Systematic Review: Patient Perceptions of Monitoring Tools in Inflammatory Bowel Disease

Composite Assessment Using Intestinal Ultrasound and Calprotectin Is Accurate in Predicting Histological Activity in Ulcerative Colitis: A Cohort Study

BACKGROUND

Beyond endoscopic remission, histological remission in ulcerative colitis (UC) is predictive of clinical outcomes. Intestinal ultrasound (IUS) may offer a noninvasive surrogate marker for histological activity; however, there are limited data correlating validated ultrasound and histological indices.

AIM

Our aim was to determine the correlation of IUS activity in UC with a validated histological activity index.

METHODS

Twenty-nine prospective, paired, same-day IUS/endoscopy/histology/fecal calprotectin (FC) cases were included. Intestinal ultrasound activity was determined using the Milan Ultrasound Criteria, histological activity using the Nancy Histological Index, endoscopic activity using Mayo endoscopic subscore and Ulcerative Colitis Endoscopic Index of Severity, and clinical activity using the Simple Clinical Colitis Activity Score.

RESULTS

Histological activity demonstrated a significant linear association with overall IUS activity (coefficient 0.14; 95% CI, 0.03-0.25; P = .011). Intestinal ultrasound activity was also significantly associated with endoscopic activity (0.32; 95% CI, 0.14-0.49; P < 0.001), total Mayo score (0.31; 95% CI, 0.02-0.60; P = .036) but not FC (0.10; 95% CI, -0.01 to 0.21; P = .064) or clinical disease activity (0.04; 95% CI, -0.21 to 0.28; P = .768). A composite of IUS and FC showed the greatest association (1.31; 95% CI, 0.43-2.18; P = .003) and accurately predicted histological activity in 88% of cases (P = .007), with sensitivity of 88%, specificity 80%, positive predictive value 95%, and negative predictive value 57%.

CONCLUSIONS

Intestinal ultrasound is an accurate noninvasive marker of histological disease activity in UC, the accuracy of which is further enhanced when used in composite with FC. This can reduce the need for colonoscopy in routine care by supporting accurate point-of-care decision-making in patients with UC.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

Fecal Biomarkers of Neutrophil and Eosinophil Origin Reflect the Response to Biological Therapy and Corticosteroids in Patients With Inflammatory Bowel Disease

INTRODUCTION

Fecal calprotectin (FC) is a noninvasive tool for examining response to biologics in inflammatory bowel disease (IBD), but its performance in relation to other novel fecal markers of various cellular origins is unknown.

METHODS

We performed a prospective multicenter cohort study and included patients with active IBD who provided a fecal sample at initiation of biological therapy. Levels of FC, myeloperoxidase (MPO), human neutrophil lipocalin (HNL), and eosinophil-derived neurotoxin (EDN) were analyzed and related to clinical remission status at 3 months. Changes in levels of markers at 3 months were calculated, and the impact of concomitant use of corticosteroids at baseline was estimated.

RESULTS

In patients achieving clinical remission (n = 27), a decrease in levels of FC ( P = 0.005), MPO ( P < 0.001), HNL ( P < 0.001), and EDN ( P < 0.001) was observed, whereas no significant decrease was seen in patients not achieving remission (n = 39). There was a significant difference in the change in the level of MPO ( P = 0.01) and HNL ( P = 0.02) between patients achieving clinical remission and those who did not, but changes in FC and EDN could not differentiate between these groups. Patients with concomitant systemic corticosteroids at inclusion had lower levels of HNL ( P = 0.01) and EDN ( P < 0.001) at baseline, compared with patients without corticosteroids.

DISCUSSION

Fecal MPO, HNL, and EDN are all promising biomarkers for assessing the treatment outcome of biologics in patients with IBD. Fecal levels of EDN and HNL are significantly affected by corticosteroids indicating a greater sensitivity to the effects of corticosteroids compared with levels of FC and MPO.

Small bowel imaging in inflammatory bowel disease: updates for 2023

INTRODUCTION

Cross-sectional imaging techniques including MR and CT enterography and ultrasound are integral to Crohn's disease management, accurate, responsive, and well tolerated. They assess the full thickness of the bowel wall, perienteric environment, and distant complications. As we strive toward tighter disease control, imaging's role will expand further with transmural healing becoming an increasingly important therapeutic target.

AREAS COVERED

MEDLINE and Web of Science were searched from 2012 to 2023 inclusive. We review the evidence for cross-sectional imaging in assessing disease activity, phenotyping, and therapeutic response assessment. Emerging novel imaging applications such as quantifying enteric motility and fibrosis, prognostication, and potential utility of artificial intelligence will be covered. Recent international consensus statements highlight the need for standardized imaging reporting and definitions of transmural healing and remission. We will discuss how recent advances may be best integrated into patient care and highlight key outstanding research questions.

EXPERT OPINION

Cross-sectional imaging is established in Crohn's disease management. Research emphasis should be placed on optimal integration of imaging modalities in clinical care pathways, workforce training, definitions, and evidence for use of imaging based therapeutic targets such as transmural healing, better phenotyping of stricturing disease, and developing novel techniques, including integration of artificial intelligence.

Integrating Intestinal Ultrasound into an Inflammatory Bowel Disease Practice: How to Get Started

Intestinal ultrasound (IUS) offers a safe, noninvasive, point-of-care tool for diagnosing and monitoring disease activity in patients with inflammatory bowel disease (IBD). IUS is used widely in Europe and Canada for IBD, but it remains underutilized in the United States. Growing interest in IUS in the United States has prompted many IBD centers to train their faculty in IUS. This, however, raises questions about how to effectively use this new tool in the United States, which does not use a social medicine model like those implemented in Europe and Canada. Here, we provide a practical framework for incorporating IUS in an IBD practice in the United States, including training requirements, equipment, and protocols for implementing IUS in daily practice.

Aptamer-Functionalized Microbubbles Targeted to P-selectin for Ultrasound Molecular Imaging of Murine Bowel Inflammation

PURPOSE

Our objectives were to develop a targeted microbubble with an anti-P-selectin aptamer and assess its ability to detect bowel inflammation in two murine models of acute colitis.

PROCEDURES

Lipid-shelled microbubbles were prepared using mechanical agitation. A rapid copper-free click chemistry approach (azide-DBCO) was used to conjugate the fluorescent anti-P-selectin aptamer (Fluor-P-Ap) to the microbubble surface. Bowel inflammation was chemically induced using 2,4,6-trinitrobenzenesulfonic acid (TNBS) in both Balb/C and interleukin-10-deficient (IL-10 KO) mice. Mouse bowels were imaged using non-linear contrast mode following an i.v. bolus of 1 × 10⁸ microbubbles. Each mouse received a bolus of aptamer-functionalized and non-targeted microbubbles. Mouse phenotypes and the presence of P-selectin were validated using histology and immunostaining, respectively.

RESULTS

Microbubble labelling of Fluor-P-Ap was complete after 20 min at 37 ̊C. We estimate approximately 300,000 Fluor-P-Ap per microbubble and confirmed fluorescence using confocal microscopy. There was a significant increase in ultrasound molecular imaging signal from both Balb/C (p = 0.003) and IL-10 KO (p = 0.02) mice with inflamed bowels using aptamer-functionalized microbubbles in comparison to non-targeted microbubbles. There was no signal in healthy mice (p = 0.4051) using either microbubble.

CONCLUSIONS

We constructed an aptamer-functionalized microbubble specific for P-selectin using a clinically relevant azide-DBCO click reaction, which could detect bowel inflammation in vivo. Aptamers have potential as a next generation targeting agent for developing cost-efficient and clinically translatable targeted microbubbles.

Crohn's Disease Patient Experiences and Preferences With Disease Monitoring: An International Qualitative Study

Background

Strategies incorporating objective disease monitoring in Crohn's disease (CD), beyond clinical symptoms are important to improve patient outcomes. Little evidence exists to explore patient understanding of CD treatment goals, nor preferences and experiences with monitoring options. This qualitative study aimed to explore patient experiences and preferences of CD monitoring to inform monitoring strategies, improve patient engagement, and optimize a patient-centered approach to care.

Methods

This study used a patient-oriented, qualitative descriptive design. Convenience and snowball sampling were used to recruit adult participants diagnosed with CD who had experience with at least 2 types of disease monitoring. Online focus groups were conducted and data were analyzed using thematic analysis.

Results

This international study included 37 participants from Australia, Canada, United Kingdom, and the United States. Overall, participants preferred more noninvasive types of monitoring [eg, intestinal ultrasound (IUS)] but were willing to undergo more invasive monitoring (eg, colonoscopy) if required. To improve disease monitoring, participants wanted increased access to IUS, establishment of a patient-centered interdisciplinary team and access to information and self-testing. Participants identified challenges with communication between patients and providers and stressed the importance of participating in shared decision making and being equal team members in their care.

Conclusions

It is imperative to incorporate patient-driven preferences into how we can best structure monitoring strategies, to ensure equitable access to those preferred modalities and embrace a shared decision-making approach to disease management in CD.

Pediatric Patient and Caregiver Satisfaction With the Use of Transabdominal Bowel Ultrasound in the Assessment of Inflammatory Bowel Diseases

OBJECTIVES

Transabdominal bowel ultrasound (TABUS) is emerging as an attractive, noninvasive tool in inflammatory bowel disease (IBD). Patient and caregiver experience with TABUS is not well described. We aimed to determine pediatric patient and caregiver satisfaction with TABUS and the impact of IBD severity, gender, age, and a history of anxiety on satisfaction.

METHODS

Pediatric patients (0-18 years old) with suspected IBD prospectively underwent baseline TABUS, magnetic resonance enterography (MRE), blood work, stool studies, and endoscopy. Patients and their caregiver each completed a cross-sectional satisfaction questionnaire (5-point Likert scale) after the baseline investigations.

RESULTS

There were 54 patients included (67% male). The majority were completely satisfied and strongly agree TABUS was better tolerated than other investigations, regardless of disease severity ( P > 0.05). Patients with higher Simple Endoscopic Score for Crohn Disease (SES-CD) scores felt that TABUS increased their understanding of their IBD ( P < 0.05) and disease location ( P < 0.05). Patients with Crohn disease had similar responses to those with ulcerative colitis, but more strongly agreed that TABUS was better than MRE and endoscopy ( P < 0.05). Those with anxiety did not have an increased level of worry about potential ultrasound findings ( P > 0.05).

CONCLUSIONS

Pediatric patients and their caregivers were highly satisfied with TABUS, preferring it to other modalities. It did not lead to increased worry, and was particularly important in those with severe IBD. These findings support wider implementation of this well tolerated and preferred monitoring tool in pediatrics.

Recent advances in clinical practice: advances in cross-sectional imaging in inflammatory bowel disease

Endoscopy remains the reference standard for the diagnosis and assessment of patients with inflammatory bowel disease (IBD), but it has several important limitations. Cross-sectional imaging techniques such as magnetic resonance enterography (MRE) and intestinal ultrasound (IUS) are better tolerated and safer. Moreover, they can examine the entire bowel, even in patients with stenoses and/or severe inflammation. A variety of cross-sectional imaging activity scores strongly correlate with endoscopic measures of mucosal inflammation in the colon and terminal ileum. Unlike endoscopy, cross-sectional techniques allow complete visualisation of the small-bowel and assess for extraintestinal disease, which occurs in nearly half of patients with IBD. Extramural findings may predict outcomes better than endoscopic mucosal assessment, so cross-sectional techniques might help identify more relevant therapeutic targets. Coupled with their high sensitivity, these advantages have made MRE and IUS the primary non-invasive options for diagnosing and monitoring Crohn's disease; they are appropriate first-line investigations, and have become viable alternatives to colonoscopy. This review discusses cross-sectional imaging in IBD in current clinical practice as well as research lines that will define the future role of these techniques.

Health Confidence Is Associated With Disease Outcomes and Health Care Utilization in Inflammatory Bowel Disease: A Nationwide Cross-sectional Study

BACKGROUND

We aimed to examine the associations between health confidence (one's belief on the degree of control on their health and disease), inflammatory bowel disease (IBD) outcomes, and health care utilization among adults with IBD.

METHODS

In total, 17,205 surveys were analyzed from a cross-sectional sample of IBD patients at 23 gastroenterology (GI) practices participating in the Crohn's and Colitis Foundations' IBD Qorus Learning Health System. We used bivariate analyses and multivariable logistic regression to examine associations between health confidence and disease activity, opioid use, glucocorticoid use, well-being, and health care utilization. We used receiver operating curve analysis to determine a clinically relevant cutoff for health confidence (0-10 Likert scale).

RESULTS

Health confidence was highly correlated with patients' well-being, symptomatic disease activity, opioid use, and glucocorticoid use (all P < .0001). Health confidence scores <8 had 69% sensitivity for emergency department (ED) visits and 66% for hospitalizations. In patients with inactive disease, patients with low health confidence (<8) were 10 times more likely to call/message the GI office >4 times/month (adjusted odds ratio [aOR], 10.3; 95% CI, 6.1-17.3; P < .0001), 3-4 times more likely to have an IBD-related ED visit (aOR, 4.0; 95% CI, 2.9, 5.4. P < .0001), or hospitalization (aOR, 3.0, 95% CI, 2.1, 4.1, P < .0001) compared with patients with high health confidence (≥8).

CONCLUSIONS

In a large, national sample of adults with IBD, there were strong associations between patients' health confidence and multiple disease outcome measures. Health confidence scores <8 on a 0-10 Likert scale may be clinically useful to screen for patients who are at risk for ED visits and hospitalizations.

Positioning intestinal ultrasound in a UK tertiary centre: significant estimated clinical role and cost savings

OBJECTIVE

Intestinal ultrasound (IUS) is an inexpensive, non-invasive method of diagnosing and monitoring inflammatory bowel disease (IBD). We aimed to establish the proportion of lower gastrointestinal endoscopies (LGIEs) and magnetic resonance enterographies (MREs) that could have been performed as IUS, the potential pathology miss-rates if IUS was used and the associated cost savings.

METHODS

All MREs and LGIEs performed for either assessment of IBD activity or investigation of possible IBD, performed at a single UK tertiary centre in January 2018, were retrospectively reviewed against predetermined criteria for IUS suitability. Case outcomes were recorded and cost of investigation if IUS was performed instead was calculated.

RESULTS

73 of 260 LGIEs (28.1%) and 58 of 105 MREs (55.2%) met the criteria for IUS suitability. Among potential IUS-suitable endoscopy patients, one case each of a <5 mm adenoma and sessile serrated lesion were found; no other significant pathology that would be expected to be missed with IUS was encountered. Among IUS-suitable MRE patients, no cases of isolated upper gastrointestinal inflammation likely to be missed by IUS were found, and extraintestinal findings not expected to be seen on IUS were of limited clinical significance. The predicted cost saving over 1 month if IUS was used instead was £8642, £25 866 and £5437 for MRE, colonoscopy and flexible sigmoidoscopy patients, respectively.

CONCLUSION

There is a significant role for IUS, with annual projected cost savings of up to almost £500 000 at our centre. Non-inflammatory or non-gastrointestinal pathology predicted to be missed in this cohort was of limited clinical significance.

Toward transmural healing: Sonographic healing is associated with improved long-term outcomes in patients with Crohn's disease

BACKGROUND AND AIMS

Transmural healing has emerged as a treatment target in Crohn's disease (CD). We investigated whether transmural healing assessed with intestinal ultrasound (IUS) is associated with improved clinical outcomes in patients with CD in clinical remission.

METHODS

Patients with CD in clinical remission at baseline (HBI <4) having IUS between August 2017 and June 2020 with at least 6-months' follow-up were retrospectively studied. Time to medication escalation, corticosteroid use and CD-related hospitalisation or surgery were compared by the presence or absence of sonographic healing, defined as bowel wall thickness ≤3 mm without hyperemia on color Doppler, inflammatory fat, or disrupted bowel wall stratification. Factors associated with survival were analyzed by Kaplan-Meier analysis using Cox proportional-hazard model.

RESULTS

Of 202 consecutive patients (50% male), sonographic inflammation was present in 61%. During median follow-up of 19 (IQR 13-27) months, medication escalation occurred in 52%, corticosteroid use in 23%, hospitalisation in 21%, and CD-related surgery in 13%. Sonographic healing was significantly associated with a reduced risk of medication escalation (p = 0.0018), corticosteroid use (p = 0.0247), hospitalisation (p = 0.0102), and surgery (p = 0.083). On multivariable analysis, sonographic healing was significantly associated with an increased odds of medication escalation-free survival (hazard ratio [HR]:1.94; 95% CI 1.23-3.06; p = 0.004) and corticosteroid-free survival (HR:2.41; 95% CI 1.24-4.67; p = 0.009), but not with hospitalisation or surgery.

CONCLUSION

In patients with CD in clinical remission, sonographic healing is associated with improved clinical outcomes. Further studies are needed to determine whether sonographic healing should be a treatment target.

Review article: randomised controlled trials in inflammatory bowel disease-common challenges and potential solutions

BACKGROUND

Recruitment rates for Crohn's disease and ulcerative colitis clinical trials continue to decrease annually. The inability to reach recruitment targets and complete trials has serious implications for stakeholders in the inflammatory bowel disease (IBD) community. Action is required to ensure patients with an unmet medical need have access to new therapies to improve the management of their IBD.

AIMS

Identify challenges contributing to recruitment decline in IBD clinical trials and propose potential solutions.

METHODS

PubMed and Google were used to identify literature, regulatory guidelines and conference proceedings related to IBD clinical trials and related concepts. Data on IBD clinical trials conducted between 1989 and 2020 were extracted from the Trialtrove database.

RESULTS

Key aspects that may improve recruitment rates were identified. An increasingly patient-centric approach should be taken to study design including improvements to the readability of key trial documentation and inclusion of patient representatives in trial planning. Placebo is unappealing to patients; approaches including platform trials should be explored to minimise placebo exposure. Non-invasive imaging, biomarkers and novel digital endpoints should continue to be examined to reduce the burden on patients. Reducing the administrative burden associated with trials via the use of electronic signatures, for example, may benefit study sites and investigators. Changes implemented to IBD trials during the COVID-19 pandemic provided examples of how trial conduct can be rapidly and constructively adapted.

CONCLUSIONS

To improve recruitment in Crohn's disease and ulcerative colitis trials, the IBD community should address a broad range of issues related to clinical trial conduct.

The child's perception on monitoring inflammatory bowel disease activity

To determine the perception of children with inflammatory bowel disease (IBD) regarding monitoring tests, we first compared the reported discomfort and patient perspective during gastro-intestinal (GI)-endoscopy, magnetic resonance entrography (MRE), and ultrasound (US) and, in a second comparison, patient preference on non-invasive tests (venipuncture, sampling stool and US). A cross-sectional study in children 8-18 years undergoing an US, MRE, and GI-endoscopy for diagnosis or follow-up of IBD. After each procedure, the children filled out the Discomfort during research procedures questionnaire (DISCO-RC). Items of the DISCO-RC are as follows: nervousness, annoyance, pain, fright, boredom, and tiredness. Answers range from "not" (= 0 points) to "extremely" (= 4 points) (range total score: 0-24). Differences between the procedures were assessed with Friedman test, with subsequent Wilcoxon signed-rank test. The children were also asked which non-invasive test they preferred not to undergo regularly (venipuncture, stool-sampling, or US). Answers were analyzed with χ²-test. Forty-nine patients (27 (55%) female, median age 15 (range 9-17)) were included. The children reported to be most nervous, frightened, and tired after GI-endoscopy (median: 1, 1, 2 points, respectively), equally annoyed by MRE and GI-endoscopy (median 1 point), and equally bored by MRE and US. GI-endoscopy was ranked as most discomfortable, followed by MRE and US (total DISCO-RC scores: 7 vs. 5 vs. 2, p < 0.001). Most of the children preferred not to sample stool or perform venipuncture regularly (n = 20 (41%, both) (p < 0.001)).Conclusion: Our results suggest that the children with IBD report low discomfort after US, MRE, and GI-endoscopy. US is preferred as a monitoring tool, also among non-invasive monitoring tests. GI-endoscopy was most discomfortable. What is Known: • Children with inflammatory bowel disease need to be monitored frequently for disease activity. • Adult studies - including a systematic review - on acceptability of monitoring tools among IBD patients showed mixed results. What is New: • Children in our study ranked gastro-intestinal endoscopy as most discomfortable, followed by MRE and US. • With regard to non-invasive monitoring, most children preferred not to sample stool or perform venipuncture regularly, and preferred US.

Intestinal Ultrasound to Evaluate Treatment Response During Pregnancy in Patients With Inflammatory Bowel Disease

INTRODUCTION

Active disease in inflammatory bowel disease patients during pregnancy is associated with poor maternal and fetal outcomes. Objective evaluation of disease activity is a core strategy in IBD, and during pregnancy noninvasive modalities are preferred. We aimed to evaluate feasibility and accuracy of intestinal ultrasound (IUS) to objectify disease activity throughout pregnancy.

METHODS

Pregnant patients with known IBD were included and followed throughout pregnancy for clinical disease activity, with fecal calprotectin (FCP) and with IUS every trimester. Feasibility of IUS was assessed for all colonic segments and terminal ileum (TI). Intestinal ultrasound outcomes to detect active disease and treatment response were compared with clinical scores combined with FCP.

RESULTS

In total, 38 patients (22 CD, 16 UC) were included, with 27 patients having serial IUS. Feasibility of IUS decreases significantly in third trimester for TI (first vs third trimester: 91.3% vs 21.7%, P < .0001) and sigmoid (first vs third trimester: 95.6% vs 69.5%, P = .023). Intestinal ultrasound activity showed moderate to strong correlation with clinical activity (r = 0.60, P < .0001) and FCP (r = 0.73, P < .0001). Throughout pregnancy, IUS distinguished active from quiescent disease with 84% sensitivity and 98% specificity according to FCP combined with clinical activity. IUS showed disease activity in >1 segment in 52% of patients and detected treatment response with 80% sensitivity and 92% specificity.

CONCLUSIONS

IUS is feasible and accurate throughout pregnancy, although visualization of the sigmoid and TI decreases in the third trimester. IUS provides objective information on disease activity, extent, and treatment response, even during second and third trimester, and offers a noninvasive strategy to closely monitor patients during pregnancy.

Understanding attitudes, concerns, and health behaviors of patients with inflammatory bowel disease during the coronavirus disease 2019 pandemic

BACKGROUND AND AIM

The coronavirus disease 2019 (COVID-19) pandemic has led to a rapid shift in care delivery models for patients with inflammatory bowel disease (IBD); however, little is known about patient perceptions during this period. We aimed to prospectively evaluate the attitudes, concerns, and health behavior of IBD patients during COVID-19.

METHODS

An online survey was sent to patients from a tertiary IBD Service. The survey included demographic information and questions about the impact of COVID-19, levels of concern caused by COVID-19, perceived risk of IBD medications, medication cessation, and care delivery preferences.

RESULTS

Of 97 respondents (39%), 95 (98%) reported concern about the impact of COVID-19 on their health, and 43% felt their risk of contracting COVID-19 was above average; 62% reported concern about medication-induced COVID-19 risk, and 11% stopped medications because of COVID-19. Patients considered all medications to increase the risk of COVID-19 susceptibility and severity; 45% preferred telehealth while 16% preferred face-to-face clinic reviews. Preference for IBD monitoring tools in decreasing order was blood testing, stool collection, gastrointestinal ultrasound, magnetic resonance enterography, and then colonoscopy.

CONCLUSIONS

Patients with IBD are demonstrated to experience concern related to their diagnosis and medications. The insights provided by the survey are informative for a possible "second-wave" of COVID-19 and routine care, including acceptance of telemedicine, preference for non-invasive investigations, and a need for dissemination of information and education.

Patient perceptions of current and potential inflammatory bowel disease diagnostic and monitoring tests

BACKGROUND

Less invasive inflammatory bowel disease (IBD) tests are increasingly being incorporated into clinical practice as adjuncts to endoscopy to monitor disease activity and guide optimal care. Little is known about patient perspectives of these tests.

AIMS

To assess patient perspectives of the current IBD tests and potential future tests, such as saliva, urine or breath.

METHODS

New Zealand adults with IBD were invited to complete an anonymous online survey. Experiences relating to blood or faecal tests, medical imaging (abdominal ultrasound, abdominal computerised tomography and magnetic resonance enterography) and colonoscopy were collected.

RESULTS

Of the 117 completed surveys, 112 respondents provided background details. The majority (85%) of participants were female and 88% were under 55 years of age with a mean disease duration of 8.98 years. General blood tests were reported as the most prescribed, completed, comfortable test and the least worrying test results. Imaging tests were reported as the least ordered and the most refused tests. Colonoscopy was rated as the least comfortable and generated the most worry. Test explanations by a referring clinician significantly impacted on respondents' levels of understanding across all tests, but did not affect the level of worry when receiving test results. Saliva, blood and breath tests were chosen as the most preferred disease monitoring tests.

CONCLUSION

Patients with IBD preferred any tests less invasive than colonoscopy. An explanation by referring doctor enhanced patients' understanding, but did not necessarily influence their level of comfort or worry. This article is protected by copyright. All rights reserved.

Patients' perception of colonoscopy and acceptance of colonoscopy based IBD related colorectal cancer surveillance

OBJECTIVES

Patients with Inflammatory Bowel Disease (IBD) are at an increased risk of colorectal cancer (CRC). Current surveillance for CRC involves often uncomfortable colonoscopy. To assess IBD patients' perception of colonoscopy and examine preferences for hypothetical alternatives.

METHODS

IBD patients in clinical remission rated acceptable frequency of colonoscopy and hypothetical alternatives to colonoscopy-based surveillance (preference of yearly blood, yearly stool or 5-yearly imaging tests over 5-yearly colonoscopy). Participants rated discomfort of the last colonoscopy was compared with hospital records.

RESULTS

Of 282 patients with recollection of colonoscopy 65.8% rated the discomfort as moderate to severe, which correlated weakly with endoscopists' perception (r = 0.225; p = 0.015). There were no significant differences in patients' or endoscopists' perceptions of discomfort between sedated and unsedated colonoscopies. Undergoing a yearly colonoscopy was acceptable to 49.5%. Experienced discomfort did not correlate with patients' views on acceptable frequency of surveillance colonoscopy. Over 95% of patients would prefer blood, stool, or imaging tests over colonoscopy but nearly half expected sensitivities ≥95%.

CONCLUSION

A large proportion of IBD patients experienced colonoscopy as moderate to severely uncomfortable but would still accept colonoscopy surveillance frequency according to current guidance. Participants expected sensitivities ≥95% for potential alternatives to colonoscopy-based surveillance programs.

EXPERT OPINION

IBD patients frequently experience colonoscopy as uncomfortable but accept colonoscopy as the gold standard for colorectal cancer surveillance. The currently suggested frequencies of surveillance by colonoscopy are acceptable to IBD patients. They do however express a clear preference for non-invasive surveillance techniques. Some promising initial results have been obtained based on faecal or blood sampling. However, these have yet to be tested in large prospective studies to determine their sensitivity and specificity. IBD patients expect these non-invasive tests to meet high standards for sensitivity. In our view it is feasible that analogue to faecal immunochemistry based testing for general population bowel cancer screening non-invasive IBD surveillance techniques will emerge. This could lead to a reduction in the need for colonoscopy to those testing positive on faecal or blood based surveillance.