Endoscopic ultrasound of the colon for the differentiation of Crohn's disease and ulcerative colitis in comparison with healthy controls

Evaluation of deep remission with through-the-scope catheter-based EUS during double-balloon enteroscopy in small-bowel Crohn's disease

BACKGROUND AND AIMS

Evaluation of deep remission in Crohn's disease (CD) can be challenging when the disease is confined to the small intestine. The aim of this study was to evaluate the effectiveness of through-the-scope EUS during double-balloon enteroscopy (DBE-EUS) in distinguishing small-bowel CD patients in endoscopic remission from those with active disease.

METHODS

Patients who underwent DBE-EUS were divided into groups of endoscopic remission and endoscopic activity according to segmental Simple Endoscopic Score for Crohn's Disease (SES-CD). The thickness of small intestinal wall layers and other parameters were evaluated by EUS.

RESULTS

EUS using an ultrasonic catheter probe by DBE showed that the total wall thickness (TWT) and submucosal thickness (SMT) of the small intestine in the active group were significantly greater than those in the remission group (3.84 ± 1.02 mm vs 2.42 ± .25 mm and 1.23 ± .34 mm vs .79 ± .13 mm, respectively; P < .001). Cutoff values of 2.65 mm for TWT and .95 mm for SMT can distinguish active small-bowel CD from inactive disease (sensitivity 91.5% and specificity 80.8% and sensitivity 70.2% and specificity 88.6%, respectively). The correlation analysis revealed a significant positive correlation between TWT and SES-CD (r =.930, P < .001). Furthermore, TWT was strongly correlated with fecal calprotectin (r = .861, P < .001) and Crohn's Disease Activity Index (r = .805, P < .001). Similar results were observed for SMT.

CONCLUSIONS

EUS using an ultrasonic catheter probe during DBE is effective in evaluation of both mucosal and transmural healing in small-bowel CD patients. DBE-EUS could become an important tool in the management of patients with small-bowel CD.

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.

A Hepatic Oxidative Metabolite of Palmatine Ameliorates DSS-Induced Ulcerative Colitis by Regulating Macrophage Polarization Through AMPK/NF-κB Pathway

Palmatine (PAL) and berberine are both classified as protoberberine alkaloids, derived from several traditional Chinese herbs such as Coptis chinensis Franch. and Phellodendron chinense Schneid. These compounds are extensively used in treating dysentery and colitis. PAL is one of the crucial quality markers for these plants in the Chinese Pharmacopoeia. A key metabolite of PAL, 8-Oxypalmatine (OPAL), shows favorable anti-inflammatory activity and better safety compared to PAL, though its mechanisms in ulcerative colitis (UC) are not fully understood. This study used a dextran sodium sulfate-induced colitis mouse model to explore OPAL's effects. The results indicated that OPAL provided superior therapeutic effects to those of PAL, alleviating colitis symptoms and reducing colon inflammation by modulating pro-inflammatory (tumor necrosis factor-α, interleukin-1β, and interleukin-6) and anti-inflammatory (transforming growth factor-β and interleukin-10) cytokines. Additionally, OPAL helped rebuild the mucus barrier and upregulated tight junction proteins, thereby restoring intestinal integrity. Notably, OPAL inhibited the M1 macrophages infiltration while promoting M2 macrophage distribution in the colon. Its role in fostering M2 polarization and modulating the inflammatory cytokine profile was further confirmed in vitro. Importantly, the anti-inflammatory effects were primarily linked to AMP-activated protein kinase activation, which subsequently inhibited the nuclear factor-kappa B pathway. These findings highlight OPAL as a crucial active metabolite responsible for the therapeutic effects of PAL against UC, emphasizing its potential as a novel treatment for this condition.

Role of Endoscopic Ultrasound in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

Inflammatory bowel disease-related complications are associated with a decreased quality of life, requirement for surgery, and increased morbidity. Endoscopic ultrasound (EUS) is accurate at identifying and characterizing perianal fistulae and abscesses and helps guide treatment decisions. EUS also allows us to accurately assess for mucosal and transmural inflammation and thus can help differentiate Crohn's disease from ulcerative colitis (UC). EUS use can help predict dysplasia in UC, and monitoring transmural inflammation can help assess response to treatment. In addition to diagnostic EUS, therapeutic EUS techniques have been used to endoscopically drain abscesses and bypass strictures in Crohn's disease.

Application Value of Endoscopic Ultrasonography in Diagnosis and Treatment of Inflammatory Bowel Disease

Inflammatory bowel disease refers to a group of non-specific inflammatory illnesses affecting the gastrointestinal tract. According to pathogenic characteristics, it is divided into Ulcerative colitis and Crohn's disease. The exact cause and pathogenic mechanism of these disorders are not yet fully understood. In addition, there is currently no definitive diagnostic method for inflammatory bowel disease, which mainly depends on clinical symptoms, blood testing, imaging investigations, and endoscopic examination, which includes histology. Endoscopic Ultrasonography is a digestive tract examination technique that combines endoscopy and ultrasound. Compared to conventional endoscopy, it can visualize surface and deep lesions of the gastrointestinal wall, as well as provide information on the characteristics of the surrounding layers and nearby lymph nodes. Due to these advantages, Endoscopic Ultrasonography has played a significant role in the evaluation of inflammatory bowel disease in recent years. Through this work, we aim to identify the applications of this method in the case of patients with inflammatory bowel disease.

Ultrasound Features of Helicobacter pylori-Related Gastritis

Background Abdominal ultrasound (US) is a reliable method for visualizing gastric wall layers and measuring their thickness. The objective of this study is to characterize the ultrasound features of H. pylori-induced gastritis and assess its predictive potential role for this condition. Methods A cohort of 119 patients underwent gastroscopy with biopsy and abdominal US to evaluate antral wall thickness (AWT), submucosal wall thickness (SLT), mucosal wall thickness (MLT), gastric motility, and the presence of ingested material. They were divided into three groups: group A (normal mucosa without H. pylori infection), group B (gastritis H. pylori negative) and group C (gastritis H. pylori positive). Results: SLT and reduced gastric motility were significantly increased in the H. pylori gastritis group (p < 0.001). Multivariate analysis identified SLT as the only significant independent predictor of H. pylori gastritis (p < 0.001). An SLT threshold of 1.55 mm was determined as optimal for differentiating H. pylori-positive patients from -negative, yielding a sensitivity of 77% and a specificity of 72%. Conclusions These findings suggest that H. pylori gastritis is characterized by submucosal layer thickening and impaired gastric motility.

Inflammatory bowel disease uncovered in fecal immunochemical test positive patients in a Canadian provincial colon cancer screening program

Inflammatory Bowel Disease (IBD) is a chronic inflammatory condition that usually affects younger adults but has a second incidence peak in the older population. Although diagnosis of IBD is driven by symptoms, some patients are asymptomatic and incidentally discovered while participating in colon screening program (CSP). We aimed to identify the incidence and outcome of IBD in fecal immunochemical test (FIT) positive patients in the British Columbia CSP. We conducted a retrospective chart review of patients who had colonoscopies for positive FIT and were found to have colitis based on endoscopic and histological assessment. Of 93,994 patients who underwent screening colonoscopy for positive FIT between 2009 and 2017, 608 (0.6%) were found to have colitis. From 11 CSP sites, 191 patients met the inclusion criteria. 58 patients (30.4%) were diagnosed with ulcerative colitis, 109 (57.1%) with Crohn's disease (CD), and 24 (12.6%) with IBD unclassified. 124 patients (64.9%) received treatment, of which 34 (17.8%) received biologics and 4 (2.1%) required surgery. Our study demonstrated a clinically significant incidence of IBD, with novel finding of CD predominance, within a Canadian provincial CSP. Further research is needed to guide management of older patients with varying rates of IBD progression after incidental diagnosis.

Combined gray scale ultrasonography and doppler diagnostic tools with strain elastography in assessment of inflammatory bowel disease in pediatrics patients

BACKGROUND

Intestinal changes in inflammatory bowel disease (IBD) are frequently observed on ultrasound. Invasive diagnostic procedures are often employed to differentiate between the main types of IBD and detect complications. Ultrasound Strain Elastography (SE) is a promising non-invasive technique for detecting intestinal changes and assessing inflammatory activity in pediatric IBD.

AIM OF THE STUDY

This research aims to evaluate the diagnostic performance of conventional ultrasound, color Doppler, and SE in assessing inflammatory bowel disease in pediatric patients, both separately and in combination as additional tools.

PATIENTS AND METHODS

Forty patients (18 females and 22 males) initially diagnosed with IBD through clinical and endoscopic biopsy, along with 20 healthy controls, underwent conventional ultrasound, color Doppler, SE, and laboratory evaluations, including CBC, ESR, CRP, Fecal calprotectin, and assessment of IBD activity using PIBDAI.

RESULTS

Conventional ultrasound, color Doppler, and SE significantly contributed to detecting disease activity and intestinal changes in IBD (p < 0.001; 95% CI 0.79-1.100), demonstrating better sensitivity in combination compared to each method individually. The combined approach showed 100% sensitivity, 84% specificity, 78.6% precision (Positive Predictive Value), 100% Negative Predictive Value, and an overall accuracy of 92%.

CONCLUSION

The addition of Color Doppler and SE parameters to grayscale ultrasound provides diagnostic value comparable to endoscopy, histopathology, and laboratory markers in detecting inflammatory activity and intestinal changes in IBD. This combined approach can help avoid unnecessary invasive techniques for follow-up.

Contrast-Enhanced Endoscopic Ultrasound Detects Early Therapy Response Following Anti-TNF Therapy in Patients with Ulcerative Colitis

BACKGROUND AND AIMS

Though colonoscopy plays a crucial role in assessing active ulcerative colitis [aUC], its scope is limited to the mucosal surface. Endoscopic ultrasound [EUS] coupled with contrast-enhancement [dCEUS] can precisely quantify bowel wall thickness and microvascular circulation, potentially enabling the quantitative evaluation of inflammation. We conducted a prospective, longitudinal study to assess therapy response using dCEUS in aUC patients undergoing treatment with adalimumab [ADA] or infliximab [IFX].

METHODS

Thirty ADA- and 15 IFX-treated aUC patients were examined at baseline and at 2, 6, and 14 weeks of therapy and 48 weeks of follow-up. Bowel wall thickness [BWT] was measured by EUS in the rectum. Vascularity was quantified by dCEUS using rise time [RT] and time to peak [TTP]. Therapy response was defined after 14 weeks using the Mayo Score.

RESULTS

Patients with aUC displayed a mean BWT of 3.9 ± 0.9 mm. In case of response to ADA/IFX a significant reduction in BWT was observed after 2 weeks [p = 0.04], whereas non-responders displayed no significant changes. The TTP was notably accelerated at baseline and significantly normalized by week 2 in responders [p = 0.001], while non-responders exhibited no significant alterations [p = 0.9]. At week 2, the endoscopic Mayo score did not exhibit any changes, thus failing to predict treatment responses.

CONCLUSION

dCEUS enables the early detection of therapy response in patients with aUC, which serves as a predictive marker for long-term clinical success. Therefore, dCEUS serves as a diagnostic tool for assessing the probability of future therapy success.

Imaging and endoscopic tools in pediatric inflammatory bowel disease: What's new?

Pediatric inflammatory bowel disease (IBD) is a chronic inflammatory disorder, with increasing incidence and prevalence worldwide. There have been recent advances in imaging and endoscopic technology for disease diagnosis, treatment, and monitoring. Intestinal ultrasound, including transabdominal, transperineal, and endoscopic, has been emerging for the assessment of transmural bowel inflammation and disease complications (e.g., fistula, abscess). Aside from surgery, IBD-related intestinal strictures now have endoscopic treatment options including through-the-scope balloon dilatation, injection, and needle knife stricturotomy and new evaluation tools such as endoscopic functional lumen imaging probe. Unsedated transnasal endoscopy may have a role in patients with upper gastrointestinal Crohn's disease or those with IBD with new upper gastrointestinal symptoms. Improvements to dysplasia screening in pediatric patients with longstanding colonic disease or primary sclerosing cholangitis hold promise with the addition of virtual chromoendoscopy and ongoing research in the field of artificial intelligence-assisted endoscopic detection. Artificial intelligence and machine learning is a rapidly evolving field, with goals of further personalizing IBD diagnosis and treatment selection as well as prognostication. This review summarized these advancements, focusing on pediatric patients with IBD.

High-resolution rectoscopy using MHz optical coherence tomography: a step towards real time 3D endoscopy

Colonoscopy and endoscopic ultrasound play pivotal roles in the assessment of rectal diseases, especially rectal cancer and inflammatory bowel diseases. Optical coherence tomography (OCT) offers a superior depth resolution, which is a critical factor for individualizing the therapeutic concept and evaluating the therapy response. We developed two distinct rectoscope prototypes, which were integrated into a 1300 nm MHz-OCT system constructed at our facility. The rapid rotation of the distal scanning probe at 40,000 revolutions per minute facilitates a 667 Hz OCT frame rate, enabling real-time endoscopic imaging of large areas. The performance of these OCT-rectoscopes was assessed in an ex vivo porcine colon and a post mortem human in-situ colon. The OCT-rectoscope consistently distinguished various layers of the intestinal wall, identified gut-associated lymphatic tissue, and visualized a rectal polyp during the imaging procedure with 3D-reconstruction in real time. Subsequent histological examination confirmed these findings. The body donor was preserved using an ethanol-glycerol-lysoformin-based technique for true-to-life tissue consistency. We could demonstrate that the novel MHZ-OCT-rectoscope effectively discriminates rectal wall layers and crucial tissue characteristics in a post mortem human colon in-situ. This real-time-3D-OCT holds promise as a valuable future diagnostic tool for assessing disease state and therapy response on-site in rectal diseases.

Approaches, Strategies and Procedures for Identifying Anti-Inflammatory Drug Lead Molecules from Natural Products

Natural products (NPs) have played a vital role in human survival for millennia, particularly for their medicinal properties. Many traditional medicine practices continue to utilise crude plants and animal products for treating various diseases, including inflammation. In contrast, contemporary medicine focuses more on isolating drug-lead compounds from NPs to develop new and better treatment drugs for treating inflammatory disorders such as inflammatory bowel diseases. There is an ongoing search for new drug leads as there is still no cure for many inflammatory conditions. Various approaches and technologies are used in drug discoveries from NPs. This review comprehensively focuses on anti-inflammatory small molecules and describes the key strategies in identifying, extracting, fractionating and isolating small-molecule drug leads. This review also discusses the (i) most used approaches and recently available techniques, including artificial intelligence (AI), (ii) machine learning, and computational approaches in drug discovery; (iii) provides various animal models and cell lines used in in-vitro and in-vivo assessment of the anti-inflammatory potential of NPs.

MICDnet: Multimodal information processing networks for Crohn's disease diagnosis

Crohn's disease (CD) is a chronic inflammatory disease with increasing incidence worldwide and unclear etiology. Its clinical manifestations vary depending on location, extent, and severity of the lesions. In order to diagnose Crohn's disease, medical professionals need to comprehensively analyze patients' multimodal examination data, which includes medical imaging such as colonoscopy, pathological, and text information from clinical records. The processes of multimodal data analysis require collaboration among medical professionals from different departments, which wastes a lot of time and human resources. Therefore, a multimodal medical assisted diagnosis system for Crohn's disease is particularly significant. Existing network frameworks find it hard to effectively capture multimodal patient data for diagnosis, and multimodal data for Crohn's disease is currently lacking. In addition,a combination of data from patients with similar symptoms could serve as an effective reference for disease diagnosis. Thus, we propose a multimodal information diagnosis network (MICDnet) to learn CD feature representations by integrating colonoscopy, pathology images and clinical texts. Specifically, MICDnet first preprocesses each modality data, then uses encoders to extract image and text features separately. After that, multimodal feature fusion is performed. Finally, CD classification and diagnosis are conducted based on the fused features. Under the authorization, we build a dataset of 136 hospitalized inspectors, with colonoscopy images of seven areas, pathology images, and clinical record text for each individual. Training MICDnet on this dataset shows that multimodal diagnosis can improve the diagnostic accuracy of CD, and the diagnostic performance of MICDnet is superior to other models.

Role of through-the-scope catheter-based EUS in inflammatory bowel disease diagnosis and activity assessment

BACKGROUND AND AIMS

Distinguishing Crohn's disease (CD) from ulcerative colitis (UC) may be difficult when the disease is limited to the colon. Transmural healing is an important adjunctive measure of inflammatory bowel disease activity. The aim of this study was to examine the role of EUS in differentiating CD versus UC and evaluating transmural disease activity.

METHODS

This prospective cohort study enrolled 20 patients with CD (10 active [aCD], 10 inactive), 20 patients with UC (10 active [aUC], 10 inactive), and 20 control subjects who underwent colonoscopy from 2019 to 2021 at a tertiary care center. Measurements of bowel wall layer thickness from the rectum and cecum were obtained using a through-the-scope US catheter (UM-3R-3; Olympus, Center Valley, Penn, USA) at the time of colonoscopy.

RESULTS

Compared with control subjects, patients with aCD had thicker rectal submucosa and total wall layer (submucosa median, 1.80 mm [interquartile range {IQR}, 1.40-2.00] vs .60 mm [IQR, .40-.70]; total wall median, 3.70 mm [IQR, 3.52-4.62] vs 2.10 mm [IQR, 1.70-2.40], respectively; P < .01). Similar significant findings were observed for the cecal wall layers. Compared with control subjects, patients with aUC had thicker rectal mucosa and total wall but not submucosa or muscularis propria layers (mucosa median, 1.35 mm [IQR, 1.12-1.47] vs .60 mm [IQR, .57-.70]; total wall median, 3.45 mm [IQR, 2.85-3.75] vs 2.10 mm [IQR, 1.70-2.40], respectively; P < .01). Patients with aCD compared with those with aUC had a significantly thicker rectal submucosa layer (median, 1.80 mm [IQR, 1.40-2.00] vs .55 mm [IQR, .40-.75], respectively, P < .01). Cutoff values of 1.1 mm for rectal submucosa in CD (sensitivity, 1.0; specificity, 1.0) and 1.1 mm for rectal mucosa in UC (sensitivity, .8; specificity, .9) were found to differentiate active from inactive disease.

CONCLUSIONS

EUS measurements of colon wall layers can help diagnose aCD versus aUC and assess transmural disease activity. (Clinical trial registration number: NCT03863886.).

Intestinal Ultrasound in Inflammatory Bowel Disease: A Novel and Increasingly Important Tool

New and efficacious medical therapies have become available that have greatly enhanced clinicians' ability to manage inflammatory bowel diseases (IBDs). IBD activity should be assessed regularly in scheduled examinations as the part of a treat-to-target strategy for IBD care. The gold-standard approach to investigating IBD is colonoscopy, but this is an invasive procedure. Intestinal ultrasound (IUS) has played a crucial role in recent years regarding the assessment of IBD activity because it is noninvasive, safe, reproducible, and inexpensive. IUS findings could inform changes in therapeutic interventions for IBDs; this would necessitate fewer endoscopies and enable faster decision-making processes. Furthermore, patients are accepting and tolerant of IUS examinations. This review outlines the current evidence and gives indication regarding the use of IUS in the management of IBDs.

The Use of Endoscopic Ultrasonography in Inflammatory Bowel Disease: A Review of the Literature

The diagnosis of inflammatory bowel disease (IBD) can sometimes be challenging. By corroborating clinical, imaging and histological data, the two main entities of IBD, ulcerative colitis and Crohn's disease (CD), can be differentiated in most cases. However, there remains 10-20% of patients where the diagnosis cannot be accurately established, in which case the term "IBD unclassified" is used. The imaging techniques most used to evaluate patients with IBD include colonoscopy, ultrasonography and magnetic resonance imaging. Endoscopic ultrasonography is mainly recommended for the evaluation of perianal CD. Through this work, we aim to identify other uses of this method in the case of patients with IBD.

Gastrointestinal Ultrasound in Emergency Setting

Acute bowel diseases are responsible for more than one third of subjects who were referred to the emergency department for acute abdominal pain and gastrointestinal evaluation. Gastrointestinal ultrasound (GIUS) is often employed as the first imaging method, with a good diagnostic accuracy in the setting of acute abdomen, and it can be an optimal diagnostic strategy in young females due to the radiation exposure related to X-ray and computed tomography methods. The physician can examine the gastrointestinal system in the area with the greatest tenderness by ultrasound, thus obtaining more information and data on the pathology than the standard physical examination. In this comprehensive review, we have reported the most relevant indications and advantages to using ultrasound in the investigation of abdominal acute pain.

Automatically detecting Crohn's disease and Ulcerative Colitis from endoscopic imaging

BACKGROUND

The SI-CURA project (Soluzioni Innovative per la gestione del paziente e il follow up terapeutico della Colite UlceRosA) is an Italian initiative aimed at the development of artificial intelligence solutions to discriminate pathologies of different nature, including inflammatory bowel disease (IBD), namely Ulcerative Colitis (UC) and Crohn's disease (CD), based on endoscopic imaging of patients (P) and healthy controls (N).

METHODS

In this study we develop a deep learning (DL) prototype to identify disease patterns through three binary classification tasks, namely (1) discriminating positive (pathological) samples from negative (healthy) samples (P vs N); (2) discrimination between Ulcerative Colitis and Crohn's Disease samples (UC vs CD) and, (3) discrimination between Ulcerative Colitis and negative (healthy) samples (UC vs N).

RESULTS

The model derived from our approach achieves a high performance of Matthews correlation coefficient (MCC) > 0.9 on the test set for P versus N and UC versus N, and MCC > 0.6 on the test set for UC versus CD.

CONCLUSION

Our DL model effectively discriminates between pathological and negative samples, as well as between IBD subgroups, providing further evidence of its potential as a decision support tool for endoscopy-based diagnosis.

Practical approach to linear endoscopic ultrasound examination of the rectum and anal canal

Standard endosonographic examination of the rectal area is usually performed with radial endoscopic ultrasound (EUS). However, in recent years, widespread availability of linear EUS for assessing various anatomical regions in the gastrointestinal tract has facilitated its use in the assessment of anorectal disorders. Currently, many rectal and anal diseases, including perianal abscesses, fistulae, polyps, and neoplastic lesions, can be well-visualized and evaluated with linear EUS. The aim of this review is to shed light on the anatomy and systematic examination of the anorectal region with linear EUS and clinical implications for different anorectal pathologies.

Advances in Pediatric Diagnostic Endoscopy: A State-of-the-Art Review

Pediatric endoscopy has revolutionized the way we diagnose and treat gastrointestinal disorders in children. Technological advances in computer processing and imaging continue to affect endoscopic equipment and advance diagnostic tools for pediatric endoscopy. Although commonly used by adult gastroenterologists, modalities, such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry, are not routinely used in pediatric gastroenterology. This state-of-the-art review describes advances in diagnostic modalities, including image-enhanced endoscopy, confocal laser endomicroscopy, optical coherence tomography, endo functional luminal imaging probes, wireless motility/pH capsule, wireless colon capsule endoscopy, endoscopic ultrasound, and discusses the basic principles of each technology, including adult indications and pediatric applications, safety cost, and training data.

8-Oxypalmatine, a novel oxidative metabolite of palmatine, exhibits superior anti-colitis effect via regulating Nrf2 and NLRP3 inflammasome

Palmatine (PAL) is an isoquinoline alkaloid derived from Fibraureae caulis Pierre that has been used to relieve inflammatory diseases like ulcerative colitis (UC). The metabolites of PAL were believed to contribute significantly to its outstanding biological activities. 8-Oxypalmatine (OPAL), a liver-mediated oxidative metabolite of PAL, has been firstly identified in the present work. We aimed to comparatively investigate the potential effect and mechanism of OPAL and PAL on dextran sodium sulfate (DSS)-induced colitis in Balb/c mice. Results indicated that OPAL and PAL effectively mitigated clinical manifestations, DAI scores and pathological damage compared with the model group. Moreover, treatment with OPAL and PAL effectively mitigated oxidative stress markers and inflammatory mediators in colon. Additionally, OPAL and PAL significantly activated the Nrf2 pathway, while substantially suppressed the activation of NLRP3 inflammasome. Furthermore, OPAL showed superior anti-colitis effect to PAL, which was similar to the positive drug mesalazine with much smaller dosage. These findings suggested that OPAL exerted appreciable protective effect on DSS-induced colitis, at least in part, via activating Nrf2 pathway and inhibiting NLRP3 inflammasome. OPAL might have the potential to be further developed into a promising candidate for the treatment of UC.

ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD.

METHODS

An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation.

RESULTS

Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined.

CONCLUSIONS

This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.

An Update of Research Animal Models of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a group of chronic disorders that includes two main disease forms, Crohn's disease, and ulcerative colitis. The understanding of the intestinal inflammation occurring in IBD has been immeasurably advanced by the development of the now numerous murine models of intestinal inflammation. The usefulness of this research tool in IBD arises from a convergence of underlying genetic susceptibility, immune system dysfunction, environmental factors, and shifts in gut microbiota. Due to the multifactorial feature of these diseases, different animal models have been used to investigate the underlying mechanisms and develop potential therapeutic strategies. The results of preclinical efficacy studies often inform the progression of therapeutic strategies. This review describes the distinct feature and limitations of each murine IBD model and discusses the previous and current lessons from the IBD models.

Intestinal Ultrasound in Inflammatory Bowel Disease: A Valuable and Increasingly Important Tool

Background

Intestinal ultrasound is emerging as a non-invasive tool for monitoring disease activity in inflammatory bowel disease patients due to its low cost, excellent safety profile, and availability. Herein, we comprehensively review the role of intestinal ultrasound in the management of these patients.

Summary

Intestinal ultrasound has a good accuracy in the diagnosis of Crohn's disease, as well as in the assessment of disease activity, extent, and evaluating disease-related complications, namely strictures, fistulae, and abscesses. Even though not fully validated, several scores have been developed to assess disease activity using ultrasound. Importantly, intestinal ultrasound can also be used to assess response to treatment. Changes in ultrasonographic parameters are observed as early as 4 weeks after treatment initiation and persist during short- and long-term follow-up. Additionally, Crohn's disease patients with no ultrasound improvement seem to be at a higher risk of therapy intensification, need for steroids, hospitalisation, or even surgery. Similarly to Crohn's disease, intestinal ultrasound has a good performance in the diagnosis, activity, and disease extent assessment in ulcerative colitis patients. In fact, in patients with severe acute colitis, higher bowel wall thickness at admission is associated with the need for salvage therapy and the absence of a significant decrease in this parameter may predict the need for colectomy. Short-term data also evidence the role of intestinal ultrasound in evaluating therapy response, with ultrasound changes observed after 2 weeks of treatment and significant improvement after 12 weeks of follow-up in ulcerative colitis.

Key Messages

Intestinal ultrasound is a valuable tool to assess disease activity and complications, and to monitor response to therapy. Even though longer prospective data are warranted, intestinal ultrasound may lead to a change in the paradigm of inflammatory bowel disease management as it can be used in a point-of-care setting, enabling earlier intervention if needed.

Asperuloside suppressing oxidative stress and inflammation in DSS-induced chronic colitis and RAW 264.7 macrophages via Nrf2/HO-1 and NF-κB pathways

BACKGROUND

Inflammatory bowel diseases (IBDs), which mainly include Crohn's disease (CD) and ulcerative colitis (UC), are chronic idiopathic inflammatory disease of the gastrointestinal tract for which effective pharmacological treatments are lacking or options are very limited.

PURPOSE

Here, we aim to investigate the therapeutic effects of an iridoid glycoside, asperuloside (ASP) on mice experimental chronic colitis induced by dextran sulfate sodium (DSS) and further explore underlying mechanisms in vitro and in vivo.

METHODS

LPS-treated RAW 264.7 cells showed inflammation and were assessed for various physiological, morphological and biochemical parameters in the absence or presence of ASP. Chronic colitis was induced by 2% DSS in mice, which were used as an animal model to explore the pharmacodynamics of ASP. We detected p65 and Nrf2 pathway proteins via Western blot and RT-PCR analysis, assessed the cytokines TNF-α and IL-6 via ELISA, tested p65 and Nrf2 nuclear translocation via fluorescence. In addition, the docking affinity of ASP and p65 or Nrf2 proteins in the MOE 2015 software.

RESULTS

We found that ASP attenuated weight loss, disease activity index (DAI) and colonic pathological damage in colitis mice and restored the expressions of inflammatory cytokines in the colon. In addition, ASP restored antioxidant capacity in DSS-induced chronic colitis mice and lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. Furthermore, ASP suppressed oxidative stress through increasing Nrf2, HO-1 and NQO-1 proteins expressions, and down-regulated nuclear levels of p65 to inhibit DSS-induced colonic oxidative stress and inflammation. Validation of the molecular docking results also indicated that ASP interacts with Nrf2 or p65 proteins. In summary, ASP improved DSS-induced chronic colitis by alleviating inflammation and oxidative stress, activating Nrf2/HO-1 signaling and limiting NF-κB signaling pathway, which may be an effective candidate for the treatment of IBD.

Bowel wall thickening and hyperemia assessed by high-frequency ultrasound indicate histological inflammation in Crohn's ileitis

PURPOSE

We evaluated ileal bowel wall thickness and semiquantitative vascularization by ultrasound in correlation with the presence or absence of histopathological inflammation in patients with Crohn's disease (CD).

METHODS

We conducted a retrospective analysis of 221 ultrasound examinations of the terminal ileum or neoterminal ileum in CD patients with biopsies of the ileum during colonoscopies within 8 weeks of the ultrasound. Ultrasound data were obtained from an inflammatory bowel disease ultrasound register from 2011 to 2017. Bowel wall ultrasound was performed by a high-frequency, linear transducer (7-12 MHz). Presence of bowel wall thickening (> 3 mm), vascularization by the Limberg score, and presence of ileal histopathological inflammation were analyzed.

RESULTS

In 221 bowel wall ultrasound examinations of CD patients (128 female, 93 male, mean age 37.5 years), a thickened bowel wall was found in 140 (63.3%) and hypervascularization (corresponding to a Limberg score ≥ 2) in 96 (43.4%) cases. In 187 (84.6%) cases, ileal inflammation was confirmed by histopathology and in 34 (15.4%) cases no inflammation was shown. Bowel wall thickening showed a sensitivity of 70.1%, a negative predictive value (NPV) of 30.9%, a specificity of 73.5% and a positive predictive value (PPV) of 93.6% for the detection of histopathological ileal inflammation. Hypervasularization had a low sensitivity (49.7%) and NPV (24.8%), but high specificity (91.2%) and PPV (96.9%).

CONCLUSION

In this CD subcohort of an ultrasound register, pathologic ultrasound findings were quite common. Bowel wall thickening (> 3 mm) and hypervascularization are good predictors of histopathological inflammation within the terminal ileum or neoterminal ileum. Normal ultrasound findings without bowel wall thickening and without hypervascularization do not rule out histopathological inflammation.

Imaging Inflammation - From Whole Body Imaging to Cellular Resolution

Imaging techniques have evolved impressively lately, allowing whole new concepts like multimodal imaging, personal medicine, theranostic therapies, and molecular imaging to increase general awareness of possiblities of imaging to medicine field. Here, we have collected the selected (3D) imaging modalities and evaluated the recent findings on preclinical and clinical inflammation imaging. The focus has been on the feasibility of imaging to aid in inflammation precision medicine, and the key challenges and opportunities of the imaging modalities are presented. Some examples of the current usage in clinics/close to clinics have been brought out as an example. This review evaluates the future prospects of the imaging technologies for clinical applications in precision medicine from the pre-clinical development point of view.

Predicting pediatric esophageal wall thickness: An EUS study

BACKGROUND AND OBJECTIVE

EUS has been shown in two small series to be capable of documenting increases in the total esophageal wall thickness (TWT) in children and adults with eosinophilic esophagitis (EoE). To apply EUS-derived TWT in clinical situations or in scientific investigations in pediatric EoE, measurements of esophageal TWT in children of differing ages and heights are required.

MATERIALS AND METHODS

Thirty patients (18M: 12F, 7 months to 20 years and 10 months) with a history of esophageal symptoms, but no endoscopic or histologic criteria of EoE were studied using a through the scope 20 MHZ Olympus Ultrasound miniprobe UM-3R (Olympus America, Center Valley Pa 18034) through a GIF Q180 or 160 (Olympus) standard pediatric upper endoscope. The mucosa, the mucosa plus submucosa, and the TWT were measured in the mid- and distal esophagus immediately before taking diagnostic biopsies.

RESULTS

Measurements from both sites showed a statistically significant increase in TWT as a function of age (P < 0.001) and height (P < 0.001), as did the individual layers. The width of the mucosa and the submucosa were equivalent and together, they contributed more than half of the entire TWT. There were no significant differences between the means of the mid- and distal esophageal measurements. A multiple regression equation that can predict TWT based on age, with 95% confidence limits, is presented.

CONCLUSIONS

EUS has demonstrated that esophageal TWT in a cohort of control children correlates with height and with age and has provided insights into the organization of the esophageal wall. Esophageal TWT values obtained by EUS can now be interpreted to recognize esophageal wall thickening throughout childhood.

FA-97, a New Synthetic Caffeic Acid Phenethyl Ester Derivative, Ameliorates DSS-Induced Colitis Against Oxidative Stress by Activating Nrf2/HO-1 Pathway

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory disorder of gastro-intestinal tract, lacking effective drug targets and medications. Caffeic acid phenethyl ester (CAPE), a phenolic constituent derived from propolis, has been reported to be a potential therapeutic agent for IBD with low water solubility and poor bioavailability. In this study, we synthesized a new CAPE derivative (FA-97) and aimed to investigate the effect of FA-97 on DSS-induced colitis. Here, we found that FA-97 attenuated body weight loss, colon length shortening and colonic pathological damage in colitis mice, as well as inhibited inflammatory cell infiltration and expression of pro-inflammatory cytokines in colons. In addition, FA-97 reduced ROS production and MDA generation, while total antioxidant capacity both in DSS-induced colitis mice and LPS-stimulated primary BMDMs and RAW 264.7 cells were enhanced. Mechanically, FA-97 activated Nrf2 followed by increased HO-1 and NQO-1 and down-regulated nuclear levels of p65 and c-Jun, to suppress DSS-induced colonic oxidative stress. Moreover, FA-97 decreased pro-inflammatory cytokine expression and increased the antioxidant defenses in RAW 264.7 via Nrf2 activation. In general, this study reveals that FA-97 activates Nrf2/HO-1 pathway to eventually alleviate DSS-induced colitis against oxidative stress, which has potential activity and may serve as a candidate for IBD therapy.

Ulcerative Colitis: Shifting Sands

Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with considerable disease burden. We review some current misconceptions about UC in adults with the aim of optimizing care for patients. Although UC and Crohn's disease (CD) are considered discrete diseases, distinctions between them are not always clear-cut and phenotypes may change over time. Patient management should take into account disease manifestations, disease severity and extent, and response to prior treatments. Although disease extent often defines severity, distal UC is not always less disabling than extensive disease as patients can progress to more extensive disease. In addition, severe proctitis can give rise to severe and debilitating symptoms, with a substantial impact on health-related quality of life. UC carries an increased risk of colorectal cancer (CRC) compared with CD; however, more recent data indicate a similar risk of CRC in CD with colonic involvement as with UC. Corticosteroids are widely used to induce remission in UC, and prolonged use of steroids in patients with UC is common, but corticosteroid-free maintenance of remission is an important therapeutic goal. Although biologic therapies provide a valuable treatment option in UC, they are not clinically effective in all patients and are also associated with secondary loss of response.

Assessing colitis ex vivo using optical coherence elastography in a murine model

BACKGROUND

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that causes regions of ulceration within the interior of the colon. UC is estimated to afflict hundreds of thousands of people in the United States alone. In addition to traditional colonoscopy, ultrasonic techniques can detect colitis, but have limited spatial resolution, which frequently results in underdiagnoses. Nevertheless, clinical diagnosis of colitis is still generally performed via colonoscopy. Optical techniques such as confocal microscopy and optical coherence tomography (OCT) have been proposed to detect UC with higher resolution. However, UC can potentially alter tissue biomechanical properties, providing additional contrast for earlier and potentially more accurate detection. Although clinically available elastography techniques have been immensely useful, they do not have the resolution for imaging small tissues, such as in small mammalian disease models. However, OCT-based elastography, optical coherence elastography (OCE), is well-suited for imaging the biomechanical properties of small mammal colon tissue.

METHODS

In this work, we induced elastic waves in ex vivo mouse colon tissue using a focused air-pulse. The elastic waves were detected using a phase-stabilized swept source OCE system, and the wave velocity was translated into stiffness. Measurements were taken at six positions for each sample to assess regional sample elasticity. Additional contrast between the control and diseased tissue was detected by analyzing the dispersion of the elastic wave and tissue optical properties obtained from the OCT structural image.

RESULTS

The results show distinct differences (P<0.05) in the stiffness between control and colitis disease samples, with a Young's modulus of 11.8±8.0 and 5.1±1.5 kPa, respectively. The OCT signal standard deviations for control and diseased samples were 5.8±0.3 and 5.5±0.2 dB, respectively. The slope of the OCT signal spatial frequency decay in the control samples was 92.7±10.0 and 87.3±4.7 dB∙µm in the colitis samples. The slope of the linearly fitted dispersion curve in the control samples was 1.5 mm, and 0.8 mm in the colitis samples.

CONCLUSIONS

Our results show that OCE can be utilized to distinguish tissue based on stiffness and optical properties. Our estimates of tissue stiffness suggest that the healthy colon tissue was stiffer than diseased tissue. Furthermore, structural analysis of the tissue indicates a distinct difference in tissue optical properties between the healthy and UC-like diseased tissue.

Differentiation of Crohn's disease and ulcerative colitis using intestinal wall thickness of the colon: A Diagnostic accuracy study of endoscopic ultrasonography

Background: The differentiation between Ulcerative Colitis (UC) and Crohn's Disease (CD) is an important issue for choosing the appropriate treatment. Endoscopic Ultrasonography (EUS) has been used to distinguish different layers of the gastrointestinal wall. We performed this study to evaluate the accuracy of EUS in differentiating colonic UC from CD compared to standard tests (colonoscopy, pathology, imaging, and clinical presentation). Methods: This is a prospective, single-blinded diagnostic accuracy study, on 70 patients (30 UC, 30 CD, and 10 healthy controls). After obtaining informed consent, patients underwent a complete workup and were referred to an endosonographist who was blind to the diagnosis. The thickness of mucosa, submucosa and the total wall (TWT) of mid-sigmoid colon were measured by Pentax radial echoendoscope EPKI-7000 with Avius Hitachi ultrasound system (Japan). Statistical analyses were performed using the SPSS statistical software (v23). Statistical significance was considered if P-values were less than 0.05. Results: Our study revealed a sensitivity of 100% (90.7-100%) and specificity of 90.9% (70.8-98.8%) for EUS to differentiate UC and CD compared to standard diagnostic tests. Mean mucosal thickness in patients with UC was significantly greater than patients with CD, while, the mean sub-mucosal thickness was significantly greater in patients with CD (p<0.001). The sensitivity and specificity of mean mucosal thickness for differentiating UC from CD and controls were 92.3% and 88.6% with a cut-off point of 1.1 mm (p<0.001). Moreover, sensitivity and specificity of mean submucosal thickness for differentiating CD from UC and controls were 100% and 86.1% with a cut-off point of 1.08 mm (p<0.001). Conclusion: EUS can be used as an efficient modality with acceptable accuracy to differentiate Crohn's disease and Ulcerative Colitis and to determine disease activity.

Rectal Endoscopic Ultrasound in Clinical Practice

PURPOSE OF REVIEW

Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS.

RECENT FINDINGS

Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.

Detecting murine Inflammatory Bowel Disease using Optical Coherence Elastography

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that causes regions of ulceration within the interior of the colon. UC is estimated to afflict hundreds of thousands of people in the United States alone. Ultrasonic techniques can detect colitis, but have limited spatial resolution, which frequently results in underdiagnoses. Nevertheless, clinical diagnosis of colitis is still generally performed via colonoscopy. Optical techniques such as confocal microscopy and optical coherence tomography (OCT) have been proposed as higher resolution alternative imaging modalities to detect colitis. Additionally, IBD can potentially alter tissue biomechanical properties, which cannot be quantified from structural imaging alone. Elastography is a potential method to assess colon biomechanical properties to provide additional contrast for distinguishing healthy and diseased colon tissue. In this work, we induced elastic waves in ex vivo mouse colon tissue using a focused air-pulse. The elastic waves were detected using a phase-stabilized swept source optical coherence elastography system, and the wave velocity was translated into stiffness. Measurements were taken at six random positions for each sample in order to assess regional sample elasticity. The results show distinct differences ($p \lt 0.05$) in the stiffness between healthy and IBD-diseased samples, with a Young's Modulus of $10.2 \pm 3.7$ kPa and $4.9 \pm 0.3$ kPa, respectively. Dispersion analysis presents another parameter to distinguish tissue health. The high frequency components of the phase velocity dispersion curve indicate a variation between healthy and IBD colonic tissue. Our results show that OCE may be useful for detecting IBD noninvasively.

Modern Endoscopic Imaging in Diagnosis and Surveillance of Inflammatory Bowel Disease Patients

Endoscopy remains the most important diagnostic and monitoring modality in the management of inflammatory bowel disease. Advances in imaging have progressively added new tools into the armamentarium of endoscopists with the goal of more accurate, sensitive, and accessible visual diagnoses for the benefit of patients with gastrointestinal diseases. Here, we review the relevant literature regarding commonly used endoscopic techniques (dye-based and digital chromoendoscopy, high-definition endoscopy, capsule endoscopy, and endosonography), as well as advanced and experimental technologies (full-spectrum endoscopy, endocytoscopy, autofluorescence, laser endoscopy, and endomicroscopy, including molecular imaging), applicable to inflammatory bowel diseases and emerging for implementation into everyday practice. Additionally, we discuss future directions and techniques as candidates for a superior inflammation imaging in the diagnosis and prediction of therapeutic response.

Diagnostic classification of endosonography for differentiating colorectal ulcerative diseases: A new statistical method

AIM

To establish a classification method for differential diagnosis of colorectal ulcerative diseases, especially Crohn’s disease (CD), primary intestinal lymphoma (PIL) and intestinal tuberculosis (ITB).

METHODS

We searched the in-patient medical record database for confirmed cases of CD, PIL and ITB from 2008 to 2015 at our center, collected data on endoscopic ultrasound (EUS) from randomly-chosen patients who formed the training set, conducted univariate logistic regression analysis to summarize EUS features of CD, PIL and ITB, and created a diagnostic classification method. All cases found to have colorectal ulcers using EUS were obtained from the endoscopy database and formed the test set. We then removed the cases which were easily diagnosed, and the remaining cases formed the perplexing test set. We re-diagnosed the cases in the three sets using the classification method, determined EUS diagnostic accuracies, and adjusted the classification accordingly. Finally, the re-diagnosing and accuracy-calculating steps were repeated.

RESULTS

In total, 272 CD, 60 PIL and 39 ITB cases were diagnosed from 2008 to 2015 based on the in-patient database, and 200 CD, 30 PIL and 20 ITB cases were randomly chosen to form the training set. The EUS features were summarized as follows: CD: Thickened submucosa with a slightly high echo level and visible layer; PIL: Absent layer and diffuse hypoechoic mass; and ITB: Thickened mucosa with a high or slightly high echo level and visible layer. The test set consisted of 77 CD, 30 PIL, 23 ITB and 140 cases of other diseases obtained from the endoscopy database. Seventy-four cases were excluded to form the perplexing test set. After adjustment of the classification, EUS diagnostic accuracies for CD, PIL and ITB were 83.6% (209/250), 97.2% (243/250) and 85.6% (214/250) in the training set, were 89.3% (241/270), 97.8% (264/270) and 84.1% (227/270) in the test set, and were 86.7% (170/196), 98.0% (192/196) and 85.2% (167/196) in the perplexing set, respectively.

CONCLUSION

The EUS features of CD, PIL and ITB are different. The diagnostic classification method is reliable in the differential diagnosis of colorectal ulcerative diseases.

Histologic scoring indices for evaluation of disease activity in Crohn's disease

BACKGROUND

Histologic assessment of mucosal disease activity has been increasingly used in clinical trials of treatment for Crohn's disease. However, the operating properties of the currently existing histologic scoring indices remain unclear.

OBJECTIVES

A systematic review was undertaken to evaluate the development and operating characteristics of available histologic disease activity indices in Crohn's disease.

SEARCH METHODS

Electronic searches of MEDLINE, EMBASE, PubMed, and the Cochrane Library (CENTRAL) databases from inception to 20 July 2016 were supplemented by manual reviews of bibliographies and abstracts submitted to major gastroenterology meetings (Digestive Disease Week, United European Gastroenterology Week, European Crohn's and Colitis Organisation).

SELECTION CRITERIA

Any study design (e.g. randomised controlled trial, cohort study, case series) that evaluated a histologic disease activity index in patients with Crohn's disease was considered for inclusion. Study participants included adult patients (> 16 years), diagnosed with Crohn's disease using conventional clinical, radiographic or endoscopic criteria.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the titles and abstracts of the studies identified from the literature search. The full text of potentially relevant citations were reviewed for inclusion and the study investigators were contacted as needed for clarification. Any disagreements regarding study eligibility were resolved by discussion and consensus with a third author.Two authors independently extracted and recorded data using a standard form. The following data were recorded from each eligible study: number of patients enrolled; number of patients per treatment arm; patient characteristics: age and gender distribution; description of histologic disease activity index utilized; and outcomes such as content validity, construct validity, criterion validity, responsiveness, intra-rater reliability, inter-rater reliability, and feasibility.

MAIN RESULTS

Sixteen reports of 14 studies describing 14 different numerical histological indices fulfilled the inclusion criteria.Inter-rater reliability was assessed in one study. For the Naini and Cortina Score, estimates of correlation were 'almost perfect', ranging from r = 0.94 to 0.96. The methodological quality of this study with respect to reliability was 'good'.With respect to validity, correlation estimates between various histological scoring systems and Crohn's disease activity as measured by objective markers of inflammation (including C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin and fecal lactoferrin); endoscopic disease activity scores; clinical disease activity scores; and quality of life questionnaires were reported. Comparisons between histologic scoring indices and endoscopic scoring indices ranged from no correlation to 'substantial' (r = 0.779). The methodological quality of the studies that explored validity ranged form 'poor' to 'good'.Responsiveness data were available in seven studies. After subjects were administered a treatment of known efficacy, statistically significant change in the index score was demonstrated in five studies with respect to six indices. Two studies failed to indicate whether there was statistically significant change in the index score post-treatment. With regard to methodological quality, six of the studies were rated as 'poor' and one of the studies was rated as 'fair'.Feasibility was assessed by one study. The Naini and Cortina Score was shown to be simple to use and feasible for every given case.

AUTHORS' CONCLUSIONS

Currently there is no fully validated histological scoring index for evaluation of Crohn's disease activity. Development of a validated histological scoring index for Crohn's disease is a clinical and research priority.

Colon carcinoma staging by endoscopic ultrasonography miniprobes

Background and Objectives:

Due to the increasing use of endoscopic techniques for colon cancer resection, pretreatment locoregional staging may gain critical interest. The use of endoscopic ultrasonography (EUS) miniprobes in this context has been seldom reported. Our aim was to determine the accuracy of EUS miniprobes for colon cancer staging.

Materials and Methods:

Forty patients with colon cancer (2 in the cecum, 9 in the ascending colon, 5 in the transverse colon, 5 in the descending colon, and 19 in the sigmoid colon) were submitted to staging using 12 MHz EUS miniprobes. EUS and the anatomopathological results were compared with regard to the T and N stages. It was assessed if the location, longitudinal extension, or circumferential extension of the tumor had any influence on the accuracy in EUS staging.

Results:

Tumor staging was feasible in 39 (98%) patients except in one case with a stenosing tumor (out of 6). Globally, T stage was accurately determined in 88% of the cases. In the assessment of the presence or absence of lymph node metastasis, miniprobes presented an accuracy of 82% with a sensitivity of 67%. These results were neither affected by the location nor by the longitudinal or circumferential extension of the tumor.

Conclusions:

EUS miniprobes may play an important role in assessing T and N stages in colon cancer and may represent an incentive to the research of new therapeutic areas for this disease.

Light and sound - emerging imaging techniques for inflammatory bowel disease

Patients with inflammatory bowel disease are known to have a high demand of recurrent evaluation for therapy and disease activity. Further, the risk of developing cancer during the disease progression is increasing from year to year. New, mostly non-radiant, quick to perform and quantitative methods are challenging, conventional endoscopy with biopsy as gold standard. Especially, new physical imaging approaches utilizing light and sound waves have facilitated the development of advanced functional and molecular modalities. Besides these advantages they hold the promise to predict personalized therapeutic responses and to spare frequent invasive procedures. Within this article we highlight their potential for initial diagnosis, assessment of disease activity and surveillance of cancer development in established techniques and recent advances such as wide-view full-spectrum endoscopy, chromoendoscopy, autofluorescence endoscopy, endocytoscopy, confocal laser endoscopy, multiphoton endoscopy, molecular imaging endoscopy, B-mode and Doppler ultrasound, contrast-enhanced ultrasound, ultrasound molecular imaging, and elastography.

Role of Endoscopic Ultrasound in Pediatric Disease

The application of endoscopic ultrasound (EUS) in children is growing, with studies demonstrating a positive impact of EUS in the management of childhood diseases. EUS has shown to be useful in the evaluation and management of a spectrum of childhood diseases including pancreaticobiliary disease, congenital anomalies, submuocsal lesions, biliary stones disease, inflammatory bowel disease, and eosinophilic esophagitis. Its diagnostic capabilities with fine-needle aspiration and core-needle biopsy are shown to be technically successful, safe, and effective in several pediatric studies. Therapeutic EUS procedures include endoscopic cystgastrostomy, celiac plexus neurolysis, and biliary access. This article discusses the role of EUS for diagnostic and therapeutic purposes in pediatrics.

The role of endoscopy in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of chronic immune-mediated disorders of the gastrointestinal tract. It is often the result of the interaction of genetic and environmental factors. The role of endoscopy in disease surveillance is unprecedented. However, there is considerable debate in therapeutic goals in IBD patients, ranging from the resolution of clinical symptoms to mucosal healing. Furthermore, deep remission has recently been advocated for altering disease course in these patients. Additionally, neoplasia continues to be a significant cause of morbidity and mortality in IBD patients. This review discussed the role of several endoscopic techniques in assessing mucosal healing and neoplasia with emphasis on novel non-invasive endoscopic techniques.

Differential diagnosis in inflammatory bowel disease colitis: State of the art and future perspectives

Distinction between Crohn’s disease of the colon-rectum and ulcerative colitis or inflammatory bowel disease (IBD) type unclassified can be of pivotal importance for a tailored clinical management, as each entity often involves specific therapeutic strategies and prognosis. Nonetheless, no gold standard is available and the uncertainty of diagnosis may frequently lead to misclassification or repeated examinations. Hence, we have performed a literature search to address the problem of differential diagnosis in IBD colitis, revised current and emerging diagnostic tools and refined disease classification strategies. Nowadays, the differential diagnosis is an untangled issue, and the proper diagnosis cannot be reached in up to 10% of patients presenting with IBD colitis. This topic is receiving emerging attention, as medical therapies, surgical approaches and leading prognostic outcomes require more and more disease-specific strategies in IBD patients. The optimization of standard diagnostic approaches based on clinical features, biomarkers, radiology, endoscopy and histopathology appears to provide only marginal benefits. Conversely, emerging diagnostic techniques in the field of gastrointestinal endoscopy, molecular pathology, genetics, epigenetics, metabolomics and proteomics have already shown promising results. Novel advanced endoscopic imaging techniques and biomarkers can shed new light for the differential diagnosis of IBD, better reflecting diverse disease behaviors based on specific pathogenic pathways.

Bowel perfusion measured with dynamic contrast-enhanced ultrasound predicts treatment outcome in patients with Crohn's disease

BACKGROUND

To improve management of patients with Crohn's disease (CD), objective measurements of the degree of local inflammation in the gastrointestinal wall are needed. Increased microvessel density and perfusion are typical features of acute inflammation and can be estimated with contrast-enhanced ultrasound (CEUS). The aim of the study was to investigate whether CEUS can provide prognostic information about patients treated medically for an acute exacerbation of CD.

METHODS

Fourteen patients with CD who received medical treatment for acute exacerbation with systemic steroids or tumor necrosis factor-α inhibitors were prospectively recruited. The patients were examined with clinical scoring, blood tests, and CEUS at time 0, 1, 3, and 12 months after initiation of the treatment. Outcome was treatment efficacy or treatment failure defined as change in medical treatment after 1 month or later. The perfusion analysis was performed with a commercially available software program that analyzes the contrast intensity in a selected area, fits the data to a standardized time-intensity curve, and derives several relative perfusion parameters.

RESULTS

Six of the 14 patients had treatment failure during the study period. There was a significant difference between the groups for peak contrast enhancement (P = 0.013), rate of wash-in (P = 0.020) and wash-out (P = 0.008), and the area under the time-intensity curve in the wash-in phase (0.013) at the examination 1 month after the start of treatment.

CONCLUSIONS

Perfusion analysis of the intestinal wall with CEUS 1 month after starting treatment in patients with CD can provide prognostic information regarding treatment efficacy.