI score < 3), biochemical (fecal calprotectin ≤ 250 µg/g), endoscopic/radiological (CD: normal intestinal MRI/CT combined with normal endoscopy/UC: Mayo endoscopic score 0), and histological (normal mucosal biopsies). Both the likelihood of SF/CF, depending on the definition of remission, and associations between CF and selected factors for CD/UC in endoscopic/radiological remission were evaluated using binary logistic regression analysis.

RESULTS

In total, 711/1416 patients were included. For both CD and UC, symptomatic remission significantly reduced the odds for SF and CF. In addition, the odds for SF were significantly reduced for UC in biochemical remission. Among those in endoscopic/radiological remission (n = 181), CF was independently associated with sleep disturbances (OR = 10.40, 95%CI [3.28;32.99], p < 0.001) and current treatment with infliximab (OR = 4.31, 95%CI [1.15;16.17], p = 0.03).

CONCLUSIONS

Stricter definitions of disease remission were not associated with a decreased likelihood of fatigue. For patients in endoscopic/radiological remission, CF was independently associated with sleep disturbances and current treatment with infliximab.

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.

[Position statement of the Spanish Society of Primary Care Physicians (SEMERGEN) and Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the management of inflammatory bowel disease in Primary Care]

Primary Care is the first point of contact for most patients after the onset of symptoms of inflammatory bowel disease (IBD). Establishing an initial diagnostic process based on compatible symptoms and agreed criteria and referral pathways, depending on the degree of suspicion and the patient's situation, can reduce diagnostic delays. Once the patient is referred to the Digestive specialist and the diagnosis of IBD is established, a treatment and follow-up plan is structured. The management of the patient must be shared with the participation of the family practitioners in the diagnosis and treatment of concomitant or intercurrent pathologies, the recognition of flare-ups or complications (of IBD or treatments), education tasks or adherence control. With the purpose of developing a comprehensive guide on the management of IBD aimed at Primary Care doctors, we have developed this positioning document collaboratively between the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU).

Clinical factors influencing patency capsule excretion and confirmation in patients with intestinal patency

INTRODUCTION

The PillCam™ patency capsule is useful to prevent capsule endoscope retention; however, visual confirmation of patency capsule excretion is challenging for many patients.

OBJECTIVE

We investigated the factors related to the patency capsule remaining in the colon after 33 h and the factors hindering the visual confirmation of its excretion.

METHODS

We retrospectively analyzed 498 patients with intestinal patency who underwent patency capsule examination. Patients were categorized into the "excretion group" and "colon group," depending on whether the capsule was excreted or remained in the colon after 33 h, respectively. Patients were further classified into self-confirmed and non-self-confirmed groups within the excretion group. Univariate and multivariate logistic regression analyses were used to analyze the factors associated with the colon and unself-confirmed groups.

RESULTS

Overall, 49% of patients visually confirmed capsule excretion within 33 h, whereas 51% did not and required radiological examination. Among those without capsule excretion, 34% of patients had a detectable capsule in the colon, whereas 16% had no detectable capsule. In the excretion group, 75% and 25% of patients were self-confirmed and non-self-confirmed, respectively. Female sex, inpatient status, constipation, and capsule in the colon during the previous examination were independent factors associated with the colon group. Male sex and younger age were the independent factors associated with the non-self-confirmed group.

CONCLUSIONS

Our findings highlight the need for new approaches to facilitate patency capsule excretion to avoid radiation exposure, especially in females, inpatients, those with constipation, and those with capsule remaining in the colon from the previous examination.

Preclinical Protein Signatures of Crohn's Disease and Ulcerative Colitis: A Nested Case-Control Study Within Large Population-Based Cohorts

BACKGROUND & AIMS

Biomarkers are needed to identify individuals at elevated risk of inflammatory bowel disease. This study aimed to identify protein signatures predictive of inflammatory bowel disease.

METHODS

Using large population-based cohorts (n ≥180,000), blood samples were obtained from individuals who later in life were diagnosed with inflammatory bowel disease and compared with age and sex-matched controls, free from inflammatory bowel disease during follow-up. A total of 178 proteins were measured on Olink platforms. We used machine-learning methods to identify protein signatures of preclinical disease in the discovery cohort (n = 312). Their performance was validated in an external preclinical cohort (n = 222) and assessed in an inception cohort (n = 144) and a preclinical twin cohort (n = 102).

RESULTS

In the discovery cohort, a signature of 29 proteins differentiated preclinical Crohn's disease (CD) cases from controls, with an area under the curve (AUC) of 0.85. Its performance was confirmed in the preclinical validation (AUC = 0.87) and the inception cohort (AUC = 1.0). In preclinical samples, downregulated (but not upregulated) proteins related to gut barrier integrity and macrophage functionality correlated with time to diagnosis of CD. The preclinical ulcerative colitis signature had a significant, albeit lower, predictive ability in the discovery (AUC = 0.77), validation (AUC = 0.67), and inception cohorts (AUC = 0.95). The preclinical signature for CD demonstrated an AUC of 0.89 when comparing twins with preclinical CD with matched external healthy twins, but its predictive ability was lower (AUC = 0.58; P = .04) when comparing them with their healthy twin siblings, that is, when accounting for genetic and shared environmental factors.

CONCLUSION

We identified protein signatures for predicting a future diagnosis of CD and ulcerative colitis, validated across independent cohorts. In the context of CD, the signature offers potential for early prediction.

Primary Sclerosing Cholangitis and Inflammatory Bowel Disease

Primary sclerosing cholangitis (PSC) is a rare pathology seen in patients with inflammatory bowel disease (IBD), especially ulcerative colitis. PSC increases patients' morbidity and requires the attention of a multidisciplinary team as those patients require frequent colonoscopies and biopsies due to the elevated risk of malignancy, biliary screening and management of progressive disease that could leave patients in liver failure requiring liver transplant. Some consider this a separate form of IBD in addition to Crohn's and ulcerative colitis. These patients should be monitored closely and managed carefully due to implications of ongoing management on quality of life and survival.

Modified Shi Hui San decoction ameliorates murine experimental colitis through multiple mechanisms

BACKGROUND

Modified Shi Hui San (MSHS) has shown excellent therapeutic effects on ulcerative colitis (UC) patients clinically in China. However, the exact mechanism underlying its effect remains unclear and needs to further investigation.

AIMS

This study aimed to investigate the therapeutic effects of modified Shi Hui San decoction (MSHSD) in murine experimental colitis and explore its underlying mechanisms.

METHODS

To examine the effects of MSHSD on UC, a murine model of colitis was induced using 2.5 % dextran sodium sulfate (DSS). The mice were then treated with MSHSD at the doses of 6.25 or 25 g/kg for 10 days. The progression of colitis was evaluated through clinical symptoms, histopathological analysis, evaluation of mucosal barrier integrity, biochemical assays, and analysis of the gut microbiota composition.

RESULTS

MSHSD administration markedly ameliorated experimental colitis in DSS-treated mice by suppressing inflammation, restoring the intestinal mucus barrier, alleviating oxidative stress, and reestablishing immunity. More importantly, it transformed the gut microbiota structure from an imbalanced state to a normal state.

CONCLUSIONS

These findings for the first time extend our understanding of the mechanisms, by which MSHSD ameliorates murine experimental colitis, and support the clinical use of MSHS for UC treatment.

Impact of ustekinumab exposure on clinical outcomes during induction in inflammatory bowel disease

BACKGROUND

understanding the relationship between ustekinumab (UST) exposure and clinical outcomes in inflammatory bowel disease (IBD) induction is crucial. However, evidence remains limited, highlighting the need to comprehend UST's pharmacokinetic variability for tailored treatments.

AIMS

this study aimed to investigate the association between UST exposure during the induction phase and clinical outcomes and identifying factors associated with UST exposure during this period.

METHODS

a retrospective observational study was conducted on a cohort of consecutive IBD patients. The primary endpoint was to assess the association between UST exposure at week 8 and both clinical and biochemical remission at week 26, as well as the absence of disease flare-ups during the initial six months of treatment. The secondary endpoint was to investigate the relationship between baseline characteristics and UST exposure at week 8.

RESULTS

a total of 56 IBD patients were included. Variables associated with adequate UST exposure included baseline fecal calprotectin < 500 µg/g (OR: 7.72 [95 % CI: 1.75-34.03]) and female sex (OR: 4.56 [95 % CI: 1.12-18.60]). A cut-off UST trough levels of 8.3 μg/ml yielded an area under the curve (AUC) of 0.74 (95 % CI: 0.58-0.90, p = 0.021) to predict normal fecal calprotectin levels, and 8.6 µg/ml resulted in an AUC of 0.724 (95 % CI: 0.558-0.863) to predict clinical remission.

CONCLUSIONS

this study demonstrates a significant association between UST concentrations and clinical and biochemical remission in IBD patients. Results suggest that standard induction doses may not be sufficient for all patients, highlighting the importance of treatment individualization to optimize outcomes.

Usefulness of Magnifying Endoscopy With Narrow-Band Imaging for Diagnosis of Ulcerative Colitis-Associated Neoplasia

BACKGROUND AND AIM

Qualitative diagnosis of ulcerative colitis-associated neoplasia (UCAN) is crucial for surveillance colonoscopy in patients with ulcerative colitis (UC). Although the utility of magnifying endoscopy with narrow-band imaging (ME-NBI) in sporadic neoplasia diagnosis has been reported, its efficacy in UCAN remains unclear. This study aimed to evaluate the usefulness of ME-NBI for qualitative diagnosis of UCAN.

METHODS

We generated 60 ME-NBI images (30 UCANs and 30 nonneoplasia lesions, including 10 polypoid and 20 nonpolypoid lesions) from patients with UC who underwent colonoscopy at our hospital between 2015 and 2023. Eleven endoscopists (seven experts and four trainees) independently assessed these images. Lesions were categorized into high- (≥ 80%), moderate- (50%-79%), and low- (< 50%) accuracy groups on the basis of the correct diagnostic rate.

RESULTS

Overall sensitivity, specificity, and correct diagnostic rates were 66.5%, 79.0%, and 71.8%, respectively. Experts tended to exhibit higher specificity than trainees (83% vs. 70%). Polypoid lesions showed higher sensitivity (92% vs. 54%) and lower specificity (61% vs. 88%) than nonpolypoid lesions. Overall, the kappa value was 0.411. In UCAN, 37%, 37%, and 24% were classified into the high-, moderate-, and low-accuracy groups, respectively. All endoscopists assessed one case of UCAN in the low-accuracy group as a nonneoplastic vessel with a surface pattern. Only two nonneoplasias were identified as having nonneoplastic vessel and surface patterns by all endoscopists.

CONCLUSIONS

This study demonstrated the usefulness of ME-NBI for qualitative diagnosis, along with its limitations. A unique endoscopic diagnostic algorithm for UCAN, incorporating ME-NBI and other modalities, is necessary.

Patients' Attitudes to Magnetic Resonance Imaging in Perianal Fistulizing Crohn's Disease: A Global Survey

Background

There is limited patient involvement in radiological research for perianal fistulizing Crohn's disease (pfCD), despite magnetic resonance imaging (MRI)'s critical role in diagnosis and management. Patient and public involvement is essential for aligning research with patient priorities. This study aimed to gather patient perspectives on the use of MRI in pfCD.

Methods

A mixed-methods approach was used, following Guidance for Reporting Involvement of Patients and the Public (GRIPP2) guidelines. An online survey, co-developed with a patient representative, included open and closed questions on MRI experiences, advantages, challenges, and the potential for Artificial Intelligence (AI)-generated reports. This was followed by a virtual session for further exploration of patient views. Thematic analysis was conducted on the data.

Results

Forty-seven patients with Crohn's disease (37 with pfCD) from 6 countries participated, with 28/37 (76%) completing the survey. Key themes included patient expectations for MRI, preferences for scan intervals, and report content. Most (93%) wanted MRI reports to compare with previous scans, highlighting fistula changes and new abscesses. A majority (57%) preferred MRI scans annually when well, and more frequently after surgery (64.3% preferred scans at 3 months). Emotional relief was associated with MRI improvements, though access to services and report clarity remained challenging. Interest in AI-generated reports was expressed if clearly explained and validated by professionals.

Conclusions

This is the first study exploring patient views on MRI use in pfCD, emphasizing the need for patient-centred MRI reporting and clearer communication. Future work should enhance patient access and validate AI-generated MRI reports.

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.

A practical guide to dilating inflammatory bowel disease strictures

INTRODUCTION

Stricturing Crohn's disease is a common phenotype and treatment aims to improve symptoms, prevent complications, assess for proximal bowel disease activity, and screen for upstream neoplasm. Management is challenging due to diagnostic limitations, stricture composition, and recurrence rate.

AREAS COVERED

Categorizing a stricture as inflammatory or fibrotic is necessary to determine appropriate management. Inflammatory strictures are treated with medical therapy, and fibrostenotic strictures require endoscopic or surgical management. While EBD is increasingly utilized, stricture recurrence rates remain high, necessitating repeat endoscopic procedures or surgery. We performed a PubMed (MEDLINE database) search for the latest research on IBD-related stricture management, including detection, diagnosis, and medical and procedural therapies. We highlight the current literature on endoscopic techniques for the treatment of intestinal strictures and future areas of research.

EXPERT OPINION

The field of intestinal stricture management is expected to evolve in the coming years and will include enhanced imaging modalities, medication optimization, and increasing use of advanced endoscopic techniques.

Diffusion-weighted imaging to predict longer-term response in Crohn's disease patients commencing biological therapy: results from the MOTILITY trial

OBJECTIVES

Predicting longer-term response to biological therapy for small bowel Crohn's disease (SBCD) is an unmet clinical need. Diffusion-weighted magnetic resonance (MR) imaging (DWI) may indicate disease activity, but its predictive ability, if any, is unknown. We investigated the prognostic value of DWI for 1 year response or remission (RoR) in SBCD patients commencing biologic therapy, including incremental value over C-reactive protein (CRP) and faecal calprotectin (FC).

METHODS

A subset of participants in a prospective, multicentre study investigating the predictive ability of motility MRI for 1-year RoR in patients starting biologic therapy for active SBCD, underwent additional DWI at baseline and post-induction (12-30 weeks). CRP and FC were collected in a subgroup. RoR at 1 year was evaluated using clinical and morphological MR enterography (MRE) parameters. We calculated sensitivity and specificity to predict RoR and quality of life (QoL) at 1 year, comparing apparent diffusion coefficient (ADC) value, Clermont score, and CRP using multivariable logistic regression.

RESULTS

A total of 25 participants were included (mean 36.9 years, 32% female). ADC changes and Clermont score had poor sensitivity (30.0% [95% CI, 6.7-65.2] and 40.0% [95% CI, 12.2-73.8], respectively) and poor-to-modest specificity (50.0 [95% CI, 27.2-72.8] and 65.0% [95% CI, 40.8-84.6]) for RoR. None of Clermont score, CRP, or FC predicted QoL.

CONCLUSIONS

DWI has inadequate sensitivity and specificity for RoR at 1 year. There is no significant incremental prognostic value of DWI over CRP and FC to predict RoR and/or QoL at 1 year.

ADVANCES IN KNOWLEDGE

Early post-induction DWI has no prognostic value for RoR at 1 year.

The Essential Role of Imaging in the Diagnosis, Characterization, and Treatment of Patients with Crohn's Disease

Imaging is essential in assessing patients with Crohn's disease, and it provides important and complementary information to the clinical and endoscopic findings. Patients can be accurately phenotyped and complications identified.

The Impact of Endoscopic Healing on Disease-Related Outcomes in Patients With Ulcerative Proctitis

BACKGROUND AND AIMS

Ulcerative proctitis (UP) is a limited form of ulcerative colitis. While achieving endoscopic healing (EH) in ulcerative colitis improves long-term outcomes, the benefit of EH in UP is uncertain. This study aimed to assess the impact of EH on outcomes in UP.

METHODS

This single-center retrospective study included adults with UP and ≥2 endoscopies, with active inflammation (Mayo endoscopic score [MES] 1-3) at index. EH was defined as MES 0-1 at follow-up procedure. The relationship of EH to inflammatory bowel disease (IBD)-related outcomes was assessed using univariate analysis and multivariable logistic regression assessed the effect of EH on IBD-related outcomes.

RESULTS

Among 200 UP patients, 109 (54.5%) had EH at follow-up endoscopy at median 19 months (interquartile range: 7, 32). EH was associated with fewer IBD-related emergency department (ED) visits (EH: 8.3%, no EH: 21%, P = .01), hospitalizations (5.5% vs 18%), and GI visits (mean: 1.47/year [SD: 1.40], vs 2.96/year [2.52], P < .001). Patients with EH were less likely to have iron deficiency anemia (23% vs 41%, P = .007), Clostridioides difficile (0.9% vs 6.6%, P = .048), or initiate new biologic therapy after relapse (15% vs 33%, P = .034). Patients with EH had a greater time to clinical relapse (21 [24] vs 9 months [14]; P = .006) and lower odds of an IBD-related ED visit (OR: 0.32, 95% CI: 0.13, 0.73) or hospitalization (0.26 [0.09, 0.67]). Baseline presence of a cecal patch did not impact outcomes.

CONCLUSIONS

UP patients with EH had less IBD-related healthcare utilization, fewer IBD-related complications, and were less likely to escalate therapy after relapse than patients without EH. Using a treatment target of EH may therefore be desirable in UP.

Brain-Gut Interplay: Cognitive Performance and Biomarker Correlations in IBD Patients

Background/Objectives: Inflammatory bowel diseases (IBD), including mainly ulcerative colitis (UC) and Crohn's disease (CD), have been associated with cognitive and psychological changes, though the mechanisms remain unclear. Methods: This prospective case-control study aimed to evaluate cognitive performance and biomarkers (homocysteine, serum amyloid A, brain-derived neurotrophic factor, and S100B protein) in IBD patients. Results: A total of 90 individuals (34 UC, 21 CD, and 35 controls) were assessed using the Montreal Cognitive Assessment (MoCA), the Memory Impairment Index (MIS), and biomarker analysis. MoCA and MIS testing showed significant differences between UC, CD, and the controls, with lower scores observed in IBD groups (p = 0.003, p = 0.015). Regarding trail-making tests, digit symbol substitution tests, and forward and backward digit spans, no significant changes were observed. No functional deficits were observed in daily activities. Biomarker analysis revealed lower brain-derived neurotrophic factor and higher serum amyloid A levels in IBD patients, correlated to MOCA and MIS scores. There were no significant differences in psychological distress between IBD patients and the controls. Subtle cognitive declines were noted across all groups during the 1-year follow-up, without any statistical significance when groups were compared. Conclusions: In conclusion, IBD patients reported lower cognitive scores compared to the controls, while no differences in depression and anxiety scores were observed. Higher BDNF levels correlated with better cognitive functioning, while higher serum amyloid A correlated with lower cognitive functioning.

Clinical value of using double balloon enteroscopy combined with endoscopic ultrasound to evaluate Crohn's disease of the small bowel: a retrospective study

BACKGROUND

Diagnosing and assessing Crohn's disease, which involves only the small bowel, is challenging. This study investigated the clinical value of combining double balloon enteroscopy with endoscopic ultrasound to evaluate this disease.

METHODS

This single-center retrospective study included patients with Crohn's disease of the small intestine between October 2022 and October 2023. Relevant clinical data were collected. Double balloon enteroscopy and ultrasound endoscopy of the small intestine were performed.

RESULTS

Among the 50 patients, 10, 34, and 6 had mild, moderate, and severe active phase Crohn's disease, respectively. Ten patients scored between 1 and 4 points on the modified partial simple endoscopic score for Crohn's disease (mpSES-CD), 24 scored between 5 and 8 points, and 16 scored more than 8 points. Forty patients had thickening of the intestinal wall (total thickness, 4.14 ± 0.98 mm). Submucosal and intrinsic muscle layer thickening was primarily observed. Ten patients were in remission, and all mucosal-submucosal and submucosal-intrinsic muscle boundaries could be distinguished. Thirty-four patients had moderate-phase Crohn's disease, of whom 26 (76.47%) had distinguishable mucosal-submucosal boundaries, and 28 (82.35%) had distinguishable submucosal-intrinsic muscular boundaries. Of the six patients with severe phase Crohn's disease, four (66.67%) had distinguishable mucosal submucosal boundaries, and two (33.33%) had distinguishable submucosal-intrinsic muscular boundaries.

CONCLUSIONS

The mpSES-CD and Harvey-Bradshaw Index correlate well. Endoscopic ultrasound can determine disease severity by measuring each bowel wall layer's thickness and observing the distinction between the layers. This combination of techniques can compensate for the shortcomings in diagnosing the depth of the vertical infiltration of Crohn's disease using white-light endoscopy.

FoxP3-positive T regulatory cells and its effector mechanisms in Crohn's disease: an immunohistochemical and image morphometric analysis on endoscopic mucosal biopsies

OBJECTIVE

Crohn's disease (CD) is an immune inflammatory disorder of the gastrointestinal tract arising from a complex interplay of genetic, environmental, microbiome, and immune factors. Regulatory T cells (Tregs), characterized by FoxP3 expression, are crucial for maintaining immune homeostasis through PD-1/PD-L1 interaction, interleukin (IL)-10 release, and granzyme (GrB) production. This study aimed to elucidate the role of FoxP3 positive (+) Tregs in CD.

METHODS

Segmental colonoscopic biopsies from 46 treatment-naive CD cases (34 adults and 12 children) categorized into noninflamed [n = 32; Nancy histologic index (NHI) 0, 1] and inflamed (n = 100; NHI 2-4) mucosae using NHI. CD4, FoxP3, PD-1, IL-10, and GrB immunoexpression were analyzed by eyeballing and image morphometry. Findings were correlated with activity, granulomas, and skip lesions; and compared with site-matched non-inflammatory bowel disease (IBD) controls (n = 30).

RESULTS

FoxP3+ Tregs, IL-10, PD-1, and GrB expressions were significantly higher in NHI 3-4 mucosae than in NHI 0-1 and controls (P < 0.05). No significant differences were observed between adults and children, whereas those with granulomas had increased expression (P = 0.045). The FoxP3 : CD4 ratio positively correlated with IL-10 (Spearman, r = 0.307, P = 0.002), GrB (r = 0.302, P = 0.002), but not with PD-1 (r = 0.98, P = 0.33).

CONCLUSIONS

Our findings point to the possibility of a qualitative defect in FoxP3+ Tregs in CD. The functional arms of Tregs in CD need to be elucidated further in larger prospective cohorts to validate our observations and pave the way for future immunotherapy.

Switching from intravenous to subcutaneous infliximab is safe and feasible in patients with perianal Crohn's disease

Background and objectives

We assessed the evolution of perianal lesions after switching intravenous (IV) to subcutaneous (SC) infliximab in patients with Crohn's disease (CD).

Design

Subgroup analysis of REMSWITCH studies.

Methods

We described the clinical and MRI outcomes of patients with a prior or current CD perianal lesions after the switch.

Results

In REMSWITCH, 40 CD patients had a prior history of perianal lesions. No patient experienced a new perianal lesion (median follow-up = 18 months). Among the three patients (3/40, 7.5%) with clinically active perianal lesions at baseline, two patients had no more perianal lesions at month 18 while the last patient experienced lesions worsening. Another one with active perianal lesions on MRI but no symptom at baseline did not have any relapse within 18 months. Only one patient (1/40, 2.5%) had a perianal relapse (at month 25) with remission recapture after SC infliximab intensification.

Conclusion

Switching from IV to SC infliximab in CD with perianal lesions is safe and feasible.

Association of early therapeutic drug monitoring of adalimumab with biologic remission and drug survival in Crohn's Disease

Background

Therapeutic drug monitoring of adalimumab (ADA) is still controversial.

Objectives

To study the association between ADA trough levels in the early stages of treatment with biological remission (BR) and drug survival in Crohn's disease (CD).

Design

Retrospective cohort study.

Methods

Patients treated with ADA with available trough levels at weeks 2 and 6 (after the first induction and maintenance dose, respectively) were included. Fecal calprotectin (Fcal) and C-reactive protein (CRP) were registered at baseline, week 24, and week 52. BR was defined as Fcal <200 µg/g and CRP <5 mg/dl. Treatment survival and the need for dose escalation were assessed at week 52. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic accuracy of ADA cutoff levels for BR. Quartile-specific comparisons were performed to evaluate differences in the proportion of patients achieving BR at weeks 24 and 52, drug survival, and dose escalation.

Results

In all, 112 patients were included. ADA trough levels at week 6 were higher in patients achieving BR at week 24 (12.32 μg/ml vs 10.3 μg/ml, p = 0.0008), week 52 (12.3 μg/ml vs 10.8 μg/ml, p = 0.035), and in patients with 1-year treatment persistence (12.17 μg/ml vs 9.7 μg/ml, p = 0.03), but lower in patients requiring maintenance intensification (9.7 μg/ml vs 12.2 µg/ml, p < 0.0001). ADA week 6 trough levels >12.27 μg/ml predicted BR at week 24 with 79.7% specificity and 79.5% positive predictive value. Patients in the third quartile (Q3) and fourth quartile (Q4) of ADA levels at week 6 exhibited higher rates of BR at week 24, BR at week 52, 1-year drug survival, and less need for dose escalation (all p-values <0.05). In logistic regression, Q3 and Q4 of week 6 levels were significantly associated with BR at week 24 (p = 0.02 and p = 0.001); and week 6 Q4 with BR at week 52 (p = 0.02), treatment persistence (p = 0.03), and lower dose escalation (p = 0.004). ADA trough levels at week 2 did not show similar associations.

Conclusion

ADA trough levels at week 6 are associated with BR at weeks 24 and 52, drug survival, and need for dose escalation in CD. However, ADA concentrations at week 2 failed to yield similar results.

MicroRNAs in the Diagnosis of Digestive Diseases: A Comprehensive Review

MicroRNAs (miRNAs) have emerged as crucial regulators in digestive pathologies, including inflammatory bowel disease (miR-31, miR-155, and miR-21), colorectal cancer (miR-21, miR-598, and miR-494), and non-alcoholic fatty liver disease (miR-21, miR-192, and miR-122). Their capacity to modulate gene expression at the post-transcriptional level makes them highly promising candidates for biomarkers and therapeutic interventions. However, despite considerable progress, their clinical application remains challenging. Research has shown that miRNA expression is highly dynamic, varying across patients, disease stages, and different intestinal regions. Their dual function as both oncogenes and tumor suppressors further complicates their therapeutic use, as targeting miRNAs may yield unpredictable effects. Additionally, while miRNA-based therapies hold great potential, significant hurdles persist, including off-target effects, immune activation, and inefficiencies in delivery methods. The intricate interplay between miRNAs and gut microbiota adds another layer of complexity, influencing disease mechanisms and treatment responses. This review examined the role of miRNAs in digestive pathologies, emphasizing their diagnostic and therapeutic potential. While they offer new avenues for disease management, unresolved challenges underscore the need for further research to refine their clinical application.

Automated inflammatory bowel disease detection using wearable bowel sound event spotting

Introduction

Inflammatory bowel disorders may result in abnormal Bowel Sound (BS) characteristics during auscultation. We employ pattern spotting to detect rare bowel BS events in continuous abdominal recordings using a smart T-shirt with embedded miniaturised microphones. Subsequently, we investigate the clinical relevance of BS spotting in a classification task to distinguish patients diagnosed with inflammatory bowel disease (IBD) and healthy controls.

Methods

Abdominal recordings were obtained from 24 patients with IBD with varying disease activity and 21 healthy controls across different digestive phases. In total, approximately 281 h of audio data were inspected by expert raters and thereof 136 h were manually annotated for BS events. A deep-learning-based audio pattern spotting algorithm was trained to retrieve BS events. Subsequently, features were extracted around detected BS events and a Gradient Boosting Classifier was trained to classify patients with IBD vs. healthy controls. We further explored classification window size, feature relevance, and the link between BS-based IBD classification performance and IBD activity.

Results

Stratified group K-fold cross-validation experiments yielded a mean area under the receiver operating characteristic curve ≥0.83 regardless of whether BS were manually annotated or detected by the BS spotting algorithm.

Discussion

Automated BS retrieval and our BS event classification approach have the potential to support diagnosis and treatment of patients with IBD.

Relating the molecular phenotype of ulcerative colitis to the clinical course

The expanding portfolio of targeted therapies for ulcerative colitis (UC) suggests that a more precise approach to defining disease activity will aid clinical decision-making. This prospective study used genome-wide microarrays to characterize gene expression in biopsies from the most inflamed colon segments from patients with UC and analyzed associations between molecular changes and short-term outcomes while on standard-of-care treatment. We analyzed 141 biopsies-128 biopsies from 112 UC patients and 13 biopsies from eight inflammatory bowel disease unclassified (IBDU) patients. Endoscopic disease was associated with expression of innate immunity transcripts, e.g. complement factor B (CFB); inflammasome genes (ZBP1 and PIM2); calprotectin (S100A8 and S100A9); and inflammation-, injury-, and innate immunity-associated pathway analysis terms. A cross-validated molecular machine learning classifier trained on the endoscopic Mayo subscore predicted the endoscopic Mayo subscore with area-under-the-curve of 0.85. A molecular calprotectin transcript score showed strong associations with fecal calprotectin and the endoscopic Mayo subscore. Logistic regression models showed that molecular features (e.g. molecular classifier and molecular calprotectin scores) improved the prediction of disease progression over conventional, clinical features alone (e.g. total Mayo score, fecal calprotectin, physician global assessment). The molecular features of UC showed strong correlations with disease activity and permitted development of machine-learning predictive disease classifiers that can be applied to expanded testing in diverse cohorts.

Prevalence of Irritable Bowel Syndrome Based on Rome IV Criteria in Patients in Biochemical and Endoscopic Remission From Newly Diagnosed Inflammatory Bowel Disease: One- and Three-Year Results (the IBSEN III Cohort)

BACKGROUND

Distinguishing irritable bowel syndrome (IBS) from inflammatory bowel disease (IBD) flare-ups is challenging. This study used objective remission markers to accurately determine IBS prevalence in a population-based cohort of patients with IBD.

METHODS

Adults with ulcerative colitis and Crohn's disease were recruited from the IBD in South-Eastern Norway III cohort study. Irritable bowel-like symptoms were assessed using the Rome IV criteria for patients in remission from IBD at 1- and 3-year follow-ups. Remission was defined objectively using the biochemical marker fecal calprotectin (FC) ≤ 250 µg/g, and comparisons to remission based on endoscopic indices were made at 1-year follow-up.

RESULTS

Among patients with FC ≤ 250 µg/g, IBS prevalences were 21.9% (n = 62/283) and 16.1% (n = 49/304) at the 1- and 3-year follow-ups, respectively, which were higher than that in the Norwegian population (9.5%; P < .005). Of patients in endoscopic remission at 1-year follow-up, 19.2% (n = 43/224) reported IBS-like symptoms, which was not significantly different from IBS prevalence for patients with FC ≤ 250 µg/g. Irritable bowel syndrome was independently associated with substantial fatigue (odds ratio: 3.05 [95% CI, 1.48-6.27]) and female sex (odds ratio: 2.67 [95% CI, 1.34-5.32]) at the 1-year follow-up. Patients with IBS reported significantly reduced health-related quality of life (HRQoL) scores.

CONCLUSIONS

The prevalence of IBS among patients in remission from IBD was approximately twice as common as that in the Norwegian population. Irritable bowel syndrome was independently associated with substantial fatigue, female sex, and reduced HRQoL.

Superb Microvascular Imaging Is Superior to Doppler Imaging in Ruling Out Ulcerative Colitis Disease Activity

BACKGROUND

There is an unmet medical need for noninvasive techniques to determine disease activity in inflammatory bowel disease (IBD) and intestinal ultrasound (IUS) has shown promising performance in this regard. In addition to parameters such as bowel wall thickness, stratification, and mesenteric fat, color Doppler signals are used to determine inflammatory activity in the gut. However, whether superb microvascular imaging (SMI), a microvascular flow imaging technique, improves the diagnostic accuracy is currently unclear.

METHODS

We performed a prospective single-center cross-sectional cohort study including 62 patients with ulcerative colitis (UC). IUS was performed on the sigmoid colon within 30 days of colonoscopy and the International Bowel Ultrasound (IBUS) group Segmental Activity Score (SAS) as well as SMI signals were determined and correlated to established endoscopic, clinical, and biochemical read-outs of disease activity.

RESULTS

Semiquantitative scoring of SMI signals had a substantial interobserver agreement between 2 blinded and expert central readers. It showed excellent correlation to endoscopic, clinical, and biochemical disease activity. While SMI did not improve the overall diagnostic performance of the IBUS-SAS to predict endoscopic disease activity, SMI alone was highly precise and superior to Doppler imaging in predicting endoscopic remission.

CONCLUSIONS

IUS is a highly precise noninvasive diagnostic tool to monitor disease activity in UC, in particular for predicting endoscopic remission. Assessing the SMI signals in the bowel wall of patients with IBD seems a promising tool to simplify IUS diagnostics in IBD that warrants further research.

Small Bowel Motility Quantified by Cine MRI to Predict Longer-Term Response in Patients with Crohn's Disease Commencing Biological Therapy: The Motility Study

BACKGROUND

Small bowel Crohn's disease (SBCD) is increasingly treated with biological therapies. Predicting response or remission (RoR) for individual patients is difficult and complicates treatment strategy. We aimed to determine if motility magnetic resonance imaging (mMRI) is superior to CRP and fecal calprotectin (FC) for the prediction of RoR at 1 year in patients commencing biologics for SBCD.

METHODS

Prospective, multicenter (n = 13) cohort study of patients with active non-stricturing SBCD requiring anti-TNFα or anti-IL-12/23 treatment. We measured mMRI and CRP at baseline and post-induction (visit 2: 12-30 weeks), and FC in a subset. RoR was assessed at 1 year using clinical and structural magnetic resonance enterography parameters. We compared sensitivity, specificity, and area under the receiver operating characteristic curve (ROC-AUC) of changes in mMRI and CRP to predict RoR at 1 year. Secondary outcomes compared mMRI with FC, and prediction of improved quality of life (QoL).

RESULTS

Eighty-six participants completed all assessments. Stable or improved mMRI at visit 2 was more sensitive than normalization of CRP for RoR (mMRI:71.0%, 95%CI 52.0-85.8; CRP:45.2%, 95%CI 27.3-64.0%, P = .008) but less specific (mMRI:30.9%, 95%CI 19.1-44.8; CRP:67.3%, 95%CI 53.3-79.3%, P < .001). There was no significant difference in ROC-AUC (mMRI:0.48; CRP:0.53, P = .65). Similar results were obtained for FC. None of mMRI, CRP, or FC predicted patient QoL at 1 year.

CONCLUSIONS

Although improved mMRI is more sensitive than CRP and FC to predict RoR at 1 year, it is less specific. No factor predicted patient QoL. Motility MRI remains a marker of disease activity at given timepoints.

Relapse Rates and Predictors for Relapse in Ulcerative Colitis and Crohn's Disease Patients After Discontinuation of Vedolizumab or Ustekinumab: The REVEUS Study

Background/Objectives: In the current era of tailored therapy, biologics such as vedolizumab (VDZ) and ustekinumab (UST) are increasingly administered to inflammatory bowel disease (IBD) patients. The decision to discontinue biologics after side effects or a lack of response is usually simple, but the decision to stop treatment in patients in remission is more difficult: to date, no study has been conducted to investigate the effects of VDZ or UST withdrawal. Our study aims to investigate the rates and predictors of relapse of IBD after the discontinuation of VDZ and UST during a well-controlled disease phase and to evaluate the response to retreatment. Methods: In this observational, multicenter, retrospective study, we included IBD patients who discontinued VDZ or UST during a well-controlled disease phase after at least 1 year of treatment. We collected demographic and clinical data for each patient at the time of discontinuation and at follow-up visits. Results: We included 36 IBD patients from 5 different centers; 80.0%, 58.5%, and 48.3% of patients maintained clinical remission at 12, 24, and 48 months after discontinuation, respectively. Crohn's disease (CD) patients were more likely to maintain remission than ulcerative colitis (UC) patients at 48 months (70.0% vs. 40.0%). No predictors of relapse were identified, but UC patients had a higher risk of early relapse than CD patients (HR = 3.23); 81.3% of retreated IBD patients achieved clinical remission after induction and at 12 months. Conclusions: No predictors of disease relapse after treatment discontinuation were identified. Half of the patients had a relapse within 48 months after discontinuation, but most of them achieved clinical remission after retreatment.

The Intestinal Mucin Isoform Landscape Reveals Region-Specific Biomarker Panels for Inflammatory Bowel Disease Patient Stratification

BACKGROUND AND AIMS

Mucosal healing is considered a key therapeutic endpoint in inflammatory bowel diseases (IBD) and comprises endoscopic improvement of inflammation without taking barrier healing into account. Mucins are critical components of the mucosal barrier function that give rise to structurally diverse isoforms. Unraveling disease-associated mucin isoforms that could act as an indication for barrier function would greatly enhance IBD management.

METHODS

We present the intestinal mucin RNA isoform landscape in IBD and control patients using a targeted mucin isoform sequencing approach on a discovery cohort (n = 106). Random Forest modeling (n = 1683 samples) with external validation (n = 130 samples) identified unique mucin RNA isoform panels that accurately stratified IBD patients in multiple subpopulations based on inflammation, IBD subtype (Crohn's disease [CD], ulcerative colitis [UC]), and anatomical location of the intestinal tract (i.e. ileum, proximal colon, distal colon, and rectum).

RESULTS

Particularly, the mucin RNA isoform panels obtained from the inflamed UC and CD distal colon showed high performance in distinguishing inflamed biopsies from their control counterparts (AUC of 93.3% and 91.1% in the training, 95.0% and 96.0% in the test, and 89.5% and 78.3% in the external validation datasets, respectively). Furthermore, the differentially expressed MUC4 (PB.1238.363), MUC5AC (PB.2811.15), MUC16 (ENST00000397910.8), and MUC1 (ENST00000462317.5 and ENST00000620103.4) RNA isoforms frequently occurred throughout the different panels highlighting their role in IBD pathogenesis.

CONCLUSIONS

We unveiled region-specific mucin RNA isoform panels capturing the heterogeneity of the IBD patient population and showing great potential to indicate barrier function in IBD patients.

Anti-integrin αvβ6 Antibodies Predict Pouchitis in Patients With Ulcerative Colitis After Restorative Proctocolectomy With Ileal Pouch-Anal Anastomosis

BACKGROUND

Pouchitis is the most common complication of restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We previously reported the presence of anti-integrin αvβ6 antibodies in the serum of patients with UC. This study investigated the association between anti-integrin αvβ6 antibodies and the development of pouchitis in patients with UC.

METHODS

Serum levels of anti-integrin αvβ6 antibodies were measured by enzyme-linked immunosorbent assay in 16 patients with UC who underwent RPC with IPAA. Integrin αvβ6 expression in the colonic, terminal ileal, and pouch epithelium was examined using immunohistochemistry and western blot analysis.

RESULTS

Anti-integrin αvβ6 antibody levels in patients with UC were significantly decreased at 3, 9, and 12 months after RPC (P < .05). However, in patients who developed pouchitis, antibody levels remained high. The antibody levels at the time of RPC were significantly higher in patients who developed pouchitis compared to those who did not. Kaplan-Meier analysis revealed a significantly higher incidence of pouchitis in patients with antibody levels above the cutoff at the time of RPC. Although integrin αvβ6 was not expressed in the terminal ileal epithelium at the time of RPC, expression became positive in the pouch epithelium of patients with pouchitis.

CONCLUSIONS

The anti-integrin αvβ6 antibody levels in patients with UC were decreased after RPC but remained high in patients who developed pouchitis. The antibody levels at the time of RPC may serve as a potential prognostic biomarker for predicting the risk of pouchitis in patients with UC.

Pan-enteric Capsule Endoscopy to Characterize Crohn's Disease Phenotypes and Predict Clinical Outcomes in Children and Adults: The Bomiro Study

BACKGROUND

Pan-enteric capsule endoscopy (PCE) provides useful information for the management of Crohn's disease (CD), especially in children. No study has evaluated the ability of PCE to characterize CD phenotypes and outcomes in children and adults.

METHODS

In a prospective multicenter observational study, we recruited patients with CD >6 years from 4 centers in Italy. Patients underwent clinical, biomarker assessment and PCE. Lesions were graded using the PCE system. For each segment, the most common lesion (MCL), the most severe lesion (MSL), and the extent of involvement were defined. Disease severity, extent, and clinical outcomes were compared between children and adults. A logistic regression analysis was used to identify predictive factors for negative outcomes in both age groups.

RESULTS

One hundred ninety-four consecutive patients (adults/children: 144/50) were evaluated for a total of 249 procedures. Children were more likely to have extensive disease, particularly in the colon. Higher MCL scores were independently associated with treatment escalation (odds ratio [OR], 4.09; 95% CI, 1.80-9.25; P = .001), while >30% disease extent was more indicative of clinical and endoscopic relapse (OR, 2.98; 1.26-7.08; P = .013). Disease extent was the only factor associated with endoscopic recurrence in children (OR, 4.50; 95% CI, 1.47-13.77; P = .008), while severe lesions in adults provided a better predictor of treatment escalation (OR, 4.31; 95% CI, 1.52-12.1; P = .006). Postexamination, PCE contributed to a change of therapy in 196/249 (79%) of the procedures.

CONCLUSIONS

PCE allowed the characterization of CD phenotypes in children and adults by assessing disease severity and extent, which are of different importance in predicting clinical outcomes in these age groups.

Circulating Extracellular Matrix Products as Indicators of Disease Burden and Predictors of Disease Course in Ulcerative Colitis

BACKGROUND

Ulcerative colitis (UC) is characterized by recurrent inflammation and challenging disease monitoring, with invasive endoscopy as the primary diagnostic tool despite the inadequacy of standard noninvasive biomarkers. This study evaluates serum extracellular matrix (ECM) fragments, which reflect the remodeling of mucosa and submucosa, as potential indicators of disease burden and treatment efficacy. We aim to determine whether serum ECM levels correlate with the extent and severity and predict treatment response.

METHODS

We conducted a prospective study comparing serum ECM formation (PRO-C3, PRO-C7, PRO-C11, PRO-C22), turnover (PRO-C4), and degradation markers (C1M, C3M, C4M, C7M) at Weeks 0, 12, and 24 in 49 UC patients and 50 healthy controls measured by enzyme-linked immunosorbent assay.

RESULTS

ECM biomarkers, notably PRO-C11, differentiated UC patients from controls (area under the curve [AUC] 0.77), and PRO-C3 predicted endoscopic treatment response vs nonresponse (AUC 0.74). C7M separated moderate from severe disease in endoscopy (AUC 0.74) as well as mild from severe disease (AUC 0.84), as did the ratio C7M/PRO-C7 (AUC 0.82). Combining new and conventional markers, including hemoglobin, C-reactive protein, PRO-C3, and PRO-C22, achieved a combined AUC of 0.84 for predicting 24-week endoscopic response, adding index endoscopic activity increased the AUC to 0.92 compared to an AUC of 0.84 for endoscopy alone.

CONCLUSIONS

Soluble ECM fragments reflect endoscopic disease severity and extent and are also predictive of therapeutic efficacy. They may as well reflect degenerative aspects of UC and may as such be future therapeutic targets aimed at prevention of intestinal damage.

Reducing diagnostic delays of extraintestinal manifestations in inflammatory bowel disease: a comparative study of a multidisciplinary outpatient clinic versus conventional referral specialists

Background

Managing extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) patients remains challenging due to considerable heterogeneity in diagnostic criteria and the lack of a standardised definition and validated diagnostic pathways. Delays in recognising and treating EIMs can lead to significant disease progression. Therefore, early detection and treatment are crucial.

Objectives

We aimed to assess the effectiveness of a dedicated immune-mediated inflammatory diseases (IMIDs) clinic in reducing EIM diagnostic delays and improving patients' outcomes.

Design

A single-centre observational study was conducted, including IBD patients presenting with EIMs red flags.

Methods

We compared the EIMs diagnostic delay between patients who attended a multidisciplinary IMID outpatient clinic (IMID-G) and those who attended individual referral specialists representing the standard outpatient clinic group (SOC-G). We further evaluated the impact of diagnostic timing on 18-month clinical outcomes, including therapeutic changes, steroid and immunosuppressant use and biological therapy switch/swap.

Results

We enrolled 238 IBD patients, 127 in the IMID-G and 111 in the SOC-G. The average time to EIM diagnosis was 2.48 ± 1.8 and 5.36 ± 2.3 months for the IMID and SOC-Gs (Δ = 2.88 months, p = 0.005). The majority of patients received a diagnosis of peripheral arthritis (IMID-G = 37.5%; SOC-G = 33.7%) and spondyloarthropathy (IMID-G = 32.1%; SOC-G = 33.7%). No significant difference was observed in the rates of EIMs between the two groups (88.2% in IMID-G vs 92.8% in SOC-G, p = 0.27). Regarding therapeutic changes, the IMID-G reported a mean time to the first therapeutic change driven by the specialist referral of 2.96 ± 1.8 months, compared to 6.09 ± 2.5 months in the SOC-G, showing a significant difference (p = 0.007). The IMID-G had a higher frequency of biological therapy switching/swapping and adding immunosuppressive treatment than the SOC-G (p = 0.008 and p = 0.04, respectively). Survival curves revealed a significant reduction in diagnostic delay and time to treatment in the IMID-G compared to the SOC-G (log-rank test, p < 0.001).

Conclusion

Attending a dedicated IMID clinic can enhance the diagnostic process for EIMs in IBD patients, thereby reducing diagnostic delays and allowing early interventions to avoid disease progression.

The diagnostic accuracy of plasma and serum calprotectin is inferior to C-reactive protein in patients with suspected Crohn's disease

BACKGROUND AND AIMS

Prior studies indicate that serum calprotectin (SC) and plasma calprotectin (PC) can be used as biomarkers in Crohn's disease (CD). The aim of this study was to investigate the diagnostic accuracy of SC and PC in patients with a clinical suspicion of CD.

METHOD

This biobank study included patients from a prospective, blinded, multicenter study examining minimally invasive modalities for diagnosing CD. Patients had a standardized work-up including ileocolonoscopy, pan-enteric capsule endoscopy, and blood samples within a 2-week period. Plasma and serum were stored at - 80 °C until further analysis. A routine C-reactive protein (CRP) was measured on the same day. Pan-endoscopy served as reference standard.

RESULTS

126 patients entered the study, and 58 (46.0%) were diagnosed with CD. Patients with CD had a median PC of 0.37 mg/L (IQR 0.20-0.70) compared to 0.29 mg/L (IQR 0.16-0.41) in non-CD patients (p = 0.03). The median SC was 1.09 mg/L (IQR 0.80-1.80) and 0.93 mg/L (IQR 0.66-1.25), respectively (p = 0.01). Receiver operating characteristics curves showed an AUC of 0.63 (CI 0.53-0.73) for SC and 0.61 (CI 0.51-0.71) for PC for detection of CD, which was inferior to that of CRP (AUC = 0.76, CI 0.68-0.85) (p < 0.02). None of the biomarkers reflected the endoscopic severity of CD.

CONCLUSION

Although levels of PC and SC are elevated in patients with CD, diagnostic accuracies are inferior to CRP. SC and PC are not reliable as stand-alone blood-based biomarkers for diagnosing CD and selecting patients for endoscopy.

Small bowel Crohn's disease: Proximal lesions linked to increased inflammation and biologic treatment needs

OBJECTIVE

Crohn's disease (CD) is heterogeneous, and proximal involvement in the small bowel (SB) is associated with worse outcomes. Nonetheless, studies on the impact of duodenal and jejunal lesions in SB CD are limited. This study aimed to investigate the clinical characteristics and outcomes of individuals diagnosed with SB CD, comparing those with and without proximal inflammation.

METHODS

A cohort of 53 treatment-naive SB CD patients that underwent Capsule Endoscopy at diagnosis were retrospectively selected. The inflammatory activity was quantified using the Lewis Score for each SB tertile.

RESULTS

Thirty-seven (69.8%) patients displayed inflammatory activity in the first and/or second tertile together with third tertile involvement (Proximal+T3 group). Sixteen (30.2%) had inflammation in the third tertile only (T3 group). Individuals in the Proximal+T3 group had a higher risk for moderate-to-severe inflammation (OR 4.93, 95% CI: 1.3-18.3, p=0.013). A subgroup analysis for those with mild inflammatory activity showed that individuals in the Proximal+T3 group initiated biologic drugs more often (OR 11, 95% CI: 1.1-109.7, p=0.036).

CONCLUSION

Proximal SB lesions are associated with increased inflammatory activity, necessitating more frequent use of biologics in patients with mild disease. Early detection of proximal SB CD with Capsule Endoscopy may contribute to timely treatment.

Position statement of the Spanish Society of Primary Care Physicians (SEMERGEN) and Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the management of inflammatory bowel disease in Primary Care

Primary Care is the first point of contact for most patients after the onset of symptoms of inflammatory bowel disease (IBD). Establishing an initial diagnostic process based on compatible symptoms and agreed criteria and referral pathways, depending on the degree of suspicion and the patient's situation, can reduce diagnostic delays. Once the patient is referred to the Digestive specialist and the diagnosis of IBD is established, a treatment and follow-up plan is structured. The management of the patient must be shared with the participation of the family practitioners in the diagnosis and treatment of concomitant or intercurrent pathologies, the recognition of flare-ups or complications (of IBD or treatments), education tasks or adherence control. With the purpose of developing a comprehensive guide on the management of IBD aimed at Primary Care doctors, we have developed this positioning document collaboratively between the Spanish Society of Primary Care Physicians (SEMERGEN) and the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU).

Network Meta-Analysis: Comparison of Endoscopic Dysplasia Detection Technologies in Inflammatory Bowel Disease

BACKGROUND

Novel colorectal cancer endoscopic surveillance techniques for inflammatory bowel disease (IBD) have recently been developed.

AIMS

Compare the efficacy of currently available techniques for dysplasia detection in colonic IBD.

METHODS

We conducted a systematic literature search from inception to March 2024 for randomized controlled trials (RCTs) or prospective cohort studies enrolling adults with IBD and having surveillance colonoscopy for dysplasia screening. Primary outcome was the number of dysplastic lesions (per-lesion analysis). Secondary outcome was the number of patients with dysplasia (per-patient analysis). We assessed endpoints using the frequentist NMA random effect model.

RESULTS

We included 25 studies (22 RCTs). 4837 patients met eligibility criteria (850 total dysplastic lesions; 105 with advanced dysplasia). Nine different screening techniques were studied. In per-lesion analysis, dye-based chromoendoscopy (DCE) ranked the highest (83%) per SUCRA ranking. DCE was superior to HD-WLE (OR, 1.78; 95% CI, 1.06-3.00). There were no significant differences between NBI and DCE, HD-WLE with SR or CEM in head-to-head comparisons. In a sub-analysis confined to ulcerative colitis (UC), DCE ranked highest (98%) with per-lesion analysis, and was superior to NBI (OR, 1.69; 95% CI, 1.03-2.77).

CONCLUSIONS

HD-WLE-SR, DCE and CEM demonstrated superiority over other techniques for detection of dysplasia in colonic IBD. DCE was superior for dysplasia detection in colonic IBD. DCE was superior to HD-WLE in colonic IBD. DCE was the best technique in UC. Further studies to compare HD-WLE-SR and NBI with DCE are warranted to ascertain performance equivalency and define the optimal surveillance technique.