1
|
Deng R, Cui C, Remedios LW, Bao S, Womick RM, Chiron S, Li J, Roland JT, Lau KS, Liu Q, Wilson KT, Wang Y, Coburn LA, Landman BA, Huo Y. Cross-scale multi-instance learning for pathological image diagnosis. Med Image Anal 2024; 94:103124. [PMID: 38428271 PMCID: PMC11016375 DOI: 10.1016/j.media.2024.103124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 03/03/2024]
Abstract
Analyzing high resolution whole slide images (WSIs) with regard to information across multiple scales poses a significant challenge in digital pathology. Multi-instance learning (MIL) is a common solution for working with high resolution images by classifying bags of objects (i.e. sets of smaller image patches). However, such processing is typically performed at a single scale (e.g., 20× magnification) of WSIs, disregarding the vital inter-scale information that is key to diagnoses by human pathologists. In this study, we propose a novel cross-scale MIL algorithm to explicitly aggregate inter-scale relationships into a single MIL network for pathological image diagnosis. The contribution of this paper is three-fold: (1) A novel cross-scale MIL (CS-MIL) algorithm that integrates the multi-scale information and the inter-scale relationships is proposed; (2) A toy dataset with scale-specific morphological features is created and released to examine and visualize differential cross-scale attention; (3) Superior performance on both in-house and public datasets is demonstrated by our simple cross-scale MIL strategy. The official implementation is publicly available at https://github.com/hrlblab/CS-MIL.
Collapse
Affiliation(s)
| | - Can Cui
- Vanderbilt University, Nashville, TN 37215, USA
| | | | | | - R Michael Womick
- The University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Sophie Chiron
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jia Li
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Joseph T Roland
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Ken S Lau
- Vanderbilt University, Nashville, TN 37215, USA
| | - Qi Liu
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Keith T Wilson
- Vanderbilt University Medical Center, Nashville, TN 37232, USA; Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN 37212, USA
| | - Yaohong Wang
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lori A Coburn
- Vanderbilt University Medical Center, Nashville, TN 37232, USA; Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN 37212, USA
| | - Bennett A Landman
- Vanderbilt University, Nashville, TN 37215, USA; Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Yuankai Huo
- Vanderbilt University, Nashville, TN 37215, USA.
| |
Collapse
|
2
|
Rieder F, Mukherjee PK, Massey WJ, Wang Y, Fiocchi C. Fibrosis in IBD: from pathogenesis to therapeutic targets. Gut 2024; 73:854-866. [PMID: 38233198 PMCID: PMC10997492 DOI: 10.1136/gutjnl-2023-329963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Intestinal fibrosis resulting in stricture formation and obstruction in Crohn's disease (CD) and increased wall stiffness leading to symptoms in ulcerative colitis (UC) is among the largest unmet needs in inflammatory bowel disease (IBD). Fibrosis is caused by a multifactorial and complex process involving immune and non-immune cells, their soluble mediators and exposure to luminal contents, such as microbiota and environmental factors. To date, no antifibrotic therapy is available. Some progress has been made in creating consensus definitions and measurements to quantify stricture morphology for clinical practice and trials, but approaches to determine the degree of fibrosis within a stricture are still lacking. OBJECTIVE We herein describe the current state of stricture pathogenesis, measuring tools and clinical trial endpoints development. DESIGN Data presented and discussed in this review derive from the past and recent literature and the authors' own research and experience. RESULTS AND CONCLUSIONS Significant progress has been made in better understanding the pathogenesis of fibrosis, but additional studies and preclinical developments are needed to define specific therapeutic targets.
Collapse
Affiliation(s)
- Florian Rieder
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pranab K Mukherjee
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - William J Massey
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Yan Wang
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Claudio Fiocchi
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
3
|
Tagliamonte G, Santagata F, Fraquelli M. Current Developments and Role of Intestinal Ultrasound including the Advent of AI. Diagnostics (Basel) 2024; 14:759. [PMID: 38611672 PMCID: PMC11011653 DOI: 10.3390/diagnostics14070759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/18/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Intestinal ultrasound is a non-invasive, safe, and cost-effective technique to study the small and large intestines. In addition to conventional B-mode and color doppler imaging, new US tools have been developed in more recent years that provide auxiliary data on many GI conditions, improving the diagnosis and assessment of relevant outcomes. We have reviewed the more recent literature (from 2010 onwards) on auxiliary tools in bowel ultrasound such as elastography techniques, CEUS, SICUS, and the potential contribution by artificial intelligence (AI) to overcome current intestinal ultrasound limitations. For this scoping review, we performed an extensive literature search on PubMed and EMBASE to identify studies published until December 2023 and investigating the application of elastography techniques, CEUS, SICUS, and AI in the ultrasonographic assessment of the small and large intestines. Multiparametric intestinal ultrasound shows promising capabilities in Crohn's disease, while less is known about the role in ulcerative colitis. Despite some evidence, the CEUS role as a point-of-care examination tool for rare conditions such as intestinal GvHD and ischemic small bowel disease seems promising, possibly avoiding the need to perform further cross-sectional imaging. The use of AI in intestinal ultrasound is still anecdotical and limited to acute appendicitis.
Collapse
Affiliation(s)
- Gennaro Tagliamonte
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.T.); (F.S.)
| | - Fabrizio Santagata
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (G.T.); (F.S.)
| | - Mirella Fraquelli
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| |
Collapse
|
4
|
Weber MC, Schmidt K, Buck A, Kasajima A, Becker S, Li C, Reischl S, Wilhelm D, Steiger K, Friess H, Neumann PA. Fractal analysis of extracellular matrix for observer-independent quantification of intestinal fibrosis in Crohn's disease. Sci Rep 2024; 14:3988. [PMID: 38368499 PMCID: PMC10874456 DOI: 10.1038/s41598-024-54545-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/14/2024] [Indexed: 02/19/2024] Open
Abstract
Prevention of intestinal fibrosis remains an unresolved problem in the treatment of Crohn's disease (CD), as specific antifibrotic therapies are not yet available. Appropriate analysis of fibrosis severity is essential for assessing the therapeutic efficacy of potential antifibrotic drugs. The aim of this study was to develop an observer-independent method to quantify intestinal fibrosis in surgical specimens from patients with CD using structural analysis of the extracellular matrix (ECM). We performed fractal analysis in fibrotic and control histological sections of patients with surgery for CD (n = 28). To specifically assess the structure of the collagen matrix, polarized light microscopy was used. A score to quantify collagen fiber alignment and the color of the polarized light was established. Fractal dimension as a measure for the structural complexity correlated significantly with the histological fibrosis score whereas lacunarity as a measure for the compactness of the ECM showed a negative correlation. Polarized light microscopy to visualize the collagen network underlined the structural changes in the ECM network in advanced fibrosis. In conclusion, observer-independent quantification of the structural complexity of the ECM by fractal analysis is a suitable method to quantify the degree of intestinal fibrosis in histological samples from patients with CD.
Collapse
Affiliation(s)
- Marie-Christin Weber
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Konstantin Schmidt
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Annalisa Buck
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Institute for Advanced Study, Technical University of Munich, Munich, Germany
| | - Atsuko Kasajima
- Institute of Pathology, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Simon Becker
- Department of Mathematics, ETH Zurich, Zurich, Switzerland
| | - Chunqiao Li
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Reischl
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Institute of Diagnostic and Interventional Radiology, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Katja Steiger
- Institute of Pathology, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, TUM School of Medicine and Health, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- Institute for Advanced Study, Technical University of Munich, Munich, Germany.
| |
Collapse
|
5
|
Dudek P, Talar-Wojnarowska R. Current Approach to Risk Factors and Biomarkers of Intestinal Fibrosis in Inflammatory Bowel Disease. Medicina (Kaunas) 2024; 60:305. [PMID: 38399592 PMCID: PMC10889938 DOI: 10.3390/medicina60020305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Inflammatory bowel disease (IBD), especially Crohn's disease (CD), characterized by a chronic inflammatory process and progressive intestinal tissue damage, leads to the unrestrained proliferation of mesenchymal cells and the development of bowel strictures. Complications induced by fibrosis are related to high rates of morbidity and mortality and lead to a substantial number of hospitalizations and surgical procedures, generating high healthcare costs. The development of easily obtained, reliable fibrogenesis biomarkers is essential to provide an important complementary tool to existing diagnostic and prognostic methods in IBD management, guiding decisions on the intensification of pharmacotherapy, proceeding to surgical methods of treatment and monitoring the efficacy of anti-fibrotic therapy in the future. The most promising potential markers of fibrosis include cartilage oligomeric matrix protein (COMP), hepatocyte growth factor activator (HGFA), and fibronectin isoform- extra domain A (ED-A), as well as antibodies against granulocyte macrophage colony-stimulating factor (GM-CSF Ab), cathelicidin (LL-37), or circulatory miRNAs: miR-19a-3p and miR-19b-3p. This review summarizes the role of genetic predisposition, and risk factors and serological markers potentially contributing to the pathophysiology of fibrotic strictures in the course of IBD.
Collapse
|
6
|
Elford AT, Ardalan Z, Simkin P, Christensen B. Comprehensive review and update of stricturing Crohn's disease. Indian J Gastroenterol 2024; 43:64-77. [PMID: 38277070 DOI: 10.1007/s12664-023-01508-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024]
Abstract
Up to 50% of patients with Crohn's disease develop a stricture within 10 years of diagnosis. Crohn's strictures can compose of inflammation, fibrosis or smooth muscle expansion and usually a combination of these. There have been numerous new developments in imaging modalities in determining the composition of Crohn's strictures. Magnetic resonance imaging remains the best upfront imaging modality to characterize Crohn's strictures. Gastrointestinal ultrasound (GIUS) has an increasing role in clinical practice, particularly for monitoring stricture response as a treat-to-target tool. Novel imaging techniques to differentiate between fibrosis and inflammatory strictures have been developed including contrast-enhanced GIUS, strain or shear wave elastography with GIUS and multiple new magnetic resonance imaging (MRI) protocols, including diffusion weighted, delayed contrast enhancement and magnetization transfer MR protocols. However, these techniques require further validation and standardization. Regarding therapeutics, anti-tumor necrosis agents with a treat-to-target strategy have the highest quality evidence in treating strictures and can lead to stricture regression in some cases. Endoscopic balloon dilatation remains a mainstay in the treatment algorithm of treating predominantly fibrostenotic Crohn's strictures, particularly those which are symptomatic, < 5 cm in length and not causing prestenotic dilatation. Endoscopic balloon dilatation has greater effectiveness in anastomotic strictures. Surgery remains an important treatment option in Crohn's strictures, with segmental resection and stricturoplasty having their own advantages and disadvantages. Kono-S anastomosis may be superior to conventional anastomosis for endoscopic recurrence; however, further high-quality studies are required to confirm this. Using risk stratification models such as the BACARDI risk model is important to guide management decisions between a medical and surgical approach. Early post-operative medical prophylaxis with an advanced therapy is an important consideration to prevent disease recurrence. This review expands on the above topics, highlights research gaps and provides a suggested investigation and management pathway in stricturing Crohn's disease.
Collapse
Affiliation(s)
- Alexander T Elford
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Australia.
- Faculty of Medicine, Melbourne University, Melbourne, Australia.
- Edinburgh Inflammatory Bowel Diseases Unit, Western General Hospital, Edinburgh, UK.
| | - Zaid Ardalan
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Australia
- Faculty of Medicine, Melbourne University, Melbourne, Australia
- Faculty of Medicine, Monash University, Melbourne, Australia
- Gastroenterology Department, Alfred Health, Melbourne, Australia
| | - Paul Simkin
- Radiology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - Britt Christensen
- Gastroenterology Department, Royal Melbourne Hospital, Melbourne, Australia
- Faculty of Medicine, Melbourne University, Melbourne, Australia
| |
Collapse
|
7
|
Matsumoto H, Hata J, Imuamura H, Yo S, Sasahira M, Misawa H, Oosawa M, Handa O, Umegami E, Shiotani A. Serial Changes in Intestinal Stenotic Stiffness in Patients with Crohn's Disease Treated with Biologics: A Pilot Study Using Ultrasound Shear Wave Elastography. Turk J Gastroenterol 2023; 34:1006-1013. [PMID: 37603302 PMCID: PMC10645284 DOI: 10.5152/tjg.2023.22768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/07/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND/AIMS Intestinal strictures represent an important serious complication of Crohn's disease. Shear wave elastography is a promising noninvasive ultrasound technique for assessing tissue stiffness. This study aimed to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease using shear wave elastography and the changes in stiffness after biologics. MATERIALS AND METHODS We enrolled 21 Crohn's disease patients having intestinal stricture. The patients consisted of 3 groups, which were the infliximab naïve (n = 6) group, the ustekinumab naïve (n = 8), and the bio-switch from infliximab to ustekinumab (n = 7) group. Bowell wall thickness was examined by ultrasound sonography, and the stiffness of Crohn's disease stricture lesions was evaluated using Shear wave speed before and 1 year after anti-tumor necrosis factor-alpha antibody infliximab, anti-interleukin 12/23 antibody ustekinumab, and bio-switch from infliximab to ustekinumab. RESULTS Bowell wall thickness was significantly improved after infliximab, ustekinumab, and the bio-switch. However, shear wave speed indices only in the ustekinumab group significantly decreased after treatment (P = .028), but not in the other group. CONCLUSIONS Shear wave elastography might be a useful method to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease treated with biologics. However, a prospective randomized study evaluating the development of obstruction after biological treatment is needed to validate the study findings.
Collapse
Affiliation(s)
- Hiroshi Matsumoto
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Jiro Hata
- Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Hiroshi Imuamura
- Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Shogen Yo
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Momoyo Sasahira
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Hiraku Misawa
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Motoyasu Oosawa
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Osamu Handa
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Eiji Umegami
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| | - Akiko Shiotani
- Division of Internal Medicine, Department of Gastroenterology, Kawasaki Medical School, Matsushima, Kurashiki, Okayama, Japan
| |
Collapse
|
8
|
Steiner CA, Koch SD, Evanoff T, Welch N, Kostelecky R, Callahan R, Murphy EM, Nguyen TT, Hall CHT, Lu S, de Zoeten EF, Weiser-Evans MCM, Cartwright IM, Colgan SP. The TNF ΔARE Mouse as a Model of Intestinal Fibrosis. Am J Pathol 2023; 193:1013-1028. [PMID: 37169343 PMCID: PMC10433691 DOI: 10.1016/j.ajpath.2023.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023]
Abstract
Crohn disease (CD) is a highly morbid chronic inflammatory disease. Although many patients with CD also develop fibrostenosing complications, there are no medical therapies for intestinal fibrosis. This is due, in part, to a lack of high-fidelity biomimetic models to enhance understanding and drug development, which highlights the need for developing in vivo models of inflammatory bowel disease-related intestinal fibrosis. This study investigates whether the TNFΔARE mouse, a model of ileal inflammation, also develops intestinal fibrosis. Several clinically relevant outcomes were studied, including features of structural fibrosis, histologic fibrosis, and gene expression. These include the use of a new luminal casting technique, traditional histologic outcomes, use of second harmonic imaging, and quantitative PCR. These features were studied in aged TNFΔARE mice as well as in cohorts of numerous ages. At >24 weeks of age, TNFΔARE mice developed structural, histologic, and transcriptional changes of ileal fibrosis. Protein and RNA expression profiles showed changes as early as 6 weeks, coinciding with histologic changes as early as 14 to 15 weeks. Overt structural fibrosis was delayed until at least 16 weeks and was most developed after 24 weeks. This study found that the TNFΔARE mouse is a viable and highly tractable model of ileal fibrosis. This model and the techniques used herein can be leveraged for both mechanistic studies and therapeutic development for the treatment of intestinal fibrosis.
Collapse
Affiliation(s)
- Calen A Steiner
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
| | - Samuel D Koch
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Tamara Evanoff
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Nichole Welch
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Rachael Kostelecky
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Rosemary Callahan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Emily M Murphy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program and Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Tom T Nguyen
- Mucosal Inflammation Program and Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Caroline H T Hall
- Mucosal Inflammation Program and Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Sizhao Lu
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Edwin F de Zoeten
- Mucosal Inflammation Program and Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Mary C M Weiser-Evans
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Consortium for Fibrosis Research and Translation, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Cardiovascular Pulmonary Research Program, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ian M Cartwright
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Sean P Colgan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Mucosal Inflammation Program, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| |
Collapse
|
9
|
Tavares de Sousa H, Magro F. How to Evaluate Fibrosis in IBD? Diagnostics (Basel) 2023; 13:2188. [PMID: 37443582 DOI: 10.3390/diagnostics13132188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
In this review, we will describe the importance of fibrosis in inflammatory bowel disease (IBD) by discussing its distinct impact on Crohn's disease (CD) and ulcerative colitis (UC) through their translation to histopathology. We will address the existing knowledge on the correlation between inflammation and fibrosis and the still not fully explained inflammation-independent fibrogenesis. Finally, we will compile and discuss the recent advances in the noninvasive assessment of intestinal fibrosis, including imaging and biomarkers. Based on the available data, none of the available cross-sectional imaging (CSI) techniques has proved to be capable of measuring CD fibrosis accurately, with MRE showing the most promising performance along with elastography. Very recent research with radiomics showed encouraging results, but further validation with reliable radiomic biomarkers is warranted. Despite the interesting results with micro-RNAs, further advances on the topic of fibrosis biomarkers depend on the development of robust clinical trials based on solid and validated endpoints. We conclude that it seems very likely that radiomics and AI will participate in the future non-invasive fibrosis assessment by CSI techniques in IBD. However, as of today, surgical pathology remains the gold standard for the diagnosis and quantification of intestinal fibrosis in IBD.
Collapse
Affiliation(s)
- Helena Tavares de Sousa
- Gastroenterology Department, Algarve University Hospital Center, 8500-338 Portimão, Portugal
- ABC-Algarve Biomedical Center, University of Algarve, 8005-139 Faro, Portugal
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Department of Gastroenterology, São João University Hospital Center, 4200-319 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| |
Collapse
|
10
|
Zhang M, Xiao E, Liu M, Mei X, Dai Y. Retrospective Cohort Study of Shear-Wave Elastography and Computed Tomography Enterography in Crohn's Disease. Diagnostics (Basel) 2023; 13:1980. [PMID: 37296832 PMCID: PMC10252205 DOI: 10.3390/diagnostics13111980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/24/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
Distinguishing between inflammatory and fibrotic lesions drastically influences treatment decision-making regarding Crohn's disease. However, it is challenging to distinguish these two phenotypes before surgery. This study investigates the diagnostic yield of shear-wave elastography and computed tomography enterography to distinguish intestinal phenotypes in Crohn's disease. Thirty-seven patients (mean age, 29.51 ± 11.52; 31 men) were evaluated with average value of shear-wave elastography (Emean) and computed tomography enterography (CTE) scores. The results demonstrated that a positive correlation between the Emean and fibrosis (Spearman's r = 0.653, p = 0.000). The cut-off value for fibrotic lesions was 21.30 KPa (AUC: 0.877, sensitivity: 88.90%, specificity: 89.50%, 95% CI:0.755~0.999, p = 0.000). The CTE score showed a positive correlation with inflammation (Spearman's r = 0.479, p = 0.003), and a 4.5-point grading system was the optimal cut-off value for inflammatory lesions (AUC: 0.766, sensitivity: 73.70%, specificity: 77.80%, 95% CI: 0.596~0.936, p = 0.006). Combining these two metrics improved the diagnostic performance and specificity (AUC: 0.918, specificity: 94.70%, 95% CI: 0.806~1.000, p = 0.000). In conclusion, shear-wave elastography can be used to help detect fibrotic lesions and the computed tomography enterography score emerged as a feasible predictor of inflammatory lesions. The combination of these two imaging techniques is proposed to distinguish intestinal predominant phenotypes.
Collapse
Affiliation(s)
- Minping Zhang
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (M.Z.)
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Enhua Xiao
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (M.Z.)
| | - Minghui Liu
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| | - Xilong Mei
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha 410011, China; (M.Z.)
| | - Yinghuan Dai
- Department of Pathology, The Second Xiangya Hospital of Central South University, Changsha 410011, China
| |
Collapse
|
11
|
Solitano V, Dal Buono A, Gabbiadini R, Wozny M, Repici A, Spinelli A, Vetrano S, Armuzzi A. Fibro-Stenosing Crohn's Disease: What Is New and What Is Next? J Clin Med 2023; 12:jcm12093052. [PMID: 37176493 PMCID: PMC10179180 DOI: 10.3390/jcm12093052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/03/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Fibro-stenosing Crohn's disease (CD) is a common disease presentation that leads to impaired quality of life and often requires endoscopic treatments or surgery. From a pathobiology perspective, the conventional view that intestinal fibro-stenosis is an irreversible condition has been disproved. Currently, there are no existing imaging techniques that can accurately quantify the amount of fibrosis within a stricture, and managing patients is challenging, requiring a multidisciplinary team. Novel therapies targeting different molecular components of the fibrotic pathways are increasing regarding other diseases outside the gut. However, a large gap between clinical need and the lack of anti-fibrotic agents in CD remains. This paper reviews the current state of pathobiology behind fibro-stenosing CD, provides an updated diagnostic and therapeutic approach, and finally, focuses on clinical trial endpoints and possible targets of anti-fibrotic therapies.
Collapse
Affiliation(s)
- Virginia Solitano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Gastroenterology, Department of Medicine, Western University, London, ON N6A 4V2, Canada
| | - Arianna Dal Buono
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Roberto Gabbiadini
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marek Wozny
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Department of Endoscopy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Stefania Vetrano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| |
Collapse
|
12
|
Allocca M, Dal Buono A, D'Alessio S, Spaggiari P, Garlatti V, Spinelli A, Faita F, Danese S. Relationships Between Intestinal Ultrasound Parameters and Histopathologic Findings in a Prospective Cohort of Patients With Crohn's Disease Undergoing Surgery. J Ultrasound Med 2023. [PMID: 36744584 DOI: 10.1002/jum.16191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/24/2022] [Accepted: 01/22/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Recognition of intestinal lesions with substantial fibrosis is strategic for optimal management of patients with Crohn's disease (CD). We aimed to assess the relationships between intestinal ultrasound parameters and histopathologic findings in a prospective cohort of patients with CD undergoing surgery. METHODS Seventeen consecutive adult CD patients with involvement of the terminal ileum or the sigmoid colon who underwent bowel resective surgeries were enrolled and performed intestinal ultrasound (IUS) within 30 days prior to surgery. Uni- and multivariable analyses were used to assess the relationships between IUS parameters and histopathological elements of lesions. RESULTS Sensitivity, specificity, accuracy, PPV and NPV (95% CI) of IUS in detecting stricturing and penetrating complications (surgical specimen as reference standard) were 93% (68-100), 86% (42-100), 91% (71-99), 93% (68-100) and 86% (42-100), and 78% (40-97), 92% (64-100), 86% (65-97), 88% (47-100) and 86% (57-98), respectively. Only the presence of hyperechogenic spiculates was statistically significantly associated with collagen content (b = 7.29, 95% CI = 1.88/12.69, P = .012), while only the presence of vascular signals at color Doppler (Limberg score 3 or 4) was significantly associated with active inflammation (OR = 10.0, 95% CI = 0.9/108.6, P = .037). There was a strong correlation between IUS and histological measurements of the wall thickness (r = 0.67, P = .01). CONCLUSIONS The presence of hyperechogenic spiculates was associated with the presence of fibrosis, while the presence of marked vascular signals was associated with the presence of inflammation. Wall thickness measured by IUS was reliable and reproducible in comparison with histological measurement.
Collapse
Affiliation(s)
- Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | | | | | | | | | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Francesco Faita
- Institute of Clinical Physiology, Italian National Research Council, Pisa, Italy
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| |
Collapse
|
13
|
Steiner CA, Koch SD, Evanoff T, Welch N, Kostelecky R, Callahan R, Murphy EM, Hall CHT, Lu S, Weiser-Evans MC, Cartwright IM, Colgan SP. The TNF ΔARE mouse as a model of intestinal fibrosis. bioRxiv 2023:2023.01.13.523973. [PMID: 36712048 PMCID: PMC9882211 DOI: 10.1101/2023.01.13.523973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background & Aims Crohn's disease (CD) is a highly morbid chronic inflammatory disease. The majority of CD patients also develop fibrostenosing complications. Despite this, there are no medical therapies for intestinal fibrosis. This is in part due to lack of high-fidelity biomimetic models to enhance understanding and drug development. There is a need to develop in vivo models of inflammatory bowel disease-related intestinal fibrosis. We sought to determine if the TNF ΔARE mouse, a model of ileal inflammation, may also develop intestinal fibrosis. Methods Several clinically relevant outcomes were studied including features of structural fibrosis, histological fibrosis, and gene expression. These include the use of a luminal casting technique we developed, traditional histological outcomes, use of second harmonic imaging, and quantitative PCR. These features were studied in aged TNF ΔARE mice as well as in cohorts of numerous ages. Results At ages of 24+ weeks, TNF ΔARE mice develop structural, histological, and genetic changes of ileal fibrosis. Genetic expression profiles have changes as early as six weeks, followed by histological changes occurring as early as 14-15 weeks, and overt structural fibrosis delayed until after 24 weeks. Discussion The TNF ΔARE mouse is a viable and highly tractable model of intestinal fibrosis. This model and the techniques employed can be leveraged for both mechanistic studies and therapeutic development for the treatment of intestinal fibrosis.
Collapse
|
14
|
Sleiman J, Chirra P, Gandhi NS, Baker ME, Lu C, Gordon IO, Viswanath SE, Rieder F. Crohn's disease related strictures in cross-sectional imaging: More than meets the eye? United European Gastroenterol J 2022; 10:1167-1178. [PMID: 36326993 PMCID: PMC9752301 DOI: 10.1002/ueg2.12326] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022] Open
Abstract
Strictures in Crohn's disease (CD) are a hallmark of long-standing intestinal damage, brought about by inflammatory and non-inflammatory pathways. Understanding the complex pathophysiology related to inflammatory infiltrates, extracellular matrix deposition, as well as muscular hyperplasia is crucial to produce high-quality scoring indices for assessing CD strictures. In addition, cross-sectional imaging modalities are the primary tool for diagnosis and follow-up of strictures, especially with the initiation of anti-fibrotic therapy clinical trials. This in turn requires such modalities to both diagnose strictures with high accuracy, as well as be able to delineate the impact of each histomorphologic component on the individual stricture. We discuss the current knowledge on cross-sectional imaging modalities used for stricturing CD, with an emphasis on histomorphologic correlates, novel imaging parameters which may improve segregation between inflammatory, muscular, and fibrotic stricture components, as well as a future outlook on the role of artificial intelligence in this field of gastroenterology.
Collapse
Affiliation(s)
- Joseph Sleiman
- Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh School of MedicinePittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Prathyush Chirra
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | | | - Mark E. Baker
- Imaging InstituteDigestive Diseases and Surgery Institute and Cancer InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Cathy Lu
- Division of Gastroenterology and HepatologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Ilyssa O. Gordon
- Department of PathologyRobert J Tomsich Pathology and Laboratory Medicine InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Satish E. Viswanath
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & NutritionDigestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA,Department of Inflammation and ImmunityLerner Research InstituteCleveland Clinic FoundationClevelandOhioUSA
| | | |
Collapse
|
15
|
El Ouali S, Baker ME, Lyu R, Fletcher JG, Bruining DH, Holubar SD, Click B, Qazi T, Cohen BL, Rieder F. Validation of stricture length, duration and obstructive symptoms as predictors for intervention in ileal stricturing Crohn's disease. United European Gastroenterol J 2022; 10:958-972. [PMID: 36479841 PMCID: PMC9731662 DOI: 10.1002/ueg2.12314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Risk factors for intervention in terminal ileal (TI) stricturing Crohn's disease (CD) are poorly defined. Novel and rigorous definitions for TI strictures recently became available. OBJECTIVE We aimed to describe the rates of symptoms or need for endoscopic balloon dilation (EBD) or surgery as well as risk factors of progression in a well-defined stricturing CD cohort. METHODS Consecutive adult patients with non-penetrating stricturing TI CD, as defined by centrally-read magnetic resonance enterography CONSTRICT criteria, were separated into a derivation and validation cohort. Clinical and imaging characteristics were collected following prespecified scoring conventions. Primary outcome was a composite endpoint of EBD or surgery ("intervention"). Multivariable analysis was performed. RESULTS Eighty-six patients (48.8% female, median age 36 years) met selection criteria, 17.4% had prior EBD, 59.3% previously received biologics and 58.1% of strictures were anastomotic. Median follow-up was 63.4 [95% CI: 57, 68.9] months. In the derivation cohort, at 12 and 48 months, 26% and 45% of patients had intervention, respectively. Multivariable analysis showed obstructive symptoms (Hazard ratio [HR] 1.444; 95% CI 1.126-1.852), stricture duration (HR 0.974; 95% CI, 0.954-0.995) and length (HR 1.039; 95% CI, 1.011-1.069) predicted intervention. The concordance index for split-sample validation was 0.74 and 0.67, respectively. Biologics were not associated with intervention. An online risk calculator was constructed. CONCLUSION In patients with TI stricturing CD, 26% and 45% required intervention at 1 and 4 years. Obstructive symptoms, stricture duration and length were independent and validated predictors of the need for intervention. These findings are important for clinical practice and aid in the design of future trials for CD strictures.
Collapse
Affiliation(s)
- Sara El Ouali
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | | | - Ruishen Lyu
- Department of Quantitative Health SciencesCleveland ClinicClevelandOhioUSA
| | | | - David H. Bruining
- Department of Gastroenterology & HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Stefan D. Holubar
- Department of Colorectal SurgeryDigestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
| | - Benjamin Click
- Division of Gastroenterology and HepatologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | - Benjamin L. Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery InstituteCleveland Clinic FoundationClevelandOhioUSA
- Digestive Disease InstituteCleveland ClinicAbu DhabiUAE
- Department of Inflammation and ImmunityLerner Research InstituteCleveland Clinic FoundationClevelandOhioUSA
| | | |
Collapse
|
16
|
Xu W, Hua Z, Wang Y, Gu Y, Zhong J, Cui L, Du P. The endoscopic prediction model of simple endoscopic score for Crohn’s disease (SES-CD) as an effective predictor of intestinal obstruction in Crohn’s disease: A multicenter long-term follow-up study. Front Surg 2022; 9:984029. [PMID: 36338648 PMCID: PMC9632952 DOI: 10.3389/fsurg.2022.984029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Background The simple endoscopic score for Crohn's disease (SES-CD) is a widely used index to evaluate clinical and endoscopic activity. However, the association and predictive value of SES-CD for intestinal obstruction in Crohn's disease (CD) remains unclear. We aimed to establish the best cut-off indicators of SES-CD for early clinical intervention and subsequent prevention of intestinal obstruction in CD. Methods Data on patients with CD evaluated at our institute from January 2016 to January 2022 were retrospectively collected. The SES-CD and Crohn's Disease Activity Index scores used in the analysis indicated the results of the first clinical and colonoscopy evaluations after hospitalization. The primary outcome was the occurrence of intestinal obstruction during admission and follow-up. Results A total of 248 patients with a median follow-up time of 2 years [interquartile range: 1.0–4.0] were enrolled, of which 28.2% developed intestinal obstruction. An SES-CD score of 8 was the most significant threshold evaluation, and SES-CD ≥8 had the largest area under the receiver operating characteristic curve (0.705), with a sensitivity of 52.9% and specificity of 88.2% in predicting intestinal obstruction. Furthermore, SES-CD ≥8 had the greatest risk factor for intestinal obstruction (odds ratio: 7.731; 95% confidence interval: 3.901–15.322; p < 0.001) and significantly decreased the overall intestinal obstruction-free survival (p < 0.001). Conclusion The SES-CD endoscopic prediction model could be an effective predictor of intestinal obstruction in patients with CD. More frequent follow-up and colonoscopic surveillance should be considered in patients with SES-CD score ≥8 to prevent the development of intestinal obstruction.
Collapse
Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yubei Gu
- Department of Gastroenterology, Rui Jin Hospital, Affiliate to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Correspondence: Peng Du Long Cui Yubei Gu
| | - Jie Zhong
- Department of Gastroenterology, Rui Jin Hospital, Affiliate to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Correspondence: Peng Du Long Cui Yubei Gu
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Correspondence: Peng Du Long Cui Yubei Gu
| |
Collapse
|
17
|
Arslan ME, Brar R, Goetz L, Karamchandani D, Mikula MW, Hodge K, Li H, Ahn S, Lee H. Inflammation and tissue remodeling contribute to fibrogenesis in stricturing Crohn’s disease: image processing and analysis study. J Pathol Transl Med 2022; 56:239-248. [PMID: 36128860 PMCID: PMC9510042 DOI: 10.4132/jptm.2022.05.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/18/2022] [Indexed: 12/02/2022] Open
Abstract
Background Inflammation and structural remodeling may contribute to fibrogenesis in Crohn’s disease (CD). We quantified the immunoexpression of calretinin, CD34, and calprotectin as a surrogate for mucosal innervation, telocytes (interstitial cells playing a role in networking), and inflammation, respectively, and correlated them with bowel alterations in stricturing CD. Methods Primary resection specimens for ileal CD (n = 44, 31 stricturing CD, 13 inflammatory CD) were identified. Left-sided ulcerative colitis and trauma cases were used as controls. Proximal and distal margin and middle (diseased) sections were stained for calretinin, CD34, and calprotectin. Microscopic images were captured from the mucosa (calretinin), submucosa (calprotectin), and myenteric plexus (CD34), and the immunostaining was quantified using image processing and analysis. Bowel thickness at the corresponding sections were measured and correlated with the amount of immunoexpression. Results A total of 2,037 images were analyzed. In stricturing CD, submucosal alteration/thickening at the stricture site correlated with calprotectin staining and inversely correlated with calretinin staining at the proximal margin. Muscularis propria alteration/thickening at the stricture site correlated with mucosal calretinin staining at the proximal margin. Submucosal alteration/thickening at the proximal margin correlated with calretinin and CD34 staining at the proximal margin and inversely correlated with CD34 staining at the stricture site. Calretinin immunostaining at the distal margin was significantly higher in stricturing CD than the controls. Conclusions Inflammation and tissue remodeling appear to contribute to fibrogenesis in stricturing CD. Increased mucosal calretinin immunostaining distal to the diseased segment could be helpful in diagnosing CD in the right clinical context.
Collapse
Affiliation(s)
| | - Rupinder Brar
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | - Lianna Goetz
- Division of Anatomic Pathology, Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Dipti Karamchandani
- Division of Anatomic Pathology, Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Division of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Hua Li
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | | | - Hwajeong Lee
- Department of Pathology, Albany Medical Center, Albany, NY, USA
- Corresponding Author: Hwajeong Lee, MD, Department of Pathology, Albany Medical Center, 47 New Scotland Ave., MC81, Albany, NY 12208, USA Tel: +1-518-262-6254, Fax: +1-518-262-3663, E-mail:
| |
Collapse
|
18
|
Coimbra A, Rimola J, Cuatrecasas M, De Hertogh G, Van Assche G, Vanslembrouck R, Glerup H, Nielsen AH, Hagemann-Madsen R, Bouhnik Y, Zappa M, Cazals-Hatem D, D'Haens G, Stoker J, Meijer S, Rogler G, Boss A, Weber A, Zhao R, Keir ME, Scherl A, de Crespigny A, Lu TT, Panés J. Magnetic Resonance Enterography and Histology in Patients With Fibrostenotic Crohn's Disease: A Multicenter Study. Clin Transl Gastroenterol 2022; 13:e00505. [PMID: 35905415 PMCID: PMC10476777 DOI: 10.14309/ctg.0000000000000505] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/06/2022] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Magnetic resonance enterography (MRE) is useful for detecting bowel strictures, whereas a number of imaging biomarkers may reflect severity of fibrosis burden in Crohn's disease (CD). This study aimed to verify the association of MRE metrics with histologic fibrosis independent of inflammation. METHODS This prospective European multicenter study performed MRE imaging on 60 patients with CD with bowel strictures before surgical resection. Locations of 61 histological samples were annotated on MRE examinations, followed by central readings using the Chiorean score and measurement of delayed gain of enhancement (DGE), magnetization transfer ratio, T2-weighted MRI sequences (T2R), apparent diffusion coefficient (ADC), and the magnetic resonance index of activity (MaRIA). Correlations of histology and MRE metrics were assessed. Least Absolute Shrinkage and Selection Operator and receiver operator characteristic (ROC) curve analyses were used to select composite MRE scores predictive of histology and to estimate their predictive value. RESULTS ADC and MaRIA correlated with fibrosis (R = -0.71, P < 0.0001, and 0.59, P < 0.001) and more moderately with inflammation (R = -0.35, P < 0.01, and R = 0.53, P < 0.001). Lower or no correlations of fibrosis or inflammation were found with DGE, magnetization transfer ratio, or T2R. Least Absolute Shrinkage and Selection Operator and ROC identified a composite score of MaRIA, ADC, and DGE as a very good predictor of histologic fibrosis (ROC area under the curve = 0.910). MaRIA alone was the best predictor of histologic inflammation with excellent performance in identifying active histologic inflammation (ROC area under the curve = 0.966). DISCUSSION MRE-based scores for histologic fibrosis and inflammation may assist in the characterization of CD stenosis and enable development of fibrosis-targeted therapies and clinical treatment of stenotic patients.
Collapse
Affiliation(s)
- Alexandre Coimbra
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Jordi Rimola
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Gert De Hertogh
- University Hospitals Leuven and University of Leuven, Belgium
| | - Gert Van Assche
- University Hospitals Leuven and University of Leuven, Belgium
| | | | - Henning Glerup
- Silkeborg Hospital, Silkeborg, Denmark; Lillebaelt Hospital, Vejle, Denmark
| | | | | | | | | | | | - Geert D'Haens
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jaap Stoker
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Sybren Meijer
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Andreas Boss
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Rui Zhao
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Mary E. Keir
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Alexis Scherl
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Alex de Crespigny
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Timothy T. Lu
- Early Clinical Development, Genentech, Inc., South San Francisco, California
| | - Julián Panés
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| |
Collapse
|
19
|
Hu K, Yuan X, He H, Zhang H, Wang F, Qiao J. Pharmacological mechanisms of chitotriose as a redox regulator in the treatment of rat inflammatory bowel disease. Biomed Pharmacother 2022; 150:112988. [PMID: 35468583 DOI: 10.1016/j.biopha.2022.112988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/20/2022] Open
Abstract
Although extensive development has been made in the treatment of inflammatory bowel disease (IBD), adverse effects and incomplete efficacy of currently used medications are continuous challenge. Accumulated reports on the benefits of chitosan oligosaccharides in intestinal disorders make chitotriose (COS) a breakthrough in the development of new IBD drugs. This study aimed to investigate the biosafety, efficacy and pharmacological mechanisms of COS in the treatment of experimental IBD in compare with the commercial 5-Aminosalicylic acid (5-ASA). In this study, COS effectively relieved active inflammation, restored epithelial function, and reduced intestinal fibrosis. Further investigation demonstrated that COS treatment regulated redox state of the colon tissue by stimulating the transcription factor nuclear factor E2-related factor 2 (Nrf2), increasing production of endogenous antioxidants, and alleviating oxidative stress. The offset of oxidative stress shut down the nuclear factor kappa-B (NF-ĸB) inflammatory pathway, mitophagy of epithelial cells, M2 macrophage polarization in pre-fibrotic inflammation, and myofibroblast activation in intestinal fibrogenesis. In conclusion, COS is a safe and effective therapeutic agent for experimental IBD as a redox regulator. Our results expand the current understanding of the pharmacology of chitosan oligosaccharides for IBD treatment and provides experimental basis for the medicinal development of small molecule carbohydrates.
Collapse
|
20
|
Liu Q, Zhang X, Ko HM, Stocker D, Ellman J, Chen J, Hao Y, Bhardwaj S, Liang Y, Cho J, Colombel JF, Taouli B, Harpaz N. Constrictive and Hypertrophic Strictures in Ileal Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:e1292-e1304. [PMID: 34400338 DOI: 10.1016/j.cgh.2021.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/05/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Strictures in Crohn's disease (CD) are classically attributed to fibromuscular hypertrophy of the intestinal wall. We have identified and characterized CD-related ileal strictures that result instead from mural constriction (ie, reduced external circumference). METHODS Twenty-four strictures and internal controls from 17 adults with obstructive CD were analyzed by cross-sectional morphometry. RESULTS The stricture-to-control circumference ratios (CRs) ranged from 0.53 to 1.7. Six strictures with CR ≥1.0, designated hypertrophic, had concentrically thickened walls, mean 3-fold increases in cross-sectional area and stainable fibromucular tissue, and high transmural inflammation scores. In contrast, 18 strictures with CR <1.0, designated constrictive, had thin, pliant walls, cross-sectional areas and stainable fibromuscular tissue comparable with control values, and low transmural inflammation scores. Eight mildly constrictive strictures also showed mild fibromuscular mural expansion that fell short of statistical significance. Twelve of 18 constrictive strictures (67%) occurred multiply (2-4 strictures per specimen) in contrast with hypertrophic strictures, all of which occurred singly (P = .01). Constriction correlated quantitatively with circumferential serosal fat wrapping (P = .003) and was associated with myenteric lymphocytic plexitis (P = .02). Disease duration was shortest among subjects with constrictive strictures and correlated with increasing circumference (CR ≤0.8, 6.3 ± 6.2 years; CR >0.8, 8.7 ± 6.4 years; and CR ≥1.00, 13.7 ± 5.0 years, respectively; P = .03). CONCLUSIONS Constrictive ileal strictures in CD differ pathologically and clinically from hypertrophic strictures, featuring little or no fibromuscular mural expansion, frequent multiplicity, and earlier onset. Mesenteric fat wrapping and myenteric plexitis may contribute to their pathogenesis. Pathologic manifestations of constriction and hypertrophy can coexist, suggesting that stricture heterogeneity may be shaped in part by the dynamics of constrictive and hypertrophic processes.
Collapse
Affiliation(s)
- Qingqing Liu
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xiaofei Zhang
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Huaibin Mabel Ko
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Stocker
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jordan Ellman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joyce Chen
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yansheng Hao
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Swati Bhardwaj
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yuanxin Liang
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judy Cho
- Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean Frederic Colombel
- Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bachir Taouli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Dr Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| |
Collapse
|
21
|
Moroi R, Shiga H, Nochioka K, Shimoyama Y, Kuroha M, Kakuta Y, Kinouchi Y, Masamune A. A pilot study investigating the safety and feasibility of endoscopic dilation using a radial incision and cutting technique for benign strictures of the small intestine: a study protocol. Pilot Feasibility Stud 2022; 8:85. [PMID: 35440064 PMCID: PMC9017048 DOI: 10.1186/s40814-022-01046-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Small benign intestinal stenosis is usually treated by endoscopic balloon dilation (EBD) or surgery. Although EBD and surgery are able to resolve the stenosis in most cases, they are associated with several problems such as insufficient dilation and surgical stress, respectively. On the contrary, a novel approach called radial incision and cutting (RIC) is reported to have several benefits when compared to EBD and surgery. We can currently adopt RIC only for the strictures in the colon or terminal ileum and not for those stenotic lesions present further in the small intestine where balloon-assisted endoscopy is utilized, because the long-type electric knife is currently not approved for use in Japan. We will herein conduct a pilot study to investigate the safety and feasibility of RIC for treating the benign stenoses of the small intestine using the long-type electric knife. Methods This will be a single-center, single-arm, interventional trial. The major criteria for inclusion will be age ranging from 20 to 80 years and the presence of benign stenosis in the small intestine. We will perform RIC on 10 participants. The primary outcome is the safety of this procedure, which will be assessed by measuring the frequency of adverse events of special interest. The secondary outcomes will be technical success rate, improvement in subjective symptoms, procedure time, and duration of hospitalization. Discussion This pilot study will provide useful information that will aid in adopting RIC for treating the benign strictures present in the small intestine. Trial registration jRCT Identifier, jRCTs022200040. Registered on 1 March 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01046-8.
Collapse
Affiliation(s)
- Rintaro Moroi
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan.
| | - Hisashi Shiga
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| | - Kotaro Nochioka
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yusuke Shimoyama
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| | - Masatake Kuroha
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| | - Yoichi Kakuta
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| | - Yoshitaka Kinouchi
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Hospital, 1-1, Seiryo, Aoba, Sendai, Miyagi, 980-8574, Japan
| |
Collapse
|
22
|
Steiner CA, Berinstein JA, Louissaint J, Higgins PDR, Spence JR, Shannon C, Lu C, Stidham RW, Fletcher JG, Bruining DH, Feagan BG, Jairath V, Baker ME, Bettenworth D, Rieder F. Biomarkers for the Prediction and Diagnosis of Fibrostenosing Crohn's Disease: A Systematic Review. Clin Gastroenterol Hepatol 2022; 20:817-846.e10. [PMID: 34089850 PMCID: PMC8636551 DOI: 10.1016/j.cgh.2021.05.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/20/2021] [Accepted: 05/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Intestinal strictures are a common complication of Crohn's disease (CD). Biomarkers of intestinal strictures would assist in their prediction, diagnosis, and monitoring. Herein we provide a comprehensive systematic review of studies assessing biomarkers that may predict or diagnose CD-associated strictures. METHODS We performed a systematic review of PubMed, EMBASE, ISI Web of Science, Cochrane Library, and Scopus to identify citations pertaining to biomarkers of intestinal fibrosis through July 6, 2020, that used a reference standard of full-thickness histopathology or cross-sectional imaging or endoscopy. Studies were categorized based on the type of biomarker they evaluated (serum, genetic, histopathologic, or fecal). RESULTS Thirty-five distinct biomarkers from 3 major groups were identified: serum (20 markers), genetic (9 markers), and histopathology (6 markers). Promising markers include cartilage oligomeric matrix protein, hepatocyte growth factor activator, and lower levels of microRNA-19-3p (area under the curves were 0.805, 0.738, and 0.67, respectively), and multiple anti-flagellin antibodies (A4-Fla2 [odds ratio, 3.41], anti Fla-X [odds ratio, 2.95], and anti-CBir1 [multiple]). Substantial heterogeneity was observed and none of the markers had undergone formal validation. Specific limitations to acceptance of these markers included failure to use a standardized definition of stricturing disease, lack of specificity, and insufficient relevance to the pathogenesis of intestinal strictures or incomplete knowledge regarding their operating properties. CONCLUSIONS There is a lack of well-defined studies on biomarkers of intestinal stricture. Development of reliable and accurate biomarkers of stricture is a research priority. Biomarkers can support the clinical management of CD patients and aid in the stratification and monitoring of patients during clinical trials of future antifibrotic drug candidates.
Collapse
Affiliation(s)
- Calen A Steiner
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Jeffrey A Berinstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jeremy Louissaint
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Peter D R Higgins
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jason R Spence
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Cathy Lu
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ryan W Stidham
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Mark E Baker
- Section of Abdominal Imaging, Imaging Institute, Digestive Diseases and Surgery Institute and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, Germany
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| |
Collapse
|
23
|
Wen H, Zhang X, Li Q, Huang J, Liu G, Zhao J, Liu Y, Shen L, Li Y, Yang K, Zuo L, Li J, Nian J, Xiang P, Zhao H, Yu L, Liu M, Geng Z, Song X, Tahmasbpour E. Ruscogenins Improve CD-Like Enteritis by Inhibiting Apoptosis of Intestinal Epithelial Cells and Activating Nrf2/NQO1 Pathway. Oxidative Medicine and Cellular Longevity 2022; 2022:1-12. [PMID: 35308175 PMCID: PMC8930266 DOI: 10.1155/2022/4877275] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 01/22/2022] [Accepted: 01/30/2022] [Indexed: 12/14/2022]
Abstract
Interaction of intestinal barrier dysfunction and intestinal inflammation promotes the progression of Crohn's disease (CD). A more recent study has suggested that ruscogenins (RUS) can exert anti-inflammatory effects through activation of the Nrf2/NQO1 pathway. The current study is aimed at determining the functionalization of RUS on CD-like colitis. Wild-type (WT) mice induced with trinitrobenzene sulfonic acid (TNBS) exhibit a significant inflammation in their colon and are hence widely used for CD models. In the current study, the mice were treated with the Nrf-2 antagonist (ML385) or ruscogenin (RUS) whereas normal WT mice were kept as the negative control. Comparative analysis was then performed on the inflammation and barrier function of the colons. In vitro analysis of mouse colonic organoid systems revealed the influence of RUS on LPS-induced apoptosis, cytokine, and chemokine expressions in the intestinal epithelium. It was found that RUS ameliorates murine colitis through activation of the Nrf2/NQO1 pathway which was presented as a decrease in inflammation score and downregulated levels of cytokine and chemokine synthesis, as well as increased intestinal permeability. Further, it was noted that RUS alleviated LPS-induced apoptosis in the intestinal epithelium cells through upregulation of the Nrf2/NQO1 signaling pathway in the mouse colonic organoids. In addition, ruscogenin (RUS) attenuated the levels of Bax and C-caspase-3 through activation of the Nrf2/HO1 signaling pathway both in vivo and in vitro. Therefore, it was evident that RUS can be applied as a potential alternative therapeutic agent in CD based on its protective effects on the barrier function and anti-inflammatory activity.
Collapse
|
24
|
Gordon IO, Bettenworth D, Bokemeyer A, Srivastava A, Rosty C, de Hertogh G, Robert ME, Valasek MA, Mao R, Li J, Harpaz N, Borralho P, Pai RK, Odze R, Feakins R, Parker CE, Guizzetti L, Nguyen T, Shackelton LM, Sandborn WJ, Jairath V, Baker M, Bruining D, Fletcher JG, Feagan BG, Pai RK, Rieder F. International consensus to standardise histopathological scoring for small bowel strictures in Crohn's disease. Gut 2022; 71:479-486. [PMID: 33952604 PMCID: PMC8903083 DOI: 10.1136/gutjnl-2021-324374] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/31/2021] [Accepted: 04/26/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Effective medical therapy and validated trial outcomes are lacking for small bowel Crohn's disease (CD) strictures. Histopathology of surgically resected specimens is the gold standard for correlation with imaging techniques. However, no validated histopathological scoring systems are currently available for small bowel stricturing disease. We convened an expert panel to evaluate the appropriateness of histopathology scoring systems and items generated based on panel opinion. DESIGN Modified RAND/University of California Los Angeles methodology was used to determine the appropriateness of 313 candidate items related to assessment of CD small bowel strictures. RESULTS In this exercise, diagnosis of naïve and anastomotic strictures required increased bowel wall thickness, decreased luminal diameter or internal circumference, and fibrosis of the submucosa. Specific definitions for stricture features and technical sampling parameters were also identified. Histopathologically, a stricture was defined as increased thickness of all layers of the bowel wall, fibrosis of the submucosa and bowel wall, and muscularisation of the submucosa. Active mucosal inflammatory disease was defined as neutrophilic inflammation in the lamina propria and any crypt or intact surface epithelium, erosion, ulcer and fistula. Chronic mucosal inflammatory disease was defined as crypt architectural distortion and loss, pyloric gland metaplasia, Paneth cell hyperplasia, basal lymphoplasmacytosis, plasmacytosis and fibrosis, or prominent lymphoid aggregates at the mucosa/submucosa interface. None of the scoring systems used to assess CD strictures were considered appropriate for clinical trials. CONCLUSION Standardised assessment of gross pathology and histopathology of CD small bowel strictures will improve clinical trial efficiency and aid drug development.
Collapse
Affiliation(s)
- Ilyssa O Gordon
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, NRW, Germany
| | - Arne Bokemeyer
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, NRW, Germany
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Christophe Rosty
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia,Department of Clinical Pathology, The University of Melbourne, Parville, VIC, Australia,Envoi Specialist Pathologists, Brisbane, QLD, Australia
| | - Gert de Hertogh
- Department of Pathology, University Hospital Gasthuisberg, KULeuven, Leuven, Belgium
| | - Marie E Robert
- Department of Pathology and Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark A Valasek
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China,Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jiannan Li
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Noam Harpaz
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paula Borralho
- Faculdade de Medicina da Universidade de Lisboa, Instituto de Anatomia Patológica, Lisbon, Portugal
| | - Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Roger Feakins
- Department of Cellular Pathology, Royal London Hospital, London, UK
| | - Claire E Parker
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Leonardo Guizzetti
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Tran Nguyen
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - Lisa M Shackelton
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Vipul Jairath
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada,Department of Medicine and Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Mark Baker
- Section of Abdominal Imaging, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian G Feagan
- Alimentiv, Inc (formerly Robarts Clinical Trials, Inc), London, Ontario, Canada,Department of Medicine and Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Florian Rieder
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA .,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | |
Collapse
|
25
|
D'Alessio S, Ungaro F, Noviello D, Lovisa S, Peyrin-Biroulet L, Danese S. Revisiting fibrosis in inflammatory bowel disease: the gut thickens. Nat Rev Gastroenterol Hepatol 2022; 19:169-184. [PMID: 34876680 DOI: 10.1038/s41575-021-00543-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
Intestinal fibrosis, which is usually the consequence of chronic inflammation, is a common complication of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. In the past few years, substantial advances have been made in the areas of pathogenesis, diagnosis and management of intestinal fibrosis. Of particular interest have been inflammation-independent mechanisms behind the gut fibrotic process, genetic and environmental risk factors (such as the role of the microbiota), and the generation of new in vitro and in vivo systems to study fibrogenesis in the gut. A huge amount of work has also been done in the area of biomarkers to predict or detect intestinal fibrosis, including novel cross-sectional imaging techniques. In parallel, researchers are embarking on developing and validating clinical trial end points and protocols to test novel antifibrotic agents, although no antifibrotic therapies are currently available. This Review presents the state of the art on the most recently identified pathogenic mechanisms of this serious IBD-related complication, focusing on possible targets of antifibrotic therapies, management strategies, and factors that might predict fibrosis progression or response to treatment.
Collapse
Affiliation(s)
| | - Federica Ungaro
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Noviello
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Sara Lovisa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IBD Centre, Laboratory of Gastrointestinal Immunopathology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- INSERM NGERE, University of Lorraine, Vandoeuvre-les-Nancy, Nancy, France.,Nancy University Hospital, Vandoeuvre-les-Nancy, Nancy, France
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy. .,University Vita-Salute San Raffaele, Milan, Italy.
| |
Collapse
|
26
|
Hong JT, Kutaiba N, Parameswaran B, James S, Hong A, Ng SC, An V. Sensitivity of pre‐operative imaging and radiologist inter‐rater reliability in detecting lesions in Crohn's disease. ANZ J Surg 2022; 92:1085-1090. [DOI: 10.1111/ans.17477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Jason T. Hong
- Department of Colorectal Surgery Box Hill Hospital Melbourne Victoria Australia
| | - Numan Kutaiba
- Department of Radiology (Imaging Associates) Box Hill Hospital Melbourne Victoria Australia
- Department of Radiology Austin Health Melbourne Victoria Australia
| | - Bimal Parameswaran
- Department of Radiology (Imaging Associates) Box Hill Hospital Melbourne Victoria Australia
| | - Simon James
- School of Information Technology Deakin University Geelong Victoria Australia
| | - Alton Hong
- Department of Colorectal Surgery Box Hill Hospital Melbourne Victoria Australia
| | - Suat Chin Ng
- Department of Colorectal Surgery Box Hill Hospital Melbourne Victoria Australia
| | - Vinna An
- Department of Colorectal Surgery Box Hill Hospital Melbourne Victoria Australia
| |
Collapse
|
27
|
Jerala M, Hauptman N, Kojc N, Zidar N. Expression of Fibrosis-Related Genes in Liver and Kidney Fibrosis in Comparison to Inflammatory Bowel Diseases. Cells 2022; 11:314. [PMID: 35159124 PMCID: PMC8834113 DOI: 10.3390/cells11030314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/08/2022] [Accepted: 01/14/2022] [Indexed: 12/21/2022] Open
Abstract
Fibrosis is an important feature of inflammatory bowel diseases (IBD), but its pathogenesis is incompletely understood. Our aim was to identify genes important for fibrosis in IBD by comparison with kidney and liver fibrosis. First, we performed bioinformatics analysis of Gene Expression Omnibus datasets of liver and kidney fibrosis and identified CXCL9, THBS2, MGP, PTPRC, CD52, GZMA, DPT and DCN as potentially important genes with altered expression in fibrosis. We then performed qPCR analysis of the selected genes’ expression on samples of fibrotic kidney, liver, Crohn’s disease (CD) with and without fibrosis and ulcerative colitis (UC), in comparison to corresponding normal tissue. We found significantly altered expression in fibrosis for all selected genes. A significant difference for some genes was observed in CD with fibrosis in comparison to CD without fibrosis and UC. We conclude that similar changes in the expression of selected genes in liver, kidney fibrosis and IBD provide further evidence that fibrosis in IBD might share common mechanisms with other organs, supporting the hypothesis that fibrosis is the common pathway in diseases of various organs. Some genes were already active in IBD with inflammation without fibrosis, suggesting the early activation of profibrotic pathways or overlapping function in fibrosis and inflammation.
Collapse
|
28
|
Lin XX, Qiu Y, Zhuang XJ, Liu F, Wu XM, Chen MH, Mao R. Intestinal stricture in Crohn's disease: A 2020 update. J Dig Dis 2021; 22:390-398. [PMID: 34014617 DOI: 10.1111/1751-2980.13022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a chronic and relapsing-remitting inflammatory disorder of the gastrointestinal tract. Approximately 70% of patients inevitably develop fibrosis-associated intestinal stricture after 10 years of CD diagnosis, which seriously affects their quality of life. Current therapies play limited role in preventing or reversing the process of fibrosis and no specific anti-fibrotic therapy is yet available. Nearly half of patients thus have no alternative but to receive surgery. The potential mechanisms of intestinal fibrosis remain poorly understood; extracellular matrix remodeling, aberrant immune response, intestinal microbiome imbalance and creeping fat might exert fundamental influences on the multiple physiological and pathophysiological processes. Recently, the emerging new diagnostic techniques have markedly promoted an accurate assessment of intestinal stricture by distinguishing fibrosis from inflammation, which is crucial for guiding treatment and predicting prognosis. In this review, we concisely summarized the key studies published in the year 2020 covering pathogenesis, diagnostic modalities, and therapeutic strategy of intestinal stricture. A comprehensive and timely review of the updated researches in intestinal stricture could provide insight to further elucidate its pathogenesis and identify novel drug targets with anti-fibrotic potentiality.
Collapse
Affiliation(s)
- Xiao Xuan Lin
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Jun Zhuang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Fen Liu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao Min Wu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Min Hu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ren Mao
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| |
Collapse
|
29
|
Ou W, Xu W, Liu F, Guo Y, Huang Z, Feng T, Liu CY, Du P. Increased expression of yes-associated protein/YAP and transcriptional coactivator with PDZ-binding motif/TAZ activates intestinal fibroblasts to promote intestinal obstruction in Crohn's disease. EBioMedicine 2021; 69:103452. [PMID: 34186485 PMCID: PMC8243379 DOI: 10.1016/j.ebiom.2021.103452] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 05/29/2021] [Accepted: 06/02/2021] [Indexed: 12/18/2022] Open
Abstract
Background Intestinal obstruction caused by intestinal fibrosis is a common and serious complication of Crohn's disease (CD). Intestinal fibroblasts, the main effector cells mediating gastrointestinal fibrosis, are activated during chronic inflammation. However, the mechanism of fibroblast activation in CD has not been well elucidated. Methods Fibroblasts isolated from stenotic and nonstenotic intestines of CD patients were used for RNA sequencing. Immunohistochemical and immunofluorescent staining was performed to evaluate the correlation between intestinal fibrosis and YAP/TAZ expression in our CD cohort and a DSS-induced chronic colitis murine model. A Rho-associated coiled-coil-containing protein kinase 1 (ROCK1) inhibitor was used to explore the ROCK1-YAP/TAZ axis in intestinal fibroblasts in vitro and DSS-induced chronic colitis murine model in vivo. Findings The expression of YAP/TAZ was significantly upregulated in stenotic fibroblasts, which was associated with the YAP/TAZ target gene signature. YAP/TAZ knockdown suppressed the activation of intestinal fibroblasts. In intestinal fibroblasts, YAP/TAZ were activated by the Rho-ROCK1 signalling pathway. High YAP/TAZ expression was positively correlated with ROCK1 expression, which is a prognostic marker for intestinal obstruction in CD patients. Interpretation YAP/TAZ activation can lead to fibroblast activation and intestinal obstruction in CD. The effect of ROCK1 inhibitor on alleviating intestinal fibrosis is associated with YAP/TAZ inhibition. Targeted inhibition of YAP/TAZ in fibroblasts may be a potential therapeutic strategy to suppress intestinal fibrosis in CD. Funding This work was supported by the National Key R&D Program of China (2019YFC1316002), the NSFC (81873547, 82073201, 81874177, 82000481) and the Shanghai Sailing Program (20YF1429400).
Collapse
Affiliation(s)
- Weijun Ou
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Fangyuan Liu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Yuegui Guo
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Zhenyu Huang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Chen-Ying Liu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China.
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China.
| |
Collapse
|
30
|
Khan F, Person H, Dekio F, Ogawa M, Ho HE, Dunkin D, Secord E, Cunningham-Rundles C, Ward SC. Crohn's-like Enteritis in X-Linked Agammaglobulinemia: A Case Series and Systematic Review. J Allergy Clin Immunol Pract 2021:S2213-2198(21)00579-1. [PMID: 34029777 DOI: 10.1016/j.jaip.2021.04.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND X-linked agammaglobulinemia (XLA) is an inherited primary immunodeficiency that usually manifests clinically with recurrent sinopulmonary infections. Gastrointestinal manifestations are mostly driven by acute infections and disturbed mucosal immunity, but there is a notable prevalence of inflammatory bowel disease (IBD). Differentiating between XLA-associated enteritis, which can originate from recurrent infections, and IBD can be diagnostically and therapeutically challenging. OBJECTIVE This study presents a critical appraisal of the clinical, radiological, endoscopic, and histological features associated with XLA-associated Crohn disease (CD)-like enteritis. METHODS We report 3 cases and performed a systematic review of the literature describing the diagnoses and outcomes. RESULTS An XLA-related enteropathy presented in adolescence with an ileocolonic CD-like phenotype without perianal disease. Abdominal pain, noninfectious diarrhea, and weight loss were the most common symptoms. Imaging and endoscopic findings closely resemble CD. However, histologically, it presents without nodular lymphoid hyperplasia and only 2 studies reported the presence of granulomas. In addition, in XLA-associated enteritis, immunohistochemistry showed the absence or marked reduction in B cells and plasma cells. CONCLUSIONS An XLA-associated enteritis is a distinct pathological process that presents clinically in a manner similar to ileocolonic CD. It is important to evaluate for infectious diarrhea, which is common in XLA and can mimic IBD clinically. Complete multidisciplinary evaluation is, therefore, recommended for XLA patients with persistent gastrointestinal symptoms. Although more research is needed, therapeutic selection for XLA-associated enteritis is like that of IBD, and the possible risk of drug interactions and complications from increasing immunosuppression should be considered.
Collapse
|
31
|
Wang J, Lin S, Brown JM, van Wagoner D, Fiocchi C, Rieder F. Novel mechanisms and clinical trial endpoints in intestinal fibrosis. Immunol Rev 2021; 302:211-227. [PMID: 33993489 DOI: 10.1111/imr.12974] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/18/2021] [Accepted: 04/23/2021] [Indexed: 12/13/2022]
Abstract
The incidence of inflammatory bowel diseases (IBD) worldwide has resulted in a global public health challenge. Intestinal fibrosis leading to stricture formation and bowel obstruction is a frequent complication in Crohn's disease (CD), and the lack of anti-fibrotic therapies makes elucidation of fibrosis mechanisms a priority. Progress has shown that mesenchymal cells, cytokines, microbial products, and mesenteric adipocytes are jointly implicated in the pathogenesis of intestinal fibrosis. This recent information puts prevention or reversal of intestinal strictures within reach through innovative therapies validated by reliable clinical trial endpoints. Here, we review the role of immune and non-immune components of the pathogenesis of intestinal fibrosis, including new cell clusters, cytokine networks, host-microbiome interactions, creeping fat, and their translation for endpoint development in anti-fibrotic clinical trials.
Collapse
Affiliation(s)
- Jie Wang
- Henan Key Laboratory of Immunology and Targeted Drug, Xinxiang Medical University, Xinxiang, China.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sinan Lin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jonathan Mark Brown
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David van Wagoner
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Claudio Fiocchi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
32
|
Ferretti F, Cannatelli R, Ardizzone S, Maier JA, Maconi G. Ultrasonographic Evaluation of Intestinal Fibrosis and Inflammation in Crohn's Disease. The State of the Art. Front Pharmacol 2021; 12:679924. [PMID: 33981246 PMCID: PMC8107820 DOI: 10.3389/fphar.2021.679924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
The evaluation of the degree of inflammation and fibrosis, intrinsic elements in intestinal wall damage of Crohn’s disease, is essential to individuate the extent of the lesions and the presence of strictures. This information will contribute to the choice of the appropriate therapeutic approach, the prediction of the response to therapy and the course of the disease. The accurate evaluation of the extent and severity of inflammation and/or fibrosis in Crohn’s disease currently requires histopathological analysis of the intestinal wall. However, in clinical practice and research, transmural assessment of the intestinal wall with cross sectional imaging is increasingly used for this purpose. The B-mode ultrasonograhic characteristics of the intestinal wall, the assessment of its vascularization by color Doppler and I.V. contrast agents, and the evaluation of the mechanical and elastic properties by sonoelastography, may provide useful and accurate information on the severity and extent of inflammation and intestinal fibrosis in Crohn’s disease. The purpose of this review is to provide an update on current sonographic methods to discriminate inflammation and fibrosis in Crohn’s disease.
Collapse
Affiliation(s)
- Francesca Ferretti
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Rosanna Cannatelli
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Sandro Ardizzone
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Jeanette A Maier
- General Pathology-Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Maconi
- Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
33
|
Tavares de Sousa H, Gullo I, Castelli C, Dias CC, Rieder F, Carneiro F, Magro F. Ileal Crohn's Disease Exhibits Similar Transmural Fibrosis Irrespective of Phenotype. Clin Transl Gastroenterol 2021; 12:e00330. [PMID: 33848279 PMCID: PMC8049162 DOI: 10.14309/ctg.0000000000000330] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/17/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION In Crohn's disease (CD), the assessment of transmural inflammation and fibrosis is of utmost importance. This study aimed to quantify these parameters in CD ileal specimens and correlate them with disease progression. METHODS This is a retrospective unicentric study based on the analysis of archived specimens (n = 103) of primary ileal resection. Data were retrieved from a prospective national inflammatory bowel disease registry. Two pathologists, blinded for CD phenotype and clinical indications for surgery, examined 3 sections per patient and graded inflammation and fibrosis, based on a histopathological score. RESULTS Penetrating (B3, n = 74) CD exhibited significantly higher inflammation in diseased areas, compared with stricturing (B2, n = 29) disease (score 3: 96% vs 76%, P = 0.005 in inflamed areas; 78% vs 55%, P = 0.019 in most affected areas). This was also observed for the comparison of B2 CD with B3 CD with (B3s, n = 54) and without associated stricture (B3o, n = 20): B3s vs B2: 81% vs 55%, P = 0.033 in most affected areas; B3o vs B2: 100% vs 76%, P = 0.006 in inflamed areas; 70% vs 55%, P = 0.039 in most affected areas. We could not show differences in fibrosis scores between the subphenotypes. Postoperative new penetrating events occurred only in B3s (n = 6, 11%, P = 0.043) patients. The changing of biologic therapy after surgery correlated with severe inflammation at the proximal ileal margin (55% changed vs 25% not changed, P = 0.035). DISCUSSION In our cohort, fibrosis scores and fibromuscular changes were comparable, irrespective of CD phenotype. Inflammation severity was the major differentiator between penetrating and stricturing disease.JOURNAL/cltg/04.03/01720094-202104000-00012/inline-graphic1/v/2021-04-13T161901Z/r/image-tiff.
Collapse
Affiliation(s)
- Helena Tavares de Sousa
- Gastroenterology Department, Algarve University Hospital Center, Portimão, Portugal
- ABC—Algarve Biomedical Center, University of Algarve, Faro, Portugal
| | - Irene Gullo
- Department of Pathology, São João University Hospital Center and Faculty of Medicine, University of Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal
- Institute of Investigation and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Claudia Castelli
- Section of Pathology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Cláudia Camila Dias
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Fátima Carneiro
- Department of Pathology, São João University Hospital Center and Faculty of Medicine, University of Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup), Porto, Portugal
- Institute of Investigation and Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, Portugal
- Department of Gastroenterology, São João University Hospital Center, Porto, Portugal
- MedInUP, Center for Drug Discovery and Innovative Medicines, Porto, Portugal
| |
Collapse
|
34
|
Sleiman J, Ouali SE, Qazi T, Cohen B, Steele SR, Baker ME, Rieder F. Prevention and Treatment of Stricturing Crohn's Disease - Perspectives and Challenges. Expert Rev Gastroenterol Hepatol 2021; 15:401-411. [PMID: 33225766 PMCID: PMC8026566 DOI: 10.1080/17474124.2021.1854732] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Fibrostenosis is a hallmark of Crohn's disease (CD), remains a challenge in today's clinical management of inflammatory bowel disease patients and represents a key event in the disease course necessitating improved preventative strategies and a multidisciplinary approach to diagnosis and management. With the advent of anti-fibrotic therapies and well-defined clinical endpoints for stricturing CD, there is promise to impact the natural history of disease.Areas covered: This review summarizes current evidence in the natural history of stricturing Crohn's disease, discusses management approaches as well as future perspectives on intestinal fibrosis.Expert opinion: Currently, there are no specific therapies to prevent progression to fibrosis or to treat it after it becomes clinically apparent. In addition to the international effort by the Stenosis Therapy and Anti-Fibrotic Research (STAR) consortium to standardize definitions and propose endpoints in the management of stricturing CD, further research to improve our understanding of mechanisms of intestinal fibrosis will help pave the way for the development of future anti-fibrotic therapies.
Collapse
Affiliation(s)
- Joseph Sleiman
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sara El Ouali
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Taha Qazi
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R. Steele
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark E. Baker
- Section Abdominal Imaging, Imaging Institute, Digestive Diseases and Surgery Institute, Cleveland, Ohio, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Corresponding author: Florian Rieder, Address: Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue – NC22, Cleveland, OH, 44195,
| |
Collapse
|
35
|
Gabbiadini R, Zacharopoulou E, Furfaro F, Craviotto V, Zilli A, Gilardi D, Roda G, Loy L, Fiorino G, Peyrin-Biroulet L, Danese S, Allocca M. Application of Ultrasound Elastography for Assessing Intestinal Fibrosis in Inflammatory Bowel Disease: Fiction or Reality? Curr Drug Targets 2021; 22:347-355. [PMID: 33213341 DOI: 10.2174/1389450121666201119142919] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/07/2020] [Accepted: 09/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intestinal fibrosis and subsequent strictures represent an important burden in inflammatory bowel disease (IBD). Both the detection and evaluation of the degree of fibrosis in stricturing Crohn's disease (CD) are important when deciding the best therapeutic strategy (medical anti-inflammatory therapy, endoscopic dilation, surgery). Ultrasound elastography (USE) is a non-invasive technique that has been proposed in the field of IBD for evaluating intestinal stiffness as a biomarker of intestinal fibrosis. OBJECTIVE The aim of this review is to discuss the ability and current role of ultrasound elastography in the assessment of intestinal fibrosis. RESULTS AND CONCLUSION Data on USE in IBD are provided by pilot and proof-of-concept studies with small sample size. The first type of USE investigated was strain elastography, while shear wave elastography has been introduced recently. Despite the heterogeneity of the methods of the studies, USE has been proven to be able to assess intestinal fibrosis in patients with stricturing CD. However, before introducing this technique in current practice, further studies with larger sample sizes are needed. In addition, the use of homogeneous parameters, the assessment of reproducibility, and the identification of validated cut-off values are essential.
Collapse
Affiliation(s)
- Roberto Gabbiadini
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Eirini Zacharopoulou
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Federica Furfaro
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Vincenzo Craviotto
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Alessandra Zilli
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Daniela Gilardi
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Giulia Roda
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Laura Loy
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Gionata Fiorino
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy, France
| | - Silvio Danese
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Mariangela Allocca
- Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| |
Collapse
|
36
|
Mao R, Doyon G, Gordon IO, Li JN, Lin SN, Wang J, Le THN, Elias M, Kurada S, Southern BD, Olman M, Chen MH, Zhao S, Dejanovic D, Chandra J, Mukherjee PK, West G, van Wagoner DR, Fiocchi C, Rieder F. Activated intestinal muscle cells promote preadipocyte migration: a novel mechanism for creeping fat formation in Crohn's disease. Gut 2021; 71:55-67. [PMID: 33468536 PMCID: PMC8286985 DOI: 10.1136/gutjnl-2020-323719] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/22/2020] [Accepted: 01/07/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Creeping fat, the wrapping of mesenteric fat around the bowel wall, is a typical feature of Crohn's disease, and is associated with stricture formation and bowel obstruction. How creeping fat forms is unknown, and we interrogated potential mechanisms using novel intestinal tissue and cell interaction systems. DESIGN Tissues from normal, UC, non-strictured and strictured Crohn's disease intestinal specimens were obtained. The muscularis propria matrisome was determined via proteomics. Mesenteric fat explants, primary human preadipocytes and adipocytes were used in multiple ex vivo and in vitro cell migration systems on muscularis propria muscle cell derived or native extracellular matrix. Functional experiments included integrin characterisation via flow cytometry and their inhibition with specific blocking antibodies and chemicals. RESULTS Crohn's disease muscularis propria cells produced an extracellular matrix scaffold which is in direct spatial and functional contact with the immediately overlaid creeping fat. The scaffold contained multiple proteins, but only fibronectin production was singularly upregulated by transforming growth factor-β1. The muscle cell-derived matrix triggered migration of preadipocytes out of mesenteric fat, fibronectin being the dominant factor responsible for their migration. Blockade of α5β1 on the preadipocyte surface inhibited their migration out of mesenteric fat and on 3D decellularised intestinal tissue extracellular matrix. CONCLUSION Crohn's disease creeping fat appears to result from the migration of preadipocytes out of mesenteric fat and differentiation into adipocytes in response to an increased production of fibronectin by activated muscularis propria cells. These new mechanistic insights may lead to novel approaches for prevention of creeping fat-associated stricture formation.
Collapse
Affiliation(s)
- Ren Mao
- Department of Gastroenterology, First Affiliated Hospital
of Sun Yat-sen University, Guangzhou, China,Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Genevieve Doyon
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Aging Institute, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
| | - Ilyssa O. Gordon
- Department of Pathology, Robert J. Tomsich Pathology and
Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, USA
| | - Jian-Nan Li
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Si-Nan Lin
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jie Wang
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thi Hong Nga Le
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Elias
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Satya Kurada
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Gastroenterology, Hepatology and Nutrition,
Digestive Diseases and Surgery Institute; Cleveland Clinic Foundation, Cleveland,
USA
| | - Brian D. Southern
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mitchell Olman
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Min-hu Chen
- Department of Gastroenterology, First Affiliated Hospital
of Sun Yat-sen University, Guangzhou, China
| | - Shuai Zhao
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Dina Dejanovic
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jyotsna Chandra
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Pranab K. Mukherjee
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gail West
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David R. van Wagoner
- Department of Cardiovascular and Metabolic Science, Lerner
Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Claudio Fiocchi
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA,Department of Gastroenterology, Hepatology and Nutrition,
Digestive Diseases and Surgery Institute; Cleveland Clinic Foundation, Cleveland,
USA
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA .,Department of Gastroenterology, Hepatology and Nutrition, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
37
|
Bhatnagar G, Rodriguez-Justo M, Higginson A, Bassett P, Windsor A, Cohen R, Halligan S, Taylor SA. Inflammation and fibrosis in Crohn's disease: location-matched histological correlation of small bowel ultrasound features. Abdom Radiol (NY) 2021; 46:144-155. [PMID: 32564208 PMCID: PMC7864849 DOI: 10.1007/s00261-020-02603-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the utility of mural and extramural sonographic features of Crohn's Disease as potential imaging biomarkers of inflammation and fibrosis against whole-mount histological sections. METHODS Twelve Crohn's disease patients (Mean age 35(25-69), 7 males) underwent small bowel ultrasound prior to small bowel resection. Two radiologists in consensus graded multiple parameters including mural, mucosal and submucosal thickness, submucosal/mesenteric echogenicity and clarity and mural Doppler signal in 50 selected bowel cross-sections. Matching with histological sampling sites was facilitated via scanning of the resected specimen. A histopathologist scored acute and chronic inflammation, and fibrosis (using histological scoring systems) following analysis of whole mount block sections. The association between sonographic observations and histopathological scores was examined via univariable and multivariable analysis. RESULTS In univariate analyses, bowel wall thickness (regression co-efficient and 95% CI 0.8 (0.3, 1.3) p = 0.001), mesenteric fat echogenicity (8.7(3.0, 14.5) p = 0.005), submucosal layer thickness (7.4(1.2, 13.5) p = 0.02), submucosal layer clarity (4.4(0.6, 8.2) p = 0.02) and mucosal layer thickness (4.6(1.8, 7.4) p = 0.001) were all significantly associated with acute inflammation. Mesenteric fat echogenicity (674(8.67, 52404) p = 0.009), submucosal layer thickness (79.9(2.16, 2951) p = 0.02) and mucosal layer thickness (13.6(1.54, 121) p = 0.02) were significantly associated with chronic inflammation. Submucosal layer echogenicity (p = 0.03), clarity (25.0(1.76, 356) p = 0.02) and mucosal layer thickness (53.8(3.19, 908) p = 0.006) were significantly associated with fibrosis. In multivariate analyses, wall and mucosal thickness remained significantly associated with acute inflammation (p = 0.02), mesenteric fat echogenicity with chronic inflammation (p = 0.009) and mucosal thickness (p = 0.006) with fibrosis. CONCLUSION Multiple sonographic parameters are associated with histological phenotypes in Crohn's disease although there is overlap between ultrasonic stigmata of acute inflammation, chronic inflammation and fibrosis.
Collapse
Affiliation(s)
- Gauraang Bhatnagar
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| | - Manuel Rodriguez-Justo
- grid.439749.40000 0004 0612 2754Department of Histology, University College Hospitals, London, UK
| | - Antony Higginson
- grid.415470.30000 0004 0392 0072Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Alastair Windsor
- grid.439749.40000 0004 0612 2754Department of Colorectal Surgery, University College Hospitals, London, UK
| | - Richard Cohen
- grid.439749.40000 0004 0612 2754Department of Colorectal Surgery, University College Hospitals, London, UK
| | - Steve Halligan
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| | - Stuart A. Taylor
- grid.83440.3b0000000121901201Centre for Medical Imaging, University College London, 2nd Floor Charles Bell House, 43-45 Foley Street, London, W1W 7TS UK
| |
Collapse
|
38
|
Alfredsson J, Wick MJ. Mechanism of fibrosis and stricture formation in Crohn's disease. Scand J Immunol 2020; 92:e12990. [PMID: 33119150 PMCID: PMC7757243 DOI: 10.1111/sji.12990] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/06/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract that leads to substantial suffering for millions of patients. In some patients, the chronic inflammation leads to remodelling of the extracellular matrix and fibrosis. Fibrosis, in combination with expansion of smooth muscle layers, leaves the bowel segment narrowed and stiff resulting in strictures, which often require urgent medical intervention. Although stricture development is associated with inflammation in the affected segment, anti‐inflammatory therapies fall far short of treating strictures. At best, current therapies might allow some patients to avoid surgery in a shorter perspective and no anti‐fibrotic therapy is yet available. This likely relates to our poor understanding of the mechanism underlying stricture development. Chronic inflammation is a prerequisite, but progression to strictures involves changes in fibroblasts, myofibroblasts and smooth muscle cells in a poorly understood interplay with immune cells and environmental cues. Much of the experimental evidence available is from animal models, cell lines or non‐strictured patient tissue. Accordingly, these limitations create the basis for many previously published reviews covering the topic. Although this information has contributed to the understanding of fibrotic mechanisms in general, in the end, data must be validated in strictured tissue from patients. As stricture formation is a serious complication of CD, we endeavoured to summarize findings exclusively performed using strictured tissue from patients. Here, we give an update of the mechanism driving this serious complication in patients, and how the strictured tissue differs from adjacent unaffected tissue and controls.
Collapse
Affiliation(s)
- Johannes Alfredsson
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Mary Jo Wick
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
39
|
Affiliation(s)
- Roger M Feakins
- Royal Free London NHS Foundation Trust, Cellular Pathology, London, UK
| |
Collapse
|
40
|
Zidar N. Histopathology of Fibrosis in Crohn's Disease: The Importance of Understanding Its Pathogenesis. Gastroenterology 2020; 158:2313-2314. [PMID: 32201180 DOI: 10.1053/j.gastro.2020.02.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/06/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Nina Zidar
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
41
|
Affiliation(s)
- Ren Mao
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Min-Hu Chen
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
42
|
Zidar N, Langner C, Jerala M, Boštjančič E, Drobne D, Tomažič A. Pathology of Fibrosis in Crohn's Disease-Contribution to Understanding Its Pathogenesis. Front Med (Lausanne) 2020; 7:167. [PMID: 32432120 PMCID: PMC7215240 DOI: 10.3389/fmed.2020.00167] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/14/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Despite significant progress in the research of fibrosis in various organs, fibrosis remains a poorly understood complication of Crohn's disease (CD). We analyzed pathologic features of fibrosis and inflammation in CD and compared them with the normal bowel, aiming to clarify whether fibrosis in CD pathogenetically resembles fibrosis in other organs. Methods: Resection specimens from 30 patients with CD were included. Normal bowel from resection specimens of colorectal carcinoma was used for comparison. Trichrome Masson staining, immunohistochemistry for α-smooth muscle actin, fibroblast activation protein, CD34 and erg, in situ hybridization for TGF-β1 and analysis of selected fibrosis-related microRNAs were performed. Results: In normal bowel, CD34-positive fibroblasts/pericytes were detected in the submucosa and subserosa, particularly around blood vessels. In CD, fibrosis prevailed in the submucosa and subserosa, together with proliferation of myofibroblasts and disappearance of CD34-positive fibroblasts/pericytes. TGF-β1 was present in the lamina propria in normal bowel and CD, and in deeper parts of the bowel wall in CD. MicroRNAs miR-29c, miR-155 miR-150, and miR-155, which have been demonstrated to contribute to fibrosis in various organs, showed significant deregulation in CD. Conclusions: Distribution of fibroblasts/pericytes in the submucosa and subserosa of normal bowel, their disappearance in fibrosis in CD, together with the appearance of myofibroblasts, suggest that fibroblasts/pericytes are the most likely source of myofibroblasts in CD. Furthemore, fibrosis-related microRNAs showed deregulation in fibrotic areas. Pathogenesis of fibrosis in CD is thus comparable to fibrosis in other organs, in which myofibroblasts are the key effector cells, and pericytes have emerged as the main origin of myofibroblasts. Fibrosis in CD should be regarded as a result of (over)response of the bowel wall to the presence of inflammation in deep structures of the bowel wall, presenting another example of a common pathogenetic pathway of fibrosis development.
Collapse
Affiliation(s)
- Nina Zidar
- Faculty of Medicine, Institute of Pathology, University of Ljubljana, Ljubljana, Slovenia
| | - Cord Langner
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Miha Jerala
- Faculty of Medicine, Institute of Pathology, University of Ljubljana, Ljubljana, Slovenia
| | - Emanuela Boštjančič
- Faculty of Medicine, Institute of Pathology, University of Ljubljana, Ljubljana, Slovenia
| | - David Drobne
- Faculty of Medicine, Institute of Pathology, University of Ljubljana, Ljubljana, Slovenia.,Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aleš Tomažič
- Faculty of Medicine, Institute of Pathology, University of Ljubljana, Ljubljana, Slovenia.,Department of Abdominal Surgery, University Medical Center, Ljubljana, Slovenia
| |
Collapse
|
43
|
Abstract
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.
Collapse
Affiliation(s)
- Jun Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Stefan Holubar
- Department of Colorectal Surgery, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
44
|
Pous S, Frasson M, Jiménez R, Pamiés J, Puchades I, Llavador M, García-Granero E, Nos P. Relevance of dynamic studies with magnetic resonance enterography in Crohn's disease. Gastroenterol Hepatol 2020; 43:179-187. [PMID: 32089377 DOI: 10.1016/j.gastrohep.2019.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/21/2019] [Accepted: 11/17/2019] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A proper quantification of the inflammatory activity in Crohn's disease (CD) lesions is needed to establish the appropriate management for each patient. The aim of this study is to evaluate the inflammatory activity of affected segments in small bowel lesions using dynamic studies of magnetic resonance enterography (MRE) in patients undergoing surgery, and their correlation with the level of inflammation and histological fibrosis of the surgical piece. METHODS A prospective, consecutive, observational, clinical study was conducted that included all the patients with small bowel CD that underwent surgery in this center between March 2011 and September 2013. Diagnosis was established according to Lennard-Jones criteria and the Montreal classification. All the patients underwent MRE within three months before surgery, using a routine protocol involving Liver Acquisition with Volume Acceleration-Extended Volume (LAVA-XV) sequence for the dynamic studies before intravenous administering of gadolinium and 30, 70, 120, and 420s after administering this. The results allowed the designing of graphics with different uptake patterns. The Chiorean classification was used in the histological analysis, as well as a modified version published previously by this study group. RESULTS A total of 28 patients with 47 lesions were analyzed. There was a significant correlation between both curve patterns, including the modified Chiorean classification (P<0.0001) as well as the level of inflammation (P<0.0001) and fibrosis (P<0.002). Inflammatory patterns of dynamic studies are related to histological findings with 80.9% accuracy (sensitivity=75.7%; specificity=100%). CONCLUSION There is a high correlation between dynamic enhancement studies and the level of inflammatory activity. MRE is a suitable tool to differentiate between inflammatory and fibrotic lesions, making it useful to decide the appropriate management of each patient.
Collapse
Affiliation(s)
- Salvador Pous
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spain
| | - Raquel Jiménez
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spain
| | - José Pamiés
- Department of Radiology, La Fe University Hospital, Spain
| | - Icíar Puchades
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spain
| | | | - Eduardo García-Granero
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Spain
| | - Pilar Nos
- Department of Gastroenterology, Inflammatory Bowel Disease Unit, La Fe University Hospital, Spain; CIBEREHD (Networked Biomedical Research Center for Hepatic and Digestive Disease), Spain.
| |
Collapse
|
45
|
Abstract
Stricturing Crohn's disease (CD) is a significant clinical problem. The presence of a stricture may be suggested by clinical symptoms. Cross-sectional imaging using computed tomography or magnetic resonance enterography is essential in diagnosing strictures as it allows further characterization and evaluation for complications such as abscess, fistulizing disease or malignancy. Managing small bowel stricturing CD should be approached in a multidisciplinary fashion. Medical therapy can be considered in strictures which are not associated with complications, with most of the data supporting anti-TNF strategies in this setting. If the disease is refractory to medical therapy, endoscopic therapy or surgery should be performed. Endoscopic balloon dilation (EBD) is an option for short, uncomplicated and straight strictures that are within reach of a colonoscope. Although EBD has good short-term outcomes, repeat dilation is often required. Surgical options mainly include resection and strictureplasty. Strictures refractory to medical therapy, not amenable or refractory to EBD, or associated with complications or malignancy should be managed surgically. However, surgery may also be considered at an earlier stage depending on disease characteristics and patient preference. Postoperative recurrence is common, highlighting the importance of careful monitoring of the patient postoperatively and optimization of medical management accordingly. There is a pressing need to develop anti-fibrotics for the treatment of stricturing CD. This requires the development of standardized diagnostic criteria, patient-reported outcome measures and validation of endpoints in fibrostenotic CD. The STAR consortium is pioneering this effort in order to allow development and testing of anti-fibrotics in future clinical trials.
Collapse
Affiliation(s)
- Sara El Ouali
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin Click
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
46
|
Bokemeyer A, Tepasse PR, Quill L, Lenz P, Rijcken E, Vieth M, Ding N, Ketelhut S, Rieder F, Kemper B, Bettenworth D. Quantitative Phase Imaging Using Digital Holographic Microscopy Reliably Assesses Morphology and Reflects Elastic Properties of Fibrotic Intestinal Tissue. Sci Rep 2019; 9:19388. [PMID: 31852983 DOI: 10.1038/s41598-019-56045-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022] Open
Abstract
Intestinal strictures are a frequent complication in patients with Crohn’s Disease (CD) and the presence of fibrosis within strictures impacts the therapeutic treatment approach. Here, we evaluate quantitative phase imaging (QPI) using digital holographic microscopy (DHM) for the evaluation of fibrosis within CD strictures. 30 full thickness resection specimens were obtained from non-stenotic and stenotic tissue areas of 15 CD patients. Cryostat sections were analyzed by DHM to measure the spatial distribution of the refractive index (RI) to quantify tissue density. Complementary, histopathological evaluation of H&E staining and immunofluorescence (IF) targeting fibrosis markers served as the gold standard. Moreover, tissue stiffness was evaluated by elastography. RI values assessed by DHM were significantly higher in stenotic compared to non-stenotic tissue areas (p < 0.001). Histopathological analysis using H&E staining and IF confirmed the elevated expression of fibrosis markers in stenotic compared to non-stenotic tissue (all p < 0.001). The RI retrieved by DHM strongly correlated with the amount of fibrosis as determined by IF (p < 0.001; R2 = 0.48). Furthermore, elastography detected a significantly higher tissue stiffness in stenotic as compared to non-stenotic tissue sections (p < 0.001). In conclusion, QPI using DHM accurately assesses fibrotic properties of CD-associated strictures and may improve the characterization of CD strictures.
Collapse
|