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Hoerning A, Jüngert J, Siebenlist G, Knieling F, Regensburger AP. Ultrasound in Pediatric Inflammatory Bowel Disease-A Review of the State of the Art and Future Perspectives. Children (Basel) 2024; 11:156. [PMID: 38397268 PMCID: PMC10887069 DOI: 10.3390/children11020156] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
Inflammatory bowel disease (IBD) comprises a group of relapsing, chronic diseases of the gastrointestinal tract that, in addition to adults, can affect children and adolescents. To detect relapses of inflammation, these patients require close observation, frequent follow-up, and therapeutic adjustments. While reference standard diagnostics include anamnestic factors, laboratory and stool sample assessment, performing specific imaging in children and adolescents is much more challenging than in adults. Endoscopic and classic cross-sectional imaging modalities may be invasive and often require sedation for younger patients. For this reason, intestinal ultrasound (IUS) is becoming increasingly important for the non-invasive assessment of the intestine and its inflammatory affection. In this review, we would like to shed light on the current state of the art and provide an outlook on developments in this field that could potentially spare these patients more invasive follow-up procedures.
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Affiliation(s)
- André Hoerning
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- German Center Immunotherapy (DZI), University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Gregor Siebenlist
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Adrian P Regensburger
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
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Kim SW, Lee JY, Lee HC, Ahn JB, Kim JH, Park IS, Cheon JH, Kim DH. Downregulation of Heat Shock Protein 72 Contributes to Fibrostenosis in Crohn's Disease. Gut Liver 2023; 17:905-915. [PMID: 36814356 PMCID: PMC10651382 DOI: 10.5009/gnl220308] [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: 07/18/2022] [Revised: 10/21/2022] [Accepted: 11/29/2022] [Indexed: 02/24/2023] Open
Abstract
Background/Aims Crohn's disease (CD) with recurrent inflammation can cause intestinal fibrostenosis due to dysregulated deposition of extracellular matrix. However, little is known about the pathogenesis of fibrostenosis. Here, we performed a differential proteomic analysis between normal, inflamed, and fibrostenotic specimens of patients with CD and investigated the roles of the candidate proteins in myofibroblast activation and fibrosis. Methods We performed two-dimensional difference gel electrophoresis and identified candidate proteins using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and orbitrap liquid chromatography-mass spectrometry. We also verified the levels of candidate proteins in clinical specimens and examined their effects on 18Co myofibroblasts and Caco-2 intestinal epithelial cells. Results We identified five of 30 proteins (HSP72, HSPA5, KRT8, PEPCK-M, and FABP6) differentially expressed in fibrostenotic CD. Among these proteins, the knockdown of heat shock protein 72 (HSP72) promoted the activation and wound healing of myofibroblasts. Moreover, knockdown of HSP72 induced the epithelial-mesenchymal transition of intestinal epithelial cells by reducing E-cadherin and inducing fibronectin and α-smooth muscle actin, which contribute to fibrosis. Conclusions HSP72 is an important mediator that regulates myofibroblasts and epithelial-mesenchymal transition in fibrosis of CD, suggesting that HSP72 can serve as a target for antifibrotic therapy.
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Affiliation(s)
- Seung Won Kim
- Department of Internal Medicine and Institute of Gastroenterology, Graduate School of Medical Science, Brain Korea 21 Project, Seoul, Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Young Lee
- Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Han Cheol Lee
- Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Bum Ahn
- Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hyung Kim
- Department of Internal Medicine and Institute of Gastroenterology, Graduate School of Medical Science, Brain Korea 21 Project, Seoul, Korea
| | - I Seul Park
- Department of Internal Medicine and Institute of Gastroenterology, Graduate School of Medical Science, Brain Korea 21 Project, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Graduate School of Medical Science, Brain Korea 21 Project, Seoul, Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Paulus L, Buehler A, Wagner AL, Raming R, Jüngert J, Simon D, Tascilar K, Schnell A, Rother U, Eckstein M, Lang W, Hoerning A, Schett G, Neurath MF, Waldner MJ, Trollmann R, Woelfle J, Bohndiek SE, Regensburger AP, Knieling F. Contrast-Enhanced Multispectral Optoacoustic Tomography for Functional Assessment of the Gastrointestinal Tract. Adv Sci (Weinh) 2023; 10:e2302562. [PMID: 37289088 PMCID: PMC10427354 DOI: 10.1002/advs.202302562] [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] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Indexed: 06/09/2023]
Abstract
Real-time imaging and functional assessment of the intestinal tract and its transit pose a significant challenge to conventional clinical diagnostic methods. Multispectral optoacoustic tomography (MSOT), a molecular-sensitive imaging technology, offers the potential to visualize endogenous and exogenous chromophores in deep tissue. Herein, a novel approach using the orally administered clinical-approved fluorescent dye indocyanine green (ICG) for bedside, non-ionizing evaluation of gastrointestinal passage is presented. The authors are able to show the detectability and stability of ICG in phantom experiments. Furthermore, ten healthy subjects underwent MSOT imaging at multiple time points over eight hours after ingestion of a standardized meal with and without ICG. ICG signals can be visualized and quantified in different intestinal segments, while its excretion is confirmed by fluorescent imaging of stool samples. These findings indicate that contrast-enhanced MSOT (CE-MSOT) provides a translatable real-time imaging approach for functional assessment of the gastrointestinal tract.
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Affiliation(s)
- Lars‐Philip Paulus
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Adrian Buehler
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Alexandra L. Wagner
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Department of Pediatric Neurology, Center for Chronically Sick ChildrenCharité BerlinBerlinGermany
| | - Roman Raming
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Jörg Jüngert
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - David Simon
- Department of Medicine 3, University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Koray Tascilar
- Department of Medicine 3, University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Alexander Schnell
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Ulrich Rother
- Department of Vascular SurgeryUniversity Hospital ErlangenFriedrich‐Alexander Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Markus Eckstein
- Insitute of PathologyUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Werner Lang
- Department of Vascular SurgeryUniversity Hospital ErlangenFriedrich‐Alexander Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - André Hoerning
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Georg Schett
- Department of Medicine 3, University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- German Center Immunotherapy (DZI)University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Markus F. Neurath
- German Center Immunotherapy (DZI)University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Department of Medicine 1University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Maximilian J. Waldner
- German Center Immunotherapy (DZI)University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Department of Medicine 1University Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Regina Trollmann
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Joachim Woelfle
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Sarah E Bohndiek
- Department of PhysicsUniversity of CambridgeCambridgeCB3 0HEUK
- Cancer Research UK Cambridge InstituteUniversity of CambridgeCambridgeCB2 0REUK
| | - Adrian P. Regensburger
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
- Pediatric Experimental and Translational Imaging Laboratory (PETI‐Lab)Department of Pediatrics and Adolescent MedicineUniversity Hospital ErlangenFriedrich‐Alexander‐Universität (FAU) Erlangen‐Nürnberg91054ErlangenGermany
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Dandoy P, Louis E, Gast P, Poncin M, Seidel L, Loly JP. Factors associated with the efficacy and safety of endoscopic dilatation of symptomatic strictures in Crohn's disease: a retrospective cohort study. Scand J Gastroenterol 2023; 58:671-679. [PMID: 36533307 DOI: 10.1080/00365521.2022.2156808] [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: 07/30/2022] [Revised: 11/20/2022] [Accepted: 12/04/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Endoscopic balloon dilatation (EBD) is a standard treatment for intestinal strictures in Crohn's disease (CD). No evidence-based guidelines exist regarding the balloon diameter or the balloon pressure to be used, with recent studies suggesting the use of a smaller diameter than classically used. We sought to analyze the factors associated with safety and efficacy of EBD in CD strictures, particularly looking at balloon diameter and dilatation pressure. METHODS We conducted a monocentric retrospective study of patients who underwent EBD between 2005 and 2020. RESULTS Our endoscopy department performed EBD in 94 CD patients during the considered period. The mean size of balloon dilatation was 16 mm (±2.5; including 21 patients with balloon <14 mm) and the mean dilatation pressure was 5.3 atm (±1.5). No perforation was observed. Over a median follow-up of 5.6 years, the probability of being operated was 5.4% at 1 year and 10.4% at 3 years. Smaller height (HR = 0.90, p = 0.022) and a higher BMI (HR = 1.23, p = 0.014) were associated with the risk of operation. The probability of being operated or redilated was 30.1% at 1 year and 52.5% at 3 years. No factor was significantly associated with this risk. The size of the balloon had no impact on outcomes. CONCLUSION In this retrospective cohort, including a significant proportion of CD patients dilated with balloon <14 mm, no perforation was observed and the size of the balloon or the dilatation pressure had no impact on the risk of surgery or redilatation.
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Affiliation(s)
- Pierre Dandoy
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Edouard Louis
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Pierrette Gast
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Maxime Poncin
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
| | - Laurence Seidel
- Department of Clinical Research Support and Biostatistics, CHU Liège University Hospital, Liège, Belgium
| | - Jean-Philippe Loly
- Department of Gastroenterology, CHU Liège University Hospital, Liège, Belgium
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Welz L, Aden K. Fibrosis and Inflammation in Inflammatory Bowel Disease-More Than 2 Sides of the Same Coin? Gastroenterology 2023; 164:19-21. [PMID: 36341736 DOI: 10.1053/j.gastro.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Lina Welz
- Institute of Clinical Molecular Biology and, Department of Internal Medicine I, Christian-Albrechts-University, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Konrad Aden
- Institute of Clinical Molecular Biology and, Department of Internal Medicine I, Christian-Albrechts-University, University Hospital Schleswig-Holstein, Kiel, Germany.
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Wei Y, Cai J, Zhu R, Xu K, Li H, Li J. Function and therapeutic potential of transient receptor potential ankyrin 1 in fibrosis. Front Pharmacol 2022; 13:1014041. [PMID: 36278189 PMCID: PMC9582847 DOI: 10.3389/fphar.2022.1014041] [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: 08/08/2022] [Accepted: 09/26/2022] [Indexed: 11/18/2022] Open
Abstract
The transient receptor potential (TRP) protein superfamily is a special group of cation channels expressed in different cell types and signaling pathways. In this review, we focus on TRPA1 (transient receptor potential ankyrin 1), an ion channel in this family that exists in the cell membrane and shows a different function from other TRP channels. TRPA1 usually has a special activation effect that can induce cation ions, especially calcium ions, to flow into activated cells. In this paper, we review the role of TRPA1 in fibroblasts. To clarify the relationship between fibroblasts and TRPA1, we have also paid special attention to the interactions between TRPA1 and inflammatory factors leading to fibroblast activation. TRPA1 has different functions in the fibrosis process in different organs, and there have also been interesting discussions of the mechanism of TRPA1 in fibroblasts. Therefore, this review aims to describe the function of TRP channels in controlling fibrosis through fibroblasts in different organ inflammatory and immune-mediated diseases. We attempt to prove that TRPA1 is a target for fibrosis. In fact, some clinical trials have already proven that TRPA1 is a potential adjuvant therapy for treating fibrosis.
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Affiliation(s)
- Yicheng Wei
- Third Affiliated Hospital of Shanghai University/Wenzhou People’s Hospital, Wenzhou, China
- Shanghai Putuo Central School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
- Interventional Cancer Institute of Chinese Integrative Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jialuo Cai
- Interventional Cancer Institute of Chinese Integrative Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Shanghai Frontiers Science Center of Optogenetic Techniques for Cell Metabolism, Shanghai Key Laboratory of New Drug Design, School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Ruiqiu Zhu
- Shanghai Putuo Central School of Clinical Medicine, Anhui Medical University, Hefei, Anhui, China
- Interventional Cancer Institute of Chinese Integrative Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ke Xu
- Musculoskeletal Organoid Research Center, Institute of Translational Medicine, Shanghai University, Shanghai, China
- Wenzhou Institute of Shanghai University, Wenzhou, China
- *Correspondence: Ke Xu, , ; Hongchang Li, ; Jianxin Li,
| | - Hongchang Li
- Department of General Surgery, Institute of Fudan–Minhang Academic Health System, Minhang Hospital, Fudan University, Shanghai, China
- *Correspondence: Ke Xu, , ; Hongchang Li, ; Jianxin Li,
| | - Jianxin Li
- Third Affiliated Hospital of Shanghai University/Wenzhou People’s Hospital, Wenzhou, China
- *Correspondence: Ke Xu, , ; Hongchang Li, ; Jianxin Li,
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Huang L, Qian W, Xu Y, Guo Z, Yin Y, Guo F, Zhu W, Li Y. Mesenteric Adipose Tissue Contributes to Intestinal Fibrosis in Crohn's Disease Through the ATX-LPA Axis. J Crohns Colitis 2022; 16:1124-1139. [PMID: 35104318 DOI: 10.1093/ecco-jcc/jjac017] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Intestinal fibrostenosis is an important cause of surgical intervention in patients with Crohn's disease [CD]. Hypertrophic mesenteric adipose tissue [MAT] is associated with the disease process of CD. The purpose of this study was to investigate the contribution of MAT to intestinal fibrosis. METHODS MAT from surgical specimens of fibrostenotic CD patients and controls was collected for measurement of the levels of autotaxin [ATX] and lysophosphatidic acid [LPA]. ATX was inhibited in vivo in DNBS [dinitrobenzene sulfonic acid]-induced colitis mice, which were evaluated for colonic inflammation and fibrosis. 3T3-L1 cells and primary colonic fibroblasts were used in vitro to investigate the interaction between MAT and intestinal fibrosis, as well as the molecular mechanism underlying this interaction. RESULTS MAT adjacent to the fibrostenotic intestine in CD patients showed an activated ATX-LPA axis. An in vivo study indicated that inhibition of ATX was associated with the improvement of morphology and function of diseased MAT, which was combined with ameliorated intestinal inflammation and fibrosis in DNBS-instilled mice. In vitro studies showed that hypoxia stimulated adipocyte ATX expression and that LPA stabilized adipocyte HIF-1α protein, forming an ATX-LPA-HIF-1α amplification loop and aggravating adipocyte dysfunction. LPA secreted by adipocytes bound to LPA1 on the surface of fibroblasts, promoted their proliferation and differentiation, and increased the expression of fibrosis-related factors. CONCLUSIONS The ATX-LPA axis regulated intestinal fibrosis by influencing the proliferation and differentiation of intestinal fibroblasts. Inhibiting this axis may be a therapeutic target for intestinal fibrosis in CD.
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Affiliation(s)
- Liangyu Huang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Wenwei Qian
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, Jiangsu Province, China
| | - Yihan Xu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Yi Yin
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Feilong Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
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Yu L, Hu S, Huang FC, Wu YC, Zheng XY. Evaluation of dynamic contrast-enhanced magnetic resonance imaging and diffusion-weighted imaging for predicting muscular hyperplasia/hypertrophy in Crohn's disease. Abdom Radiol (NY) 2022; 47:1714-1724. [PMID: 35243533 DOI: 10.1007/s00261-022-03422-7] [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: 11/01/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The existence of smooth muscle alteration in Crohn's disease (CD) is often neglected. It has been found that muscular hyperplasia/hypertrophy rather than fibrosis was the primary component of bowel wall thickening. This study aimed to assess the value of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion weighted imaging for the characterization of histopathologic tissue composition of CD, particularly smooth muscle hypertrophy, as well as inflammation and fibrosis. METHODS The study included patients diagnosed with CD who received MRI examination 30 days before resection from August 2016 to December 2020. A semiquantitative histological grading scheme was employed to evaluate the pathological tissues. Resected sections were matched with MRI according to pathological marks. Parameters evaluated included: mural thickness, T2 ratio, apparent diffusion coefficient value; and maximum enhancement, initial slope of increase, perfusion parameters of DCE-MRI and enhancement pattern. These parameters were compared with location-matched histopathological grade. RESULTS Ninety-one sections were enrolled in this retrospective study. When active inflammation is moderate or severe, volume transfer coefficient (Ktrans), maximum enhancement (ME) and initial slope of increase (ISI) are lower, mural thickness is higher when a certain degree of smooth muscle alteration is present. When active inflammation is absent or mild, ME, mural thickness and ISI can differentiate the presence of predominant muscular alteration. By combining ME and thickness comparisons against their cutoff values to create a combined ordinal parameter, the area under the curve value for whether significant muscular alteration coexists with moderate or severe active inflammation was found to be 0.953. CONCLUSIONS MRI predicts the degree of inflammation, and can distinguish the degree of muscular alteration coexists with moderate or severe active inflammation with reasonable accuracy.
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Lee B, Dane B, Katz S. Current and Emerging Approaches to the Diagnosis and Treatment of Crohn's Disease Strictures. Gastroenterol Hepatol (N Y) 2022; 18:186-195. [PMID: 35505943 PMCID: PMC9053491] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The management and understanding of Crohn's disease (CD) continues to evolve quickly. Intestinal strictures were previously thought to be an inevitable result of irreversible fibrosis caused by chronic inflammation. However, increased understanding of the dynamic nature of strictures and of the pathophysiology of this condition has highlighted emerging targets for potential treatment. In the diagnosis of strictures, a distinction must be made between inflammatory and fibrotic types, as the former may respond to medical therapy. Emerging technologies, such as dual-energy computed tomography enterography and iodine density, have allowed more accurate characterization of strictures. Surgical and endoscopic treatment remains the mainstay for fibrotic strictures, but developments in systemic and intralesional biologic therapy have shown efficacy. This article reviews the pathophysiology of this debilitating complication of CD as well as current and emerging diagnostics and treatments.
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Affiliation(s)
- Briton Lee
- Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Bari Dane
- Department of Radiology, NYU Langone Medical Center, New York, New York
| | - Seymour Katz
- Department of Gastroenterology, NYU Langone Medical Center, New York, New York
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10
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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.
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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
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11
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Gordon IO, Abushamma S, Kurowski JA, Holubar SD, Kou L, Lyu R, Rieder F. Paediatric Ulcerative Colitis Is a Fibrotic Disease and Is Linked with Chronicity of Inflammation. J Crohns Colitis 2021; 16:804-821. [PMID: 34849664 PMCID: PMC9228908 DOI: 10.1093/ecco-jcc/jjab216] [Citation(s) in RCA: 9] [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: 06/28/2021] [Revised: 10/20/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Intestinal fibrosis has recently been characterised in adult ulcerative colitis and may affect motility, diarrhoea, and the symptom of urgency. We aimed to charactersze the presence of fibrosis in paediatric patients with ulcerative colitis, and its link to severity and chronicity of mucosal inflammation, as well as clinical factors of severity. METHODS We performed a single-centre cross-sectional study in children ages 1-18 years with ulcerative colitis, undergoing colectomy or proctocolectomy. Tissue cross-sections were derived from proximal, mid, and distal colon and rectum, and inflammation and fibrosis were graded based on previously developed scores. Clinical data were collected prospectively. RESULTS From 62 patients, 205 intestinal sections were evaluated. Median age at diagnosis was 13 years, 100% had extensive colitis, and all resections were done for refractory disease. The presence, chronicity, and degree of inflammation were linked with the presence of fibrosis. Thickness of the muscularis mucosa was also linked with presence and chronicity of inflammation. The overall submucosal fibrosis burden was associated with prior anti-tumour necrosis factor use. CONCLUSIONS Paediatric patients with ulcerative colitis exhibit colorectal submucosal fibrosis and muscularis mucosa thickening, which correlate with the presence, chronicity, and degree of mucosal inflammation. Fibrosis should be recognised as a complication of paediatric ulcerative colitis, and ulcerative colitis should be considered a progressive disease.
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Affiliation(s)
- Ilyssa O Gordon
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Suha Abushamma
- Department of Gastroenterology, Washington University School of Medicine, Barnes Jewish Hospital, St Louis, MO,USA
| | - Jacob A Kurowski
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lei Kou
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Corresponding author: Florian Rieder, MD, Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue – A3, Cleveland, OH, 44195, USA. Tel.: +1 [216] 445 4916; fax: +1 [216] 636 0104;
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12
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Wang J, Rieder F. A single-cell atlas of fibroblasts: one size does not fit all. Nat Rev Gastroenterol Hepatol 2021; 18:595-6. [PMID: 34168369 DOI: 10.1038/s41575-021-00482-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 12/08/2022]
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13
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Lu B, Lin J, Du J, He S, Cao Q, Huang L, Mao R, Sun C, Li Z, Feng S, Li X. Native T1 Mapping and Magnetization Transfer Imaging in Grading Bowel Fibrosis in Crohn's Disease: A Comparative Animal Study. Biosensors (Basel) 2021; 11:302. [PMID: 34562892 DOI: 10.3390/bios11090302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
Abstract
In this study, we investigated the utility of native T1 mapping in differentiating between various grades of fibrosis and compared its diagnostic accuracy to magnetization transfer imaging (MTI) in a rat model of CD. Bowel specimens (64) from 46 CD model rats undergoing native T1 mapping and MTI were enrolled. The longitudinal relaxation time (T1 value) and normalized magnetization transfer ratio (MTR) were compared between none-to-mild and moderate-to-severe fibrotic bowel walls confirmed by pathological assessments. The results showed that the correlation between the T1 value and fibrosis (r = 0.438, p < 0.001) was lower than that between the normalized MTR and fibrosis (r = 0.623, p < 0.001). Overall, the T1 values (t = −3.066, p = 0.004) and normalized MTRs (z = 0.081, p < 0.001) in none-to-mild fibrotic bowel walls were lower than those in moderate-to-severe fibrotic bowel walls. The area under the curve (AUC) of the T1 value (AUC = 0.716, p = 0.004) was significantly lower than that of the normalized MTR (AUC = 0.881, p < 0.001) in differentiating moderate-to-severe fibrosis from none-to-mild fibrosis (z = −2.037, p = 0.042). Our results support the view that the T1 value could be a promising imaging biomarker in grading the fibrosis severity of CD. However, the diagnostic performance of native T1 mapping was not superior to MTI.
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14
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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.
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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
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15
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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.
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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,
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16
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Bettenworth D, Bokemeyer A, Kou L, Lopez R, Bena JF, Ouali SE, Mao R, Kurada S, Bhatt A, Beyna T, Halloran B, Reeson M, Hosomi S, Kishi M, Hirai F, Ohmiya N, Rieder F. Systematic review with meta-analysis: efficacy of balloon-assisted enteroscopy for dilation of small bowel Crohn's disease strictures. Aliment Pharmacol Ther 2020; 52:1104-1116. [PMID: 32813282 PMCID: PMC8052861 DOI: 10.1111/apt.16049] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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] [Received: 05/10/2020] [Revised: 05/26/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence for endoscopic balloon dilation of small intestinal strictures in Crohn's disease (CD) using balloon-assisted enteroscopy is scarce. AIM To evaluate endoscopic balloon dilation for the treatment of small intestinal CD strictures using balloon-assisted enteroscopy. METHODS Citations in Embase, MEDLINE, and Cochrane were systematically reviewed. In a meta-analysis of 18 studies with 463 patients and 1189 endoscopic balloon dilations, technical success was defined as the ability to dilate a stricture. Individual data were also obtained on 218 patients to identify outcome-relevant risk factors. RESULTS In the pooled per-study analysis, technical success rate of endoscopic balloon dilation was 94.9%, resulting in short-term clinical efficacy in 82.3% of patients. Major complications occurred in 5.3% of patients. During follow-up, 48.3% of patients reported symptom recurrence, 38.8% were re-dilated and 27.4% proceeded to surgery. On the per-patient-based multivariable analysis, that patients with disease activity in the small intestine had lower short-term clinical efficacy (odds ratio 0.32; 95% confidence interval 0.14-0.73, P = 0.007). Patients with concomitant active disease in the small and/or large intestine had an increased risk to proceed toward surgery (hazard ratio 1.85; 95% confidence interval 1.09-3.13, P = 0.02 and hazard ratio 1.77; 95% confidence interval 1.34-2.34, P < 0.001). CONCLUSIONS Balloon-assisted enteroscopy for dilatation of CD-associated small intestinal strictures has high short-term technical and clinical efficacy and low complication rates. However, up to two-thirds of patients need re-dilation or surgery.
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Affiliation(s)
| | | | | | | | | | | | - Ren Mao
- Cleveland, OH, USA,Guangzhou, China
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17
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Marafini I, Salvatori S, Troncone E, Scarozza P, Fantini E, Monteleone G. No effect of a liquid diet in the management of patients with stricturing Crohn's disease. Int J Colorectal Dis 2020; 35:1881-1885. [PMID: 32504336 DOI: 10.1007/s00384-020-03650-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with stricturing Crohn's disease (CD) may experience episodes of intestinal sub-occlusions, which in many cases lead to surgery. The aim of this study was to examine whether adding a liquid diet to medical therapy could improve the management of patients with stricturing CD. METHODS Medical records of CD outpatients with a small bowel stricture, either receiving (group 1) or not (group 2) a 24-h liquid diet every 10-14 days, were retrospectively analyzed. Number of sub-occlusive episodes, frequency, and timing of intestinal resections for strictures were analyzed. RESULTS During the 12-month follow-up, there was no significant difference in the occurrence of new sub-occlusive episodes between the 2 groups (10/37 patients (27%) in group 1 vs 9/45 patients (20%) in group 2). Similarly, the number of patients undergoing bowel resections for sub-occlusive episodes non-responsive to medical therapy did not statistically differ between the two groups (9 patients (24.3%) in group 1 vs 7 patients (15.5%) in group 2). In group 1, surgeries were equally distributed along the 12-months of follow-up, while 85.7% of patients in group 2 underwent intestinal resection within the first 3 months of follow-up. CONCLUSION Adding a liquid diet to medical therapy does not help management of patients with stricturing CD.
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Affiliation(s)
- Irene Marafini
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy
| | - Silvia Salvatori
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy
| | - Patrizio Scarozza
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy
| | - Elisa Fantini
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy
| | - Giovanni Monteleone
- Department of Systems Medicine, Gastroenterology Unit, University of Rome "Tor Vergata", Via Montpellier, 1, 00133, Rome, Italy.
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18
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van Haaften WT, Blokzijl T, Hofker HS, Olinga P, Dijkstra G, Bank RA, Boersema M. Intestinal stenosis in Crohn's disease shows a generalized upregulation of genes involved in collagen metabolism and recognition that could serve as novel anti-fibrotic drug targets. Therap Adv Gastroenterol 2020; 13:1756284820952578. [PMID: 32922514 PMCID: PMC7457685 DOI: 10.1177/1756284820952578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Crohn's disease (CD) can be complicated by intestinal fibrosis. Pharmacological therapies against intestinal fibrosis are not available. The aim of this study was to determine whether pathways involved in collagen metabolism are upregulated in intestinal fibrosis, and to discuss which drugs might be suitable to inhibit excessive extracellular matrix formation targeting these pathways. METHODS Human fibrotic and non-fibrotic terminal ileum was obtained from patients with CD undergoing ileocecal resection due to stenosis. Genes involved in collagen metabolism were analyzed using a microfluidic low-density TaqMan array. A literature search was performed to find potential anti-fibrotic drugs that target proteins/enzymes involved in collagen synthesis, its degradation and its recognition. RESULTS mRNA expression of collagen type I (COL1A1, 0.76 ± 0.28 versus 37.82 ± 49.85, p = 0.02) and III (COL3A1, 2.01 ± 2.61 versus 68.65 ± 84.07, p = 0.02) was increased in fibrotic CD compared with non-fibrotic CD. mRNA expression of proteins involved in both intra- and extracellular post-translational modification of collagens (prolyl- and lysyl hydroxylases, lysyl oxidases, chaperones), collagen-degrading enzymes (MMPs and cathepsin-K), and collagen receptors were upregulated in the fibrosis-affected part. A literature search on the upregulated genes revealed several potential anti-fibrotic drugs. CONCLUSION Expression of genes involved in collagen metabolism in intestinal fibrosis affected terminal ileum of patients with CD reveals a plethora of drug targets. Inhibition of post-translational modification and altering collagen metabolism might attenuate fibrosis formation in the intestine in CD. Which compound has the highest potential depends on a combination anti-fibrotic efficacy and safety, especially since some of the enzymes play key roles in the physiology of collagen.
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Affiliation(s)
- Wouter Tobias van Haaften
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
| | - Tjasso Blokzijl
- Department of Laboratory Medicine, University of
Groningen, University Medical Center Groningen, Groningen, The
Netherlands
| | - Hendrik Sijbrand Hofker
- Department of Surgery, University Medical Center
Groningen, University of Groningen, Groningen, the Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Ant. Deusinglaan 1, Groningen, 9713
AV, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Ruud A. Bank
- Department of Pathology and Medical Biology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Miriam Boersema
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
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19
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Iswandana R, Pham BT, Suriguga S, Luangmonkong T, van Wijk LA, Jansen YJM, Oosterhuis D, Mutsaers HAM, Olinga P. Murine Precision-cut Intestinal Slices as a Potential Screening Tool for Antifibrotic Drugs. Inflamm Bowel Dis 2020; 26:678-686. [PMID: 31943022 PMCID: PMC7150673 DOI: 10.1093/ibd/izz329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 12/20/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intestinal fibrosis is a hallmark of Crohn's disease. Here, we investigated the impact of several putative antifibrotic compounds on the expression of fibrosis markers using murine precision-cut intestinal slices. METHODS Murine precision-cut intestinal slices were cultured for 48 hours in the presence of profibrotic and/or antifibrotic compounds. The fibrotic process was studied on gene and protein level using procollagen 1a1 (Col1α1), heat shock protein 47 (Hsp47), fibronectin (Fn2), and plasminogen activator inhibitor-1 (Pai-1). The effects of potential antifibrotic drugs mainly inhibiting the transforming growth factor β (TGF-β) pathway (eg, valproic acid, tetrandrine, pirfenidone, SB203580, and LY2109761) and compounds mainly acting on the platelet-derived growth factor (PDGF) pathway (eg, imatinib, sorafenib, and sunitinib) were assessed in the model at nontoxic concentrations. RESULTS Murine precision-cut intestinal slices remained viable for 48 hours, and an increased expression of fibrosis markers was observed during culture, including Hsp47, Fn2, and Pai-1. Furthermore, TGF-β1 stimulated fibrogenesis, whereas PDGF did not have an effect. Regarding the tested antifibrotics, pirfenidone, LY2109761, and sunitinib had the most pronounced impact on the expression of fibrosis markers, both in the absence and presence of profibrotic factors, as illustrated by reduced levels of Col1α1, Hsp47, Fn2, and Pai-1 after treatment. Moreover, sunitinib significantly reduced Hsp47 and Fn2 protein expression and the excretion of procollagen 1. CONCLUSIONS Precision-cut intestinal slices can successfully be used as a potential preclinical screening tool for antifibrotic drugs. We demonstrated that sunitinib reduced the expression of several fibrosis markers, warranting further evaluation of this compound for the treatment of intestinal fibrosis.
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Affiliation(s)
- Raditya Iswandana
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands,Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | - Bao Tung Pham
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands,Department of Pharmaceutics, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Su Suriguga
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Theerut Luangmonkong
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands,Department of Pharmacology, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Louise A van Wijk
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Yvette J M Jansen
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Dorenda Oosterhuis
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Henricus Antonius Maria Mutsaers
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Olinga
- Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Groningen, the Netherlands,Address correspondence to: Professor Peter Olinga, Division of Pharmaceutical Technology and Biopharmacy, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, the Netherlands. E-mail:
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20
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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.
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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
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21
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Torle J, Dabir PD, Korsgaard U, Christiansen J, Qvist N, El-Hussuna A. Levels of Intestinal Inflammation and Fibrosis in Resection Specimens after Preoperative Anti-Tumor Necrosis Factor Alpha Treatment in Patients with Crohn's Disease: A Comparative Pilot Study. Surg Res Pract 2020; 2020:6085678. [PMID: 32149183 DOI: 10.1155/2020/6085678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/13/2020] [Accepted: 02/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Strictures are a common complication in Crohn's disease (CD), found in more than 50% of patients. They are characterized by the excessive deposition of extracellular proteins in the tissue as a result of the chronic inflammatory process. The effect of anti-tumor necrosis factor alpha (TNF-α) therapy on the development of fibrosis is not yet fully understood. Aim To investigate whether the degree of intestinal inflammation and fibrosis is correlated with preoperative anti-TNF-α) therapy on the development of fibrosis is not yet fully understood. Methods This unblinded, prospective, single tertiary center, pilot cohort study included all adult patients with CD who underwent elective, laparoscopic, or open intestinal resection. Preoperative investigations included measurement of blood TNF-α) therapy on the development of fibrosis is not yet fully understood. Results Histopathological specimens from 10 patients with CD who underwent ileocecal or ileocolic resections were retrieved. Four of those patients were on anti-TNF-α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. p=0.01). Anti-TNF-α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. α) therapy on the development of fibrosis is not yet fully understood. Conclusions Patients who underwent preoperative anti-TNF-α treatment had a higher fibrosis score than controls.α) therapy on the development of fibrosis is not yet fully understood.
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22
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Imai J, Yahata T, Ichikawa H, Ibrahim AA, Yazawa M, Sumiyoshi H, Inagaki Y, Matsushima M, Suzuki T, Mine T, Ando K, Miyata T, Hozumi K. Inhibition of plasminogen activator inhibitor-1 attenuates against intestinal fibrosis in mice. Intest Res 2020; 18:219-228. [PMID: 32050315 PMCID: PMC7206341 DOI: 10.5217/ir.2019.00037] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/07/2019] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Intestinal fibrosis is a major complication of Crohn’s disease (CD). The profibrotic protein transforming growth factor-β (TGF-β) has been considered to be critical for the induction of the fibrotic program. TGF-β has the ability to induce not only the expression of extracellular matrix (ECM) including collagen, but also the production of plasminogen activator inhibitor-1 (PAI-1) that prevents enzymatic degradation of the ECM during the onset of fibrotic diseases. However, the significance of PAI-1 in the developing intestinal fibrosis has not been fully understood. In the present study, we examined the actual expression of PAI-1 in fibrotic legion of intestinal inflammation and its correlation with the abnormal ECM deposition. Methods Chronic intestinal inflammation was induced in BALB/c mice using 8 repeated intrarectal injections of 2,4,6-trinitrobenzene sulfonic acid (TNBS). TM5275, a PAI-1 inhibitor, was orally administered as a carboxymethyl cellulose suspension each day for 2 weeks after the sixth TNBS injection. Results Using a publicly available dataset (accession number, GSE75214) and TNBS-treated mice, we observed increases in PAI-1 transcripts at active fibrotic lesions in both patients with CD and mice with chronic intestinal inflammation. Oral administration of TM5275 immediately after the onset of intestinal fibrosis upregulated MMP-9 (matrix metalloproteinase 9) and decreased collagen accumulation, resulting in attenuation of the fibrogenesis in TNBS-treated mice. Conclusions PAI-1-mediated fibrinolytic system facilitates collagen degradation suppression. Hence, PAI-1 inhibitor could be applied as an anti-fibrotic drug in CD treatment.
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Affiliation(s)
- Jin Imai
- Center for Matrix Biology and Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Gastroenterology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Yahata
- Research Center for Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Hitoshi Ichikawa
- Department of Gastroenterology, Tokai University School of Medicine, Kanagawa, Japan
| | - Abd Aziz Ibrahim
- Research Center for Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Masaki Yazawa
- Department of Immunology, Tokai University School of Medicine, Kanagawa, Japan
| | - Hideaki Sumiyoshi
- Center for Matrix Biology and Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yutaka Inagaki
- Center for Matrix Biology and Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Masashi Matsushima
- Department of Gastroenterology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takayoshi Suzuki
- Department of Gastroenterology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsuya Mine
- Department of Gastroenterology, Tokai University School of Medicine, Kanagawa, Japan
| | - Kiyoshi Ando
- Research Center for Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Toshio Miyata
- Division of Molecular Medicine and Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Katsuto Hozumi
- Center for Matrix Biology and Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Research Center for Regenerative Medicine, Tokai University School of Medicine, Kanagawa, Japan.,Department of Immunology, Tokai University School of Medicine, Kanagawa, Japan
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23
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Chang CW, Tu CH, Chou JW, Huang TY, Hsu WH, Wang YP, Chen CC, Chung CS, Lin CP, Lin WC, Tai CM, Wang HY, Chen MJ. Endoscopic management of strictures in patients with Crohn's disease - A multi-center experience in Taiwan. J Formos Med Assoc 2020; 119:1500-1505. [PMID: 31917065 DOI: 10.1016/j.jfma.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/05/2019] [Revised: 11/11/2019] [Accepted: 12/16/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND/PURPOSE Inflammatory bowel disease (IBD) is a chronic gastrointestinal (GI) disorder that causes relapsing inflammation and severe mucosal damage in the intestine. Crohn's disease (CD)-related stricturing complications are a major cause of surgery, disability, and reduced quality of life. Endoscopic balloon dilation (EBD) has been shown to reliably delay or prevent surgery in patients with stricturing CD. However, cases of EBD performed for stricture in CD in Taiwan are rare. In this study, we want to evaluate the experiences regarding EBD for stricturing CD in Taiwan. METHODS We conducted a retrospective analysis of 9 medical centers in Taiwan. Patients with CD-related strictures who were treated with EBD were included and analyzed. RESULTS In nine medical centers, a total of 26 CD patients (19 male, 7 female, mean disease duration 75.4 ± 65.2 months) underwent 42 EBD procedures during the study period. Among the subjects, an 83.3% (35/42) EBD success rate was seen, but 26.9% (7/26) patients underwent surgery after ineffective EBD. In the surgery group, the the small bowel strictures was high compared with the non-surgery group (p = 0.01). There were no significant differences in disease phenotype, disease duration or history of fistulizing disease. In the surgery group, immunosuppressant use was high, and 5-aminosalicylic acid (5-ASA) use was low compared with the non-surgery group. After EBD, the physicians tended to change the drugs, especially increasing the use of biologic agents. CONCLUSION EBD is a safe and effective procedure for CD-related stricture, with a 83.3% success rate in Taiwan.
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Affiliation(s)
- Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tien-Yu Huang
- Department of Gastroenterology, Tri-Service General Hospital, Taipei, Taiwan
| | - Wen-Hung Hsu
- Department of Gastroenterology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Po Wang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Cheng Chen
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine,I-Shou University, Kaohsiung, Taiwan
| | - Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ching-Pin Lin
- Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chi-Ming Tai
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine,I-Shou University, Kaohsiung, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan.
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24
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Gordon IO, Bettenworth D, Bokemeyer A, Srivastava A, Rosty C, de Hertogh G, Robert ME, Valasek MA, Mao R, Kurada S, Harpaz N, Borralho P, Pai RK, Pai RK, Odze R, Feakins R, Parker CE, Nguyen T, Jairath V, Baker ME, Bruining DH, Fletcher JG, Feagan BG, Rieder F. Histopathology Scoring Systems of Stenosis Associated With Small Bowel Crohn's Disease: A Systematic Review. Gastroenterology 2020; 158:137-150.e1. [PMID: 31476299 PMCID: PMC7649049 DOI: 10.1053/j.gastro.2019.08.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 04/24/2019] [Revised: 07/29/2019] [Accepted: 08/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Stenosis is a common complication of Crohn's disease (CD) that has no effective medical therapy. Development of antifibrotic agents will require testing in randomized controlled trials. Computed tomography enterography- and magnetic resonance enterography-based technologies might be used to measure outcomes in these trials. These approaches have been validated in studies of patients with symptomatic strictures who underwent imaging evaluations followed by resection with histopathologic grading of the intestinal tissue for inflammation and/or fibrosis (the reference standard). Imaging findings have correlated with findings from quantitative or semiquantitative histologic evaluation of the degree of fibromuscular stenosis and/or inflammation on the resection specimen. However, it is not clear whether histologic findings are an accurate reference standard. We performed a systematic review of all published histologic scoring systems used to assess stenosing CD. METHODS We performed a comprehensive search of Embase and MEDLINE of studies through March 13, 2019, that used a histologic scoring system to characterize small bowel CD and assessed inflammatory and fibrotic alterations within the same adult individual. All scores fitting the criteria were included in our analysis, independent of the presence of stricturing disease, as long as inflammation and fibrosis were evaluated separately but in the same scoring system. RESULTS We observed substantial heterogeneity among the scoring systems, which were not derived from modern principles for evaluative index development. None had undergone formal validity or reliability testing. None of the existing indices had been constructed according to accepted methods for the development of evaluative indices. Basic knowledge regarding their operating properties were lacking. Specific indices for evaluating the important pathologic component of myofibroblast hypertrophy or hyperplasia have not been proposed. CONCLUSIONS In a systematic review of publications, we found a lack of validated histopathologic scoring systems for assessment of fibromuscular stenosis. Data that describe the operating properties of existing cross-sectional imaging techniques for stenosing CD should be questioned. Development and validation of a histopathology index is an important research priority.
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Affiliation(s)
- Ilyssa O Gordon
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Arne Bokemeyer
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Amitabh Srivastava
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christophe Rosty
- Department of Clinical Pathology, The University of Melbourne, Parville, Victoria, Australia; Envoi Specialist Pathologists, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Gert de Hertogh
- Department of Pathology, University Hospital Leuven, Leuven, Belgium
| | - Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Mark A Valasek
- Department of Pathology, University of California San Diego, La Jolla, California
| | - 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
| | - Satya Kurada
- 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
| | - Noam Harpaz
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - 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
| | - Rish K Pai
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Robert Odze
- Pathology Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roger Feakins
- Department of Cellular Pathology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | | | - Tran Nguyen
- Robarts Clinical Trials, Inc, London, Ontario, Canada
| | - Vipul Jairath
- Robarts Clinical Trials, 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
- Department of Diagnostic Radiology, Imaging Institute, Digestive Diseases and Surgery Institute, Cleveland, Ohio; Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - J G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Brian G Feagan
- Robarts Clinical Trials, Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - 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.
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25
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Bettenworth D, Mücke MM, Lopez R, Singh A, Zhu W, Guo F, Matsui T, James TW, Herfarth H, Goetz M, Mao R, Kurada S, Hampe J, Matthes K, Karstensen JG, Valli PV, Duijvestein M, D'Haens G, Jairath V, Qiu TB, Ding NS, Rogler G, Rieder F. Efficacy of Endoscopic Dilation of Gastroduodenal Crohn's Disease Strictures: A Systematic Review and Meta-Analysis of Individual Patient Data. Clin Gastroenterol Hepatol 2019; 17:2514-2522.e8. [PMID: 30503966 DOI: 10.1016/j.cgh.2018.11.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/19/2018] [Accepted: 11/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about the effects of endoscopic balloon dilation (EBD) for strictures of the upper gastrointestinal (UGI) tract in patients with Crohn's disease (CD). We performed a pooled analysis of the efficacy and safety of EBD for UGI CD-associated strictures. METHODS We searched Embase, Medline, and the Cochrane library, as well as bibliographies of relevant articles, for cohort studies of adults with CD and strictures of the stomach or duodenum (up to the ligament of Treitz) who underwent EBD through December 2016. We obtained data from 7 international referral centers on 94 patients who underwent 141 EBDs. We performed a patient-level meta-analysis of data from published and unpublished cohort studies to determine mechanical and clinical success. We performed a time-to-event analysis to assess symptom recurrence and need for redilation or surgery. The patients analyzed had strictures of the duodenum (n = 107), stomach (n = 30), or spanning both (n = 4). RESULTS The rate of technical success for EBD was 100%, with 87% short-term clinical efficacy; major complications arose from 2.9% of all procedures. During a median follow-up period of 23.1 months, 70.5% of patients had a recurrence of symptoms, 59.6% required redilation, and 30.8% required surgical intervention. Patients whose disease was located in the small bowel had a higher risk for symptom recurrence (hazard ratio [HR], 2.1; P = .003). Asian race (HR, 2.8; P < .001) and location of disease in the small bowel (HR, 1.9; P = .004) increased the need for redilation. Prestenotic dilation was a risk factor for needing surgery earlier (HR, 1.9; P = .001). CONCLUSIONS In a meta-analysis, we found EBD for CD-associated strictures of the UGI to be an effective alternative to surgery, with a high rate of short-term technical and clinical success, moderate long-term efficacy, and an acceptable rate of complications.
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26
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Jacobs JD, Wagner T, Gulotta G, Liao C, Li YC, Bissonnette M, Pekow J. Impact of Angiotensin II Signaling Blockade on Clinical Outcomes in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2019; 64:1938-1944. [PMID: 30725290 PMCID: PMC6586494 DOI: 10.1007/s10620-019-5474-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 03/15/2017] [Accepted: 01/17/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Preclinical data demonstrate that activation of the renin-angiotensin system (RAS) contributes to mucosal inflammation, and RAS inhibition by angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) improves colitis in animal models. Less is known regarding the effects of RAS inhibition on clinical outcomes in inflammatory bowel disease (IBD) patients. AIM Evaluate the impact of ACEI and ARB on clinical outcomes in IBD. METHODS Rates of IBD-related hospitalizations, operations, and corticosteroid use were evaluated retrospectively in two groups. First, 111 IBD patients taking an ACEI or ARB were compared to nonusers matched 1:1 based on sex, age, diagnosis, disease location, and hypertension diagnosis. Second, outcomes in a cohort of 130 IBD patients were compared prior to and during ACEI/ARB exposure. RESULTS Compared to matched controls, all IBD patients together with ACEI/ARB exposure had fewer hospitalizations (OR 0.26, p < 0.01), operations (OR 0.08, p = 0.02), and corticosteroid prescriptions (OR 0.5, p = 0.01). Comparing outcomes before and during ACEI/ARB use, there were no differences in hospitalizations, operations, or corticosteroid use for all IBD patients together, but patients with UC had increased hospitalizations (0.08 pre- vs. 0.16 during ACEI/ARB exposure, p = 0.03) and decreased corticosteroid use (0.24 pre-ACEI/ARB vs. 0.12 during ACEI/ARB exposure, p < 0.01) during ACEI/ARB use. CONCLUSIONS IBD patients with ACEI/ARB exposure had fewer hospitalizations, operations, and corticosteroid use compared to matched controls. No differences in outcomes were observed in individuals on ACEI/ARB therapy when compared to a period of time prior to medication exposure.
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Affiliation(s)
- Jeffrey D. Jacobs
- Department of Medicine, Division of Gastroenterology, University of Washington
| | | | | | - Chuanhong Liao
- Department of Public Health Sciences, University of Chicago
| | - Yan Chun Li
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago
| | - Marc Bissonnette
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago
| | - Joel Pekow
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago
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27
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Reinglas J, Bessissow T. Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon? Gastrointest Endosc Clin N Am 2019; 29:549-62. [PMID: 31078252 DOI: 10.1016/j.giec.2019.02.009] [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] [Indexed: 02/04/2023]
Abstract
Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
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28
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Bettenworth D, Bokemeyer A, Baker M, Mao R, Parker CE, Nguyen T, Ma C, Panés J, Rimola J, Fletcher JG, Jairath V, Feagan BG, Rieder F. Assessment of Crohn's disease-associated small bowel strictures and fibrosis on cross-sectional imaging: a systematic review. Gut 2019; 68:1115-1126. [PMID: 30944110 PMCID: PMC6580870 DOI: 10.1136/gutjnl-2018-318081] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [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: 12/09/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Patients with Crohn's disease commonly develop ileal and less commonly colonic strictures, containing various degrees of inflammation and fibrosis. While predominantly inflammatory strictures may benefit from a medical anti-inflammatory treatment, predominantly fibrotic strictures currently require endoscopic balloon dilation or surgery. Therefore, differentiation of the main components of a stricturing lesion is key for defining the therapeutic management. The role of endoscopy to diagnose the nature of strictures is limited by the superficial inspection of the intestinal mucosa, the lack of depth of mucosal biopsies and by the risk of sampling error due to a heterogeneous distribution of inflammation and fibrosis within a stricturing lesion. These limitations may be in part overcome by cross-sectional imaging techniques such as ultrasound, CT and MRI, allowing for a full thickness evaluation of the bowel wall and associated abnormalities. This systematic literature review provides a comprehensive summary of currently used radiologic definitions of strictures. It discusses, by assessing only manuscripts with histopathology as a gold standard, the accuracy for diagnosis of the respective modalities as well as their capability to characterise strictures in terms of inflammation and fibrosis. Definitions for strictures on cross-sectional imaging are heterogeneous; however, accuracy for stricture diagnosis is very high. Although conventional cross-sectional imaging techniques have been reported to distinguish inflammation from fibrosis and grade their severity, they are not sufficiently accurate for use in routine clinical practice. Finally, we present recent consensus recommendations and highlight experimental techniques that may overcome the limitations of current technologies.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Arne Bokemeyer
- Department of Medicine B, Gastroenterology and Hepatology, University of Münster, Münster, North Rhine-Westphalia, Germany
| | - Mark Baker
- Section of Abdominal Imaging, Imaging Institute, Digestive Disease Institute and Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Tran Nguyen
- Robarts Clinical Trials, London, Ontario, Canada
| | - Christopher Ma
- Robarts Clinical Trials, London, Ontario, Canada,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Julián Panés
- Department of Gastroenterology, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic de Barcelona, Institut d’investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vipul Jairath
- Robarts Clinical Trials, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Brian G Feagan
- Robarts Clinical Trials, London, Ontario, Canada,Department of Medicine, Western University, London, Ontario, Canada,Department of Biostatistics and Epidemiology, Western University, London, Ontario, Canada
| | - Florian Rieder
- 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, Ohio, USA
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29
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Ma C, Jairath V, Click B, Hirota SA, Lu C, Parker CE, Rieder F; Stenosis Therapy and Anti-Fibrotic Research (STAR) Consortium. Targeting anti-fibrotic pathways in Crohn's disease - The final frontier? Best Pract Res Clin Gastroenterol 2019; 38-39:101603. [PMID: 31327400 DOI: 10.1016/j.bpg.2019.02.005] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/14/2019] [Indexed: 02/08/2023]
Abstract
Intestinal fibrosis with stricture formation affects up to half of patients with Crohn's disease (CD), resulting in impaired quality of life, increased risk of surgical intervention, and associated patient morbidity. The underlying pathophysiologic mechansisms responsible for initiating and perpetuating intestinal fibrosis are complex, dynamic, and implicate both inflammation-dependent and independent pathways. Previously thought to be an irreversible complication of long-standing inflammation unresponsive to medical therapy, fibrostenotic CD has been traditionally managed with endoscopic or surgical approaches. However, recent advances in our understanding of the humoral, cellular, and environmental pathways driving intestinal fibrosis has the potential to fundamentally change these management paradigms for CD-related strictures. Furthermore, the promise of fibrosis treatments in other organ systems has encouraged hope that anti-fibrotic treatment approaches for CD may be within reach. Here, we summarize the key breakthroughs in our molecular understanding of intestinal fibrosis, review current medical, endoscopic, and surgical treatment approaches to CD-related strictures, propose future directions for anti-fibrotic therapy in CD, and identify crucial research questions in this field that require additional investigation.
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Inoue R, Kurahara LH, Hiraishi K. TRP channels in cardiac and intestinal fibrosis. Semin Cell Dev Biol 2018; 94:40-49. [PMID: 30445149 DOI: 10.1016/j.semcdb.2018.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 10/01/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 02/06/2023]
Abstract
It is now widely accepted that advanced fibrosis underlies many chronic inflammatory disorders and is the main cause of morbidity and mortality of the modern world. The pathogenic mechanism of advanced fibrosis involves diverse and intricate interplays between numerous extracellular and intracellular signaling molecules, among which the non-trivial roles of a stress-responsive Ca2+/Na+-permeable cation channel superfamily, the transient receptor potential (TRP) protein, are receiving growing attention. Available evidence suggests that several TRP channels such as TRPC3, TRPC6, TRPV1, TRPV3, TRPV4, TRPA1, TRPM6 and TRPM7 may play central roles in the progression and/or prevention of fibroproliferative disorders in vital visceral organs such as lung, heart, liver, kidney, and bowel as well as brain, blood vessels and skin, and may contribute to both acute and chronic inflammatory processes involved therein. This short paper overviews the current knowledge accumulated in this rapidly growing field, with particular focus on cardiac and intestinal fibrosis, which are tightly associated with the pathogenesis of atrial fibrillation and inflammatory bowel diseases such as Crohn's disease.
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Affiliation(s)
- Ryuji Inoue
- Department of Physiology, Fukuoka University School of medicine, Nanakuma 7-451, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Lin-Hai Kurahara
- Department of Physiology, Fukuoka University School of medicine, Nanakuma 7-451, Jonan-ku, Fukuoka 814-0180, Japan
| | - Keizo Hiraishi
- Department of Physiology, Fukuoka University School of medicine, Nanakuma 7-451, Jonan-ku, Fukuoka 814-0180, Japan
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Rieder F, Bettenworth D, Ma C, Parker CE, Williamson LA, Nelson SA, van Assche G, Di Sabatino A, Bouhnik Y, Stidham RW, Dignass A, Rogler G, Taylor SA, Stoker J, Rimola J, Baker ME, Fletcher JG, Panes J, Sandborn WJ, Feagan BG, Jairath V. An expert consensus to standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Crohn's disease. Aliment Pharmacol Ther 2018; 48:347-357. [PMID: 29920726 PMCID: PMC6043370 DOI: 10.1111/apt.14853] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [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: 04/03/2018] [Revised: 04/19/2018] [Accepted: 05/26/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fibrotic stricture is a common complication of Crohn's disease (CD) affecting approximately half of all patients. No specific anti-fibrotic therapies are available; however, several therapies are currently under evaluation. Drug development for the indication of stricturing CD is hampered by a lack of standardised definitions, diagnostic modalities, clinical trial eligibility criteria, endpoints and treatment targets in stricturing CD. AIM To standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Chron's disease. METHODS An interdisciplinary expert panel consisting of 15 gastroenterologists and radiologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 109 candidate items derived from systematic review and expert opinion focusing on small intestinal strictures were anonymously rated as inappropriate, uncertain or appropriate. Survey results were discussed as a group before a second and third round of voting. RESULTS Fibrotic strictures are defined by the combination of luminal narrowing, wall thickening and pre-stenotic dilation. Definitions of anastomotic (at site of prior intestinal resection with anastomosis) and naïve small bowel strictures were similar; however, there was uncertainty regarding wall thickness in anastomotic strictures. Magnetic resonance imaging is considered the optimal technique to define fibrotic strictures and assess response to therapy. Symptomatic strictures are defined by abdominal distension, cramping, dietary restrictions, nausea, vomiting, abdominal pain and post-prandial abdominal pain. Need for intervention (endoscopic balloon dilation or surgery) within 24-48 weeks is considered the appropriate endpoint in pharmacological trials. CONCLUSIONS Consensus criteria for diagnosis and response to therapy in stricturing Crohn's disease should inform both clinical practice and trial design.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Department of Pathobiology, Lerner Research Institute; Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Christopher Ma
- Division of Gastroenterology, University of Calgary, Calgary, AB, Canada,Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Claire E. Parker
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Lee A. Williamson
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Sigrid A. Nelson
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada
| | - Gert van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Antonio Di Sabatino
- First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Yoram Bouhnik
- Department of Gastroenterology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Ryan W. Stidham
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University of Zürich, Zürich, Switzerland
| | - Stuart A. Taylor
- Center for Medical Imaging, University College London, London, UK
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Jordi Rimola
- Department of Radiology, Centre de Diagnòstic per la Imatge (CDI), Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Mark E. Baker
- Imaging Institute/L10, Cleveland Clinic, Cleveland, OH, USA
| | | | - Julian Panes
- Institut d’Investigacions Biomèdiques August Pi i Sunyer-Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
| | - William J. Sandborn
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G. Feagan
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Vipul Jairath
- Robarts Clinical Trials Inc., University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
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Danese S, Bonovas S, Lopez A, Fiorino G, Sandborn WJ, Rubin DT, Kamm MA, Colombel JF, Sands BE, Vermeire S, Panes J, Rogler G, D'Haens G, Peyrin-Biroulet L. Identification of Endpoints for Development of Antifibrosis Drugs for Treatment of Crohn's Disease. Gastroenterology 2018; 155:76-87. [PMID: 29601825 DOI: 10.1053/j.gastro.2018.03.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [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: 01/03/2018] [Revised: 02/20/2018] [Accepted: 03/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Intestinal fibrosis is a challenge to management of patients with Crohn's disease (CD); there is an urgent need to expedite development of antifibrosis drugs for this disease. The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) aimed to identify a set of endpoints that can be used to determine efficacy of antifibrosis agents tested in clinical trials of patients with CD. METHODS We conducted a systematic review to identify clinical, radiologic, biochemical, endoscopic, and composite endpoints used in assessing activity of fibrostenosing CD and response to treatment, and determined their operational properties. A panel of IOIBD experts performed a consensus process to identify the best endpoints for inclusion in clinical trials, through a 2-round, Delphi-style online survey. RESULTS A total of 36 potentially relevant endpoints for intestinal fibrosis were selected and assessed. Forty-eight physicians with expertise in inflammatory bowel disease, from 5 regions (North America, Europe, Middle East, Asia/Pacific, and Latin America), participated in the Delphi consensus process. A core set of 13 endpoints (complete clinical response, long-term efficacy, sustained clinical benefit, treatment failure, radiological remission, normal quality of life, clinical remission without steroids, therapeutic failure, deep remission, complete absence of occlusive symptoms, symptom-free survival, bowel damage progression, and no disability) were rated as critical. Agreement was high among the experts. CONCLUSIONS Members of the IOIBD reached expert consensus on a set of endpoints that can be used to assess antifibrosis agents in trials of patients with CD. Studies are needed to clarify methods for measuring these outcomes and validate measurement instruments.
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Affiliation(s)
- Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy.
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Anthony Lopez
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Gionata Fiorino
- IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | | | | | - Michael A Kamm
- Departments of Gastroenterology and Medicine, St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Severine Vermeire
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Julian Panes
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | | | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, University of Lorraine, Vandoeuvre-lès-Nancy, France
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Hudert CA, Tzschätzsch H, Guo J, Rudolph B, Bläker H, Loddenkemper C, Luck W, Müller HP, Baumgart DC, Hamm B, Braun J, Holzhütter HG, Wiegand S, Sack I. US Time-Harmonic Elastography: Detection of Liver Fibrosis in Adolescents with Extreme Obesity with Nonalcoholic Fatty Liver Disease. Radiology 2018; 288:99-106. [DOI: 10.1148/radiol.2018172928] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Christian A. Hudert
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Heiko Tzschätzsch
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jing Guo
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Birgit Rudolph
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Hendrik Bläker
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Christoph Loddenkemper
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Werner Luck
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Hans-Peter Müller
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Daniel C. Baumgart
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Bernd Hamm
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jürgen Braun
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Hermann-Georg Holzhütter
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Susanna Wiegand
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ingolf Sack
- From the Center for Chronically Sick Children (C.A.H., S.W.), Departments of Radiology (H.T., J.G., B.H., I.S.), Pathology (B.R., H.B., C.L.), Pediatric Gastroenterology (W.L.), and Gastroenterology and Hepatology (H.P.M., D.C.B.), and the Institutes for Medical Informatics (J.B.) and Biochemistry (H.G.H.), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Bessissow T, Reinglas J, Aruljothy A, Lakatos PL, Van Assche G. Endoscopic management of Crohn’s strictures. World J Gastroenterol 2018; 24:1859-1867. [PMID: 29740201 PMCID: PMC5937203 DOI: 10.3748/wjg.v24.i17.1859] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 02/06/2023] Open
Abstract
Symptomatic intestinal strictures develop in more than one third of patients with Crohn’s disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.
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Affiliation(s)
- Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Jason Reinglas
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Achuthan Aruljothy
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
| | - Peter L Lakatos
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, QC H3G1A4, Canada
- 1st Department of Medicine, Semmelweis University, Budapest 1085, Hungary
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium and University of Leuven, Leuven 3000, Belgium
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Wagner M, Ko HM, Chatterji M, Besa C, Torres J, Zhang X, Panchal H, Hectors S, Cho J, Colombel JF, Harpaz N, Taouli B. Magnetic Resonance Imaging Predicts Histopathological Composition of Ileal Crohn's Disease. J Crohns Colitis 2018; 12:718-729. [PMID: 29300851 PMCID: PMC7189968 DOI: 10.1093/ecco-jcc/jjx186] [Citation(s) in RCA: 42] [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: 07/13/2017] [Accepted: 12/29/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Recently, smooth muscle hypertrophy has been suggested to be a contributor to small bowel lesions secondary to Crohn's disease [CD], in addition to inflammation and fibrosis. Here, we assess the value of magnetic resonance imaging [MRI] for the characterisation of histopathological tissue composition of small bowel CD, including inflammation, fibrosis, and smooth muscle hypertrophy. METHODS A total of 35 consecutive patients [male/female 17/18, mean age 33 years] with ileal CD, who underwent small bowel resection and a preoperative contrast-enhanced MRI examination within 1 month before surgery, were retrospectively included. Image assessment included qualitative [pattern/degree of enhancement, presence of ulcerations/fistulas/abscesses] and quantitative parameters [wall thickness on T2/T1-weighted images [WI], enhancement ratios, apparent diffusion coefficient [ADC], Clermont and Magnetic Resonance Index of Activity [MaRIA] scores). MRI parameters were compared with histopathological findings including active inflammation, collagen deposition, and muscle hypertrophy using chi square/Fisher or Mann-Whitney tests and univariate/multivariate logistic/linear regression analyses. RESULTS Forty ileal segments were analysed in 35 patients. Layered pattern at early-post-contrast phase was more prevalent (odds ratio [OR] = 8; p = 0.008), ADC was significantly lower [OR = 0.005; p = 0.022], and MaRIA score was significantly higher [OR = 1.125; p = 0.022] in inflammation grades 2-3 compared with grade 1. Wall thickness on T2WI was significantly increased [OR = 1.688; p = 0.043], and fistulas [OR = 14.5; p = 0.017] were more prevalent in segments with disproportionately increased muscle hypertrophy versus those with disproportionately increased fibrosis. MaRIA/Clermont scores, wall thickness on T1WI and T2WI, and ADC were all significantly correlated with degree of muscular hypertrophy. CONCLUSIONS MRI predicts the degree of inflammation, and can distinguish prominent muscle hypertrophy from prominent fibrosis in ileal CD with reasonable accuracy (area under receiver operating characteristic curve [AUROC] > 0.7).
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Affiliation(s)
- Mathilde Wagner
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Sorbonne Universités, UPMC, Department of Radiology, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Huaibin Mabel Ko
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manjil Chatterji
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cecilia Besa
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joana Torres
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiaofei Zhang
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hinaben Panchal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stefanie Hectors
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Judy Cho
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Noam Harpaz
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bachir Taouli
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA,Corresponding author: Bachir Taouli, MD, Department of Radiology and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Avenue, Room 107, New York, NY 10029, USA.
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Abstract
Crohn's disease (CD) is a chronic relapsing and remitting disease that can affect any segments of the gastrointestinal tract. More than 50% of patients with CD develop stricturing or penetrating complications within the first 10 years after diagnosis. Strictures can lead to intestinal obstruction, which is a common indication for surgery. Despite significant advances in the understanding of the pathogenesis of intestinal fibrostenosis, imaging and therapeutic armamentarium of CD, the risk of intestinal surgery remained significantly high. Endoscopic balloon dilation is a promising first-line alternative to surgery as it is less invasive and could preserve intestinal length. In this review, we will evaluate the literature on the mechanism of intestinal fibrosis, emerging imaging techniques, and management strategies for CD associated strictures.
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Affiliation(s)
- Webber Pak Wo Chan
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Fadi Mourad
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Rupert Wl Leong
- Gastroenterology and Liver Services, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Salvador P, Macías-Ceja DC, Gisbert-Ferrándiz L, Hernández C, Bernardo D, Alós R, Navarro-Vicente F, Esplugues JV, Ortiz-Masiá D, Barrachina MD, Calatayud S. CD16+ Macrophages Mediate Fibrosis in Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:589-599. [PMID: 29304229 DOI: 10.1093/ecco-jcc/jjx185] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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] [Received: 09/15/2017] [Accepted: 12/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Fibrosis is a common complication of Crohn's disease [CD], and is related to dysregulated tissular repair following inflammation, in which macrophages play a central role. We have previously observed that STAT6-/- mice present delayed mucosal recovery after 2,4,6-trinitrobenzenesulfonic acid [TNBS]-induced colitis due to a deficiency in reparatory interleukin-4 [IL4]/STAT6-dependent M2 macrophages, which can be reverted by the exogenous transfer of this cell type. In the present study, we analyse the role of STAT6-dependent macrophages in intestinal fibrosis. METHODS Colitis was induced by weekly intra-rectal administration of TNBS [6 weeks] to STAT6-/- mice and wild-type [WT] animals. Colonic surgical resections were obtained from CD patients and from colon cancer patients. RESULTS Chronic colitis provoked a fibrogenic response in STAT6-/- mice, but not in WT animals. An accumulation of M2 macrophages, defined as CD206+ cells, was observed in WT mice, but not in STAT6-/- animals. Instead, the latter group showed an increase in CD16+ macrophages that correlated with the expression of fibrogenic markers. CD16+ macrophages were also increased in the damaged mucosa of Crohn's disease patients with stenotic or penetrating complications. Finally, administration of IL4-treated WT macrophages to STAT6-/- mice reduced TNBS-induced fibrosis. CONCLUSIONS Our study demonstrates that STAT6 deficiency dysregulates the macrophage response to inflammatory outbursts by increasing the presence of a population of CD16+ macrophages that seems to contribute to intestinal fibrosis.
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Affiliation(s)
- Pedro Salvador
- Departamento de Farmacología and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | | | - Laura Gisbert-Ferrándiz
- Departamento de Farmacología and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | | | - David Bernardo
- Unidad de Gastroenterología, Hospital Universitario de La Princesa and Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Rafael Alós
- Servicio de Cirugía, Hospital de Sagunto, Sagunto, Valencia, Spain
| | | | - Juan Vicente Esplugues
- Departamento de Farmacología and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Dolores Ortiz-Masiá
- Departamento de Medicina and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Maria Dolores Barrachina
- Departamento de Farmacología and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | - Sara Calatayud
- Departamento de Farmacología and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Jiang H, Shen J, Ran Z. Epithelial-mesenchymal transition in Crohn's disease. Mucosal Immunol 2018; 11:294-303. [PMID: 29346350 DOI: 10.1038/mi.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
Crohn's disease (CD) is often accompanied by the complications of intestinal strictures and fistulas. These complications remain obstacles in CD treatment. In recent years, the importance of epithelial-mesenchymal transition in the pathogenesis of CD-associated fistulas and intestinal fibrosis has become apparent. Epithelial-mesenchymal transition refers to a dynamic change, wherein epithelial cells lose their polarity and adherence and acquire migratory function and fibroblast features. During formation of CD-associated fistulas, intestinal epithelial cells dislocate from the basement membrane and migrate to the lining of the fistula tracts, where they convert into transitional cells as a compensatory response under the insufficient wound healing condition. In CD-associated intestinal fibrosis, epithelial-mesenchymal transition may serve as a source of new fibroblasts and consequently lead to overproduction of extracellular matrix. In this review, we present current knowledge of epithelial-mesenchymal transition and its role in the pathogenesis of CD in order to highlight new therapy targets for the associated complications.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Holvoet T, Devriese S, Castermans K, Boland S, Leysen D, Vandewynckel YP, Devisscher L, Van den Bossche L, Van Welden S, Dullaers M, Vandenbroucke RE, De Rycke R, Geboes K, Bourin A, Defert O, Hindryckx P, De Vos M, Laukens D. Treatment of Intestinal Fibrosis in Experimental Inflammatory Bowel Disease by the Pleiotropic Actions of a Local Rho Kinase Inhibitor. Gastroenterology 2017. [PMID: 28642198 DOI: 10.1053/j.gastro.2017.06.013] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [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: 01/13/2023]
Abstract
BACKGROUND Intestinal fibrosis resulting in (sub)obstruction is a common complication of Crohn's disease (CD). Rho kinases (ROCKs) play multiple roles in TGFβ-induced myofibroblast activation that could be therapeutic targets. Because systemic ROCK inhibition causes cardiovascular side effects, we evaluated the effects of a locally acting ROCK inhibitor (AMA0825) on intestinal fibrosis. METHODS Fibrosis was assessed in mouse models using dextran sulfate sodium (DSS) and adoptive T-cell transfer. The in vitro and ex vivo effects of AMA0825 were studied in different cell types and in CD biopsy cultures. RESULTS ROCK is expressed in fibroblastic, epithelial, endothelial, and muscle cells of the human intestinal tract and is activated in inflamed and fibrotic tissue. Prophylactic treatment with AMA0825 inhibited myofibroblast accumulation, expression of pro-fibrotic factors, and accumulation of fibrotic tissue without affecting clinical disease activity and histologic inflammation in 2 models of fibrosis. ROCK inhibition reversed established fibrosis in a chronic DSS model and impeded ex vivo pro-fibrotic protein secretion from stenotic CD biopsies. AMA0825 reduced TGFβ1-induced activation of myocardin-related transcription factor (MRTF) and p38 mitogen-activated protein kinase (MAPK), down-regulating matrix metalloproteinases, collagen, and IL6 secretion from fibroblasts. In these cells, ROCK inhibition potentiated autophagy, which was required for the observed reduction in collagen and IL6 production. AMA0825 did not affect pro-inflammatory cytokine secretion from other ROCK-positive cell types, corroborating the selective in vivo effect on fibrosis. CONCLUSIONS Local ROCK inhibition prevents and reverses intestinal fibrosis by diminishing MRTF and p38 MAPK activation and increasing autophagy in fibroblasts. Overall, our results show that local ROCK inhibition is promising for counteracting fibrosis as an add-on therapy for CD.
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Affiliation(s)
- Tom Holvoet
- Department of Gastroenterology, Ghent University, Ghent, Belgium
| | - Sarah Devriese
- Department of Gastroenterology, Ghent University, Ghent, Belgium
| | | | | | | | | | | | | | | | - Melissa Dullaers
- Inflammation Research Center, VIB, Ghent, Belgium; Department of Pulmonary Medicine, Ghent University, Ghent, Belgium
| | - Roosmarijn E Vandenbroucke
- Inflammation Research Center, VIB, Ghent, Belgium; Department of Molecular Biomedical Research, Ghent University, Ghent, Belgium
| | - Riet De Rycke
- Inflammation Research Center, VIB, Ghent, Belgium; Department of Molecular Biomedical Research, Ghent University, Ghent, Belgium
| | - Karel Geboes
- Department of Pathology, Ghent University, Ghent, Belgium
| | | | | | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University, Ghent, Belgium
| | - Martine De Vos
- Department of Gastroenterology, Ghent University, Ghent, Belgium
| | - Debby Laukens
- Department of Gastroenterology, Ghent University, Ghent, Belgium.
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Teich N, Wallstabe I, Schiefke I. Topic infliximab injection for refractory rectal stenosis in Crohn's disease: long-term follow-up in two patients. Int J Colorectal Dis 2017; 32:1289-1294. [PMID: 28725960 DOI: 10.1007/s00384-017-2860-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE TNF blockers are approved for intravenous or subcutaneous systemic therapy of many chronic inflammatory diseases. As it is not possible to achieve a sufficient local clinical improvement through systemic therapy in every patient, diverse approaches of topical therapy using TNF blockers have been investigated in recent years. METHODS In this paper, we report on long-term clinical results of originator infliximab (IFX) injections into symptomatic combined scarring and inflammatory stenoses of the rectum in two patients with Crohn's disease. Aiming at high tissue IFX levels, 25 mg of IFX was injected into each quadrant of the stenosis after endoscopic balloon dilatation. This off-label treatment was repeated as necessary, depending on the clinical success. RESULTS Topic IFX injection after balloon dilation reduced imperative stool pressure, isolated episodes of incontinence and incomplete emptying. Improvement lasted between 4 and 14 weeks in one patient and the treatment was repeated 13 times in the following 6.6 years. In the other patient, the technique was necessary only twice with no symptom recurrence in the subsequent 5.3 years. CONCLUSION Our experience suggests that topic application of a systemically approved anti-TNF substance may be a successful individualized therapy for refractory stenosis of the rectum in patients with Crohn's disease.
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Affiliation(s)
- Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten Leipzig und Schkeuditz, Nordstr. 21, 04105, Leipzig, Germany. .,Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany.
| | - Ingo Wallstabe
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
| | - Ingolf Schiefke
- Klinikum St. Georg gGmbH, Klinik für Gastroenterologie und Hepatologie, Leipzig, Germany
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Kurahara LH, Hiraishi K, Sumiyoshi M, Doi M, Hu Y, Aoyagi K, Jian Y, Inoue R. Significant contribution of TRPC6 channel-mediated Ca 2+ influx to the pathogenesis of Crohn's disease fibrotic stenosis. J Smooth Muscle Res 2017; 52:78-92. [PMID: 27818466 PMCID: PMC5321852 DOI: 10.1540/jsmr.52.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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] [Indexed: 12/11/2022] Open
Abstract
Intestinal fibrosis is an intractable complication of Crohn's disease (CD), and, when occurring excessively, causes severe intestinal obstruction that often necessitates surgical resection. The fibrosis is characterized by an imbalance in the turnover of extracellular matrix (ECM) components, where intestinal fibroblasts/myofibroblasts play active roles in ECM production, fibrogenesis and tissue remodeling, which eventually leads to the formation of stenotic lesions. There is however a great paucity of knowledge about how intestinal fibrosis initiates and progresses, which hampers the development of effective pharmacotherapies against CD. Recently, we explored the potential implications of transient receptor potential (TRP) channels in the pathogenesis of intestinal fibrosis, since they are known to act as cellular stress sensors/transducers affecting intracellular Ca2+ homeostasis/dynamics, and are involved in a broad spectrum of cell pathophysiology including inflammation and tissue remodeling. In this review, we will place a particular emphasis on the intestinal fibroblast/myofibroblast TRPC6 channel to discuss its modulatory effects on fibrotic responses and therapeutic potential for anti-fibrotic treatment against CD-related stenosis.
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Affiliation(s)
- Lin Hai Kurahara
- Department of Physiology, Fukuoka University School of Medicine, Fukuoka 814-0180, Japan
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Di Gregorio J, Sferra R, Speca S, Vetuschi A, Dubuquoy C, Desreumaux P, Pompili S, Cristiano L, Gaudio E, Flati V, Latella G. Role of glycogen synthase kinase-3β and PPAR-γ on epithelial-to-mesenchymal transition in DSS-induced colorectal fibrosis. PLoS One 2017; 12:e0171093. [PMID: 28207769 PMCID: PMC5313173 DOI: 10.1371/journal.pone.0171093] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 01/15/2017] [Indexed: 02/07/2023] Open
Abstract
Background Intestinal fibrosis is characterized by abnormal production and deposition of extracellular matrix (ECM) proteins by activated myofibroblasts. The main progenitor cells of activated myofibroblasts are the fibroblasts and the epithelial cells, the latter through the epithelial-mesenchymal transition (EMT). Aim To evaluate the action of the new PPAR-γ modulator, GED-0507-34 Levo (GED) on the expression of EMT associated and regulatory proteins such as TGF-β, Smad3, E-cadherin, Snail, ZEB1, β-catenin, and GSK-3β, in a mouse model of DSS-induced intestinal fibrosis. Methods Chronic colitis and fibrosis were induced by oral administration of 2.5% DSS (w/v) for 6 weeks. GW9662 (GW), a selective PPAR-γ inhibitor, was also administered by intraperitoneal injection at the dose of 1 mg/kg/day combined with GED treatment. All drugs were administered at the beginning of the second cycle of DSS (day 12). 65 mice were randomly divided into five groups (H2O as controls n = 10, H2O+GED n = 10, DSS n = 15, DSS+GED n = 15, DSS+GED+GW n = 15). The colon was excised for macroscopic examination and histological and morphometric analyses. The level of expression of molecules involved in EMT and fibrosis, like TGF-β, Smad3, E-cadherin, Snail, ZEB1, β-catenin, GSK-3β and PPAR-γ, was assessed by immunohistochemistry, immunofluorescence, western blot and Real Time PCR. Results GED improved the DSS-induced chronic colitis and fibrosis. GED was able to reduce the expression of the main fibrosis markers (α-SMA, collagen I-III and fibronectin) as well as the pivotal pro-fibrotic molecules IL-13, TGF-β and Smad3, while it increased the anti-fibrotic PPAR-γ. All these GED effects were nullified by co-administration of GW with GED. Furthermore, GED was able to normalize the expression levels of E-cadherin and β-catenin and upregulated GSK-3β, that are all known to be involved both in EMT and fibrosis. Conclusions The DSS-induced intestinal fibrosis was improved by the new PPAR-γ modulator GED-0507-34 Levo through the modulation of EMT mediators and pro-fibrotic molecules and through GSK-3β induction.
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Affiliation(s)
- Jacopo Di Gregorio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberta Sferra
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Silvia Speca
- University of Lille, U995, Lille Inflammation Research International Center (LIRIC), F-59000 Lille, France
- IBD, Lille, France
| | - Antonella Vetuschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- * E-mail:
| | | | - Pierre Desreumaux
- University of Lille, U995, Lille Inflammation Research International Center (LIRIC), F-59000 Lille, France
- IBD, Lille, France
- CHR Lille, Service des Maladies de l’Appareil Digestif et de la Nutrition, Hôpital Claude Huriez, Lille, France
| | - Simona Pompili
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Loredana Cristiano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L’Aquila, Italy
| | - Eugenio Gaudio
- Department of Human Anatomy, University of Rome La Sapienza, Rome, Italy
| | - Vincenzo Flati
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, Gastroenterology Unit, University of L'Aquila, L'Aquila, Italy
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Rieder F, Fiocchi C, Rogler G. Mechanisms, Management, and Treatment of Fibrosis in Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:340-350.e6. [PMID: 27720839 PMCID: PMC5209279 DOI: 10.1053/j.gastro.2016.09.047] [Citation(s) in RCA: 273] [Impact Index Per Article: 39.0] [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: 07/11/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 02/08/2023]
Abstract
In the last 10 years, we have learned much about the pathogenesis, diagnosis, and management of intestinal fibrosis in patients with inflammatory bowel diseases. Just a decade ago, intestinal strictures were considered to be an inevitable consequence of long-term inflammation in patients who did not respond to anti-inflammatory therapies. Inflammatory bowel diseases-associated fibrosis was seen as an irreversible process that frequently led to intestinal obstructions requiring surgical intervention. This paradigm has changed rapidly, due to the antifibrotic approaches that may become available. We review the mechanisms and diagnosis of this serious complication of inflammatory bowel diseases, as well as factors that predict its progression and management strategies.
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Affiliation(s)
- Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute; Cleveland Clinic, Cleveland, Ohio; Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Claudio Fiocchi
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute; Cleveland Clinic, Cleveland, Ohio, USA,Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital, University of Zurich, Zurich, Switzerland,Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zurich, Switzerland
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Abstract
Crohn's disease (CD) is a lifelong inflammatory bowel disease with a rapidly rising incidence in the pediatric population. A common complication of CD is the development of fibrotic strictures, which may be present at initial diagnosis or develop many years later. Clinical presentation depends on stricture location and degree of obstruction, and strictures frequently contain a mixture of inflammatory and fibrotic tissue. Histological examination of Crohn's strictures shows thickening of the muscular layers and the submucosa, where increased collagen deposition by activated myofibroblasts is concentrated around islands of smooth muscle cells and at the superficial margin of the muscularis propria. No antifibrotic therapies for Crohn's strictures exist. Profibrotic transforming growth factor-β (TGFβ)/bone morphogenetic protein signaling stimulates myofibroblast differentiation and extracellular matrix deposition. Understanding and targeting TGFβ1 downstream signaling is the main focus of current research, raising the possibility of specific antifibrotic therapy in CD becoming available in the future.
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Affiliation(s)
- Emily Stenke
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Billy Bourke
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland.,Department of Pediatric Gastroenterology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Ulla Knaus
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
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Bettenworth D, Gustavsson A, Atreja A, Lopez R, Tysk C, van Assche G, Rieder F. A Pooled Analysis of Efficacy, Safety, and Long-term Outcome of Endoscopic Balloon Dilation Therapy for Patients with Stricturing Crohn's Disease. Inflamm Bowel Dis 2017; 23:133-42. [PMID: 28002130 DOI: 10.1097/MIB.0000000000000988] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) is widely used to manage Crohn's disease-associated strictures. However, most studies of the safety and efficacy are small and heterogenous. We performed a combined analysis of published studies and evaluated 676 comprehensive individual participant data sets to determine the overall effects of EBD. METHODS Citations from the Embase, MEDLINE, and the Cochrane library from 1991 through 2013 were systematically reviewed, and references of cited articles were assessed for relevant publications. We collected data from studies including ≥15 patients and additionally generated a unique individual patient database containing 676 individual data sets derived from 12 studies. Technical feasibility, short-term and long-term efficacies, and safety were evaluated. RESULTS In 1463 patients with Crohn's disease who underwent 3213 EBD procedures, 98.6% of strictures were ileal and 62% anastomotic. The technical success rate of the EBDs was 89.1% with a clinical efficacy of 80.8%. Complications occurred in 2.8% per procedure. After 24 months of follow-up, 73.5% of subjects underwent redilation and 42.9% surgical resection. In a multivariate analysis of 676 individual patients, a stricture length of ≤5 cm was associated with a surgery-free outcome; every 1 cm increase of stricture length increased the hazard of need for surgery by 8% (P = 0.008). Inflammation did not affect outcomes or rate of complications. CONCLUSIONS Based on a systematic literature review and analysis of data sets from 676 patients, EBD has a high rate of short-term technical and clinical efficacies, with substantial long-term efficacy and acceptable rates of complication.
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Li G, Ren J, Hu Q, Deng Y, Chen G, Guo K, Li R, Li Y, Wu L, Wang G, Gu G, Li J. Oral pirfenidone protects against fibrosis by inhibiting fibroblast proliferation and TGF-β signaling in a murine colitis model. Biochem Pharmacol 2016; 117:57-67. [DOI: 10.1016/j.bcp.2016.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 12/16/2022]
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Bettenworth D, Lopez R, Hindryckx P, Levesque BG, Rieder F. Heterogeneity in endoscopic treatment of Crohn's disease-associated strictures: An international inflammatory bowel disease specialist survey. J Gastroenterol 2016; 51:939-48. [PMID: 26831355 DOI: 10.1007/s00535-016-1172-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 09/29/2015] [Accepted: 01/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Crohn's disease (CD) is frequently complicated by intestinal strictures, which are commonly treated by endoscopic balloon dilation (EBD). However, available data on this area of treatment is limited. The aim of this study was to depict the heterogeneity of endoscopic management of CD-associated strictures among international CD specialists to identify common treatment standards. METHODS IBD experts of the International Organization for the Study of Inflammatory Bowel Disease (IOIBD), the European Crohn's and Colitis Organization (ECCO), and from the Prospective Value In IBD trials (PROVIT) completed a web-based questionnaire to evaluate their endoscopic experience, practice setting, and number of EBDs performed annually. Additionally, two case scenarios and technical practice parameters were investigated. RESULTS A total of 126 subjects from 15 countries completed the survey. The maximal length of dilated stricture was 4.5 ± 1.7 cm. The most commonly used maximal balloon size was graded as 15-18 mm. While 87.2 % of the participants favored EBD for anastomotic strictures, only 58.6 % did so in the case of naïve strictures. Only 35.7 % of physicians dilated actively inflamed strictures. Interventional endoscopists were more likely to dilate only clinically symptomatic strictures (p = 0.046). Surgeons favored surgical treatment of de novo ileocecal strictures compared to gastroenterologists (p = 0.026), reported a shorter stricture length being amendable by EBD (p = 0.045), and more frequently used concomitant therapies (p = 0.001). Operator experience increased the likelihood of EBD use in actively inflamed strictures (p = 0.002), maximum length of stricture, and maximum balloon size (p = 0.001). CONCLUSIONS EBD is a widely used treatment approach for stricturing CD. Individual approaches differ significantly based on background of the operator, experience level, and practice setting.
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Affiliation(s)
- Dominik Bettenworth
- Department of Medicine B, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pieter Hindryckx
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Barrett G Levesque
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Deepak P, Fletcher JG, Fidler JL, Bruining DH. Computed Tomography and Magnetic Resonance Enterography in Crohn's Disease: Assessment of Radiologic Criteria and Endpoints for Clinical Practice and Trials. Inflamm Bowel Dis 2016; 22:2280-8. [PMID: 27508513 DOI: 10.1097/MIB.0000000000000845] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Early recognition of Crohn's disease with initiation of disease-modifying therapy has emerged as a prominent inflammatory bowel disease management strategy. Clinical practice and trials have often focused on patient symptoms, and more recently, serologic tests, stool inflammatory markers, and/or endoscopic inflammatory features for study entry criteria, treatment targets, disease activity monitoring, and to assess therapeutic response. Unfortunately, patient symptoms do not correlate well with biological disease activity, and endoscopy potentially misses or underestimates disease extent and severity in small bowel Crohn's disease. Computed tomography enterography and magnetic resonance enterography (MRE) are potential tools to identify and quantify transmural structural damage and disease activity in the small bowel. In this review, we discuss the role of computed tomography enterography and MRE in disease management algorithms in clinical practice. We also compare the currently developed MRE-based scoring systems, their strengths and pitfalls, as well as the role for MRE in clinical trials for Crohn's disease.
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50
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Rieder F, Latella G, Magro F, Yuksel ES, Higgins PDR, Di Sabatino A, de Bruyn JR, Rimola J, Brito J, Bettenworth D, van Assche G, Bemelman W, d'Hoore A, Pellino G, Dignass AU. European Crohn's and Colitis Organisation Topical Review on Prediction, Diagnosis and Management of Fibrostenosing Crohn's Disease. J Crohns Colitis 2016; 10:873-85. [PMID: 26928961 DOI: 10.1093/ecco-jcc/jjw055] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [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: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 01/24/2023]
Abstract
This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focused on prediction, diagnosis, and management of fibrostenosing Crohn's disease [CD]. The objective was to achieve evidence-supported, expert consensus that provides guidance for clinical practice.
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Affiliation(s)
- Florian Rieder
- Department of Pathobiology, Lerner Research Institute, Cleveland, OH, USA Department of Gastroenterology, Hepatology & Nutrition, Lerner Research Institute, Cleveland, OH, USA
| | - Giovanni Latella
- Department of Life, Health and Environmental Sciences, Gastroenterology Unit, University of L'Aquila, L'Aquila, Italy
| | - Fernando Magro
- Department of Pharmacology & Therapeutics, Department of Gastroenterology, Faculty of Medicine University of Porto, Porto, Portugal
| | - Elif S Yuksel
- Department of Gastroenterology, Izmir Ataturk Teaching and Research Hospital-Katip Celebi University, Izmir, Turkey
| | - Peter D R Higgins
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Di Sabatino
- First Department of Internal Medicine, St Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Jessica R de Bruyn
- Academic Medical Center Amsterdam, Tytgat Institute for Liver and Intestinal Research, Amsterdam, The Netherlands
| | - Jordi Rimola
- Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jorge Brito
- Department of Radiology, Centro Hospitalar do Algarve, Lagos, Portugal
| | | | - Gert van Assche
- Division of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Willem Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Andre d'Hoore
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Leuven, Belgium
| | - Gianluca Pellino
- Department of Medicine 1, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Axel U Dignass
- Department of Pathobiology, Lerner Research Institute, Cleveland, OH, USA
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