Iron therapy supplementation in inflammatory bowel disease patients with iron deficiency anemia: findings from a real-world analysis in Italy

BACKGROUND

This real-world analysis evaluated iron therapy supplementation in inflammatory bowel disease patients with iron-deficiency anemia, considering disease progression and healthcare resource consumption.

METHODS

A retrospective observational study was conducted using administrative databases of a pool of Italian healthcare entities, covering about 9.3 million beneficiaries. Between January 2010 and September 2017, adult patients were enrolled in the presence of either hospitalization or active exemption code for ulcerative colitis/Crohn's disease, or one vedolizumab prescription. Iron-deficiency anemia was identified by at least one prescription for iron and/or hospitalization for iron-deficiency anemia and/or blood transfusion (proxy of diagnosis). Patients were divided in untreated and iron-treated during 12-month follow-up and analyzed before and after propensity score matching. Disease progression, was evaluated through inflammatory bowel disease-related hospitalizations and surgeries, and healthcare resource utilization was assessed.

RESULTS

Overall, 1753 patients were included, 1077 (61.4%) treated with iron therapy and 676 (38.6%) untreated. After propensity score matching, 655 patients were included in each group. In unbalanced cohorts, disease progression was significantly reduced in patients receiving iron therapy compared to the untreated (11.0% vs. 15.7%, P  < 0.01), and this trend was maintained also after applying propensity score matching. The overall mean cost/patient was significantly lower in iron-treated than untreated (4643€ vs. 6391€, P  < 0.01).

CONCLUSION

The findings of this real-world analysis suggest that iron therapy was associated with significant benefits in inflammatory bowel disease patients with iron-deficiency anemia, in terms of both disease progression and healthcare resource utilization.

Ustekinumab effectiveness in Crohn's disease with lesions in the intestines

Ustekinumab is prescribed for the treatment of patients with steroid-resistant moderate to severe Crohn's disease. We investigated its clinical outcome in patients with small and large intestinal lesions. Patients who were newly administered ustekinumab between March 2014 and December 2020 at Hamamatsu University Hospital were included in the study. The primary endpoint was Crohn's disease activity index score at baseline and weeks 8, 24, and 48 after the initiation of treatment, and secondary endpoints were albumin, hemoglobin, and C-reactive protein at these time points. Ustekinumab treatment retention was examined in both groups; the 2 groups were compared using the Friedman test, Mann-Whitney U test, or Fisher exact test. Overall, Crohn's disease activity index scores improved between baseline and 48 weeks, but the difference was not significant. However, there was a significant improvement between baseline and 48 weeks in patients with lesions in the small intestine only. Overall, patients showed significant improvement in albumin levels between baseline and 48 weeks but not in C-reactive protein or hemoglobin levels. When limited to patients with lesions in the small intestine, albumin and hemoglobin levels showed significant improvement. Both types showed high rates of treatment retention, although there was no significant difference. Ustekinumab appears to be a safe and effective treatment option that may be particularly effective in patients with lesions in the small intestine only.

Efficacy of vedolizumab during intravenous induction therapy in ulcerative colitis and Crohn's disease: post hoc analysis of patient-reported outcomes from the VISIBLE 1 and 2 studies

BACKGROUND

Vedolizumab is an anti-α4β7 integrin antibody used to treat moderate to severe ulcerative colitis (UC) and Crohn's disease (CD). This post hoc analysis of patient-reported outcomes (PROs) from the VISIBLE 1 (NCT02611830) and 2 (NCT02611817) phase 3 studies evaluated onset of treatment effect on patient-reported symptoms during 6-week vedolizumab induction.

METHODS

Patient-reported stool frequency (SF) and rectal bleeding (RB) (UC Mayo score), and SF and abdominal pain (AP) in CD were collected via electronic diary from VISIBLE patients receiving one or more open-label intravenous (IV) vedolizumab induction doses (weeks 0 and 2). PRO data were analyzed using descriptive statistics.

RESULTS

Data from 994 patients (UC 383, CD 611) showed mean ratings for all PROs declined consistently week-on-week from baseline through week 6, with early onset of improvement. By week 2, 22% of patients with UC reported RB improvement (≥1-point reduction in RB subscore, 7-day mean), rising to 45% by week 6. By week 6, 18% of patients with UC achieved SF improvement (SF subscore 0; 21% antitumor necrosis factor alpha [anti-TNFα] naive, 13% anti-TNFα experienced). SF improvement in patients with CD (reduction of ≥3 stools, 7-day mean) was achieved by 32% at week 6 (34% anti-TNFα naive, 30% anti-TNFα experienced). Fewer patients with CD reported severe/moderate AP at week 6 (5.1%/28.5%) than baseline (14.6%/61.5%). SF decline appeared greater and faster for anti-TNFα-naive vs. anti-TNFα-experienced patients (UC and CD).

CONCLUSION

Results indicate early onset of patient-reported UC and CD symptom improvement during vedolizumab IV induction in VISIBLE 1 and 2.

A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula

BACKGROUND

Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds.

OBJECTIVE

The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas.

DESIGN

A prospective single-arm study.

SETTINGS

A single tertiary medical center.

PATIENTS

Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease).

INTERVENTION

The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract.

MAIN OUTCOME MEASURES

Safety and efficacy at 6- and 12-months after surgery.

RESULTS

Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection).

LIMITATIONS

Noncomparative single-arm pilot study.

CONCLUSIONS

Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract .

BRAZO PARA EVALUAR LA SEGURIDAD Y EFICACIA DE RDVER, UN COGULO DE SANGRE AUTLOGO, EN EL TRATAMIENTO DE LA FSTULA ANAL

ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version ).

Analysis of current situation and influencing factors of marital adjustment in patients with Crohn's disease and their spouses

The purpose of this study was to investigate the marital adjustment of patients with Crohn's disease and their spouses, and to analyze its influencing factors. It lays the investigation foundation for the follow-up binary study of Crohn's disease patients and their spouses. Using convenience sampling, 177 pairs of patients and their spouses from a tertiary hospital in Nanjing, China were selected. With face-to-face electronic questionnaires to survey the patient and spouse, the contents include the Lock-Wollance Marriage Adjustment Test, Subjective Well-Being Scale for Chinese Citizens, Couple Support Questionnaire, and Distress Self-Disclosure Scale. The marital adjustment score of patients was (99.03 ± 24.25), and the marital adjustment score of spouses was (99.61 ± 25.39). The proportions of patients with marital disorders and their spouses with marital disorders were 52.5% and 46.9%, respectively. Multiple linear regression showed that the spouse's age, family monthly income, time of diagnosis of Crohn's, distress self-disclosure, marital support, and subjective well-being were important factors influencing the marital adjustment of patients. Self-disclosure of spousal distress, marital support, age, and subjective well-being were important factors that influenced spouses' marital adjustment. Most couples with Crohn's disease have marital disorders, and their marital adjustment affects each other. However, the assessment results of one partner should not be limited to replacing those of the couple. In clinical practice, patient age, monthly family income, self-disclosure of distress, marital support, and subjective well-being should be considered. Spouses should be encouraged to participate in patient care and patient-spouse interventions should be implemented as a whole to improve marital stability.

Effectiveness and safety of vedolizumab and infliximab in biologic-naive patients with Crohn's disease: results from the EVOLVE study

OBJECTIVES

This study compared the real-world effectiveness and safety of α 4 β 7 -integrin inhibitor vedolizumab and anti-tumor necrosis factor alpha (anti-TNFα) inhibitor infliximab in biologic-naive patients with Crohn's disease (CD).

METHODS

EVOLVE was a retrospective, multicenter, medical chart review of biologic-naive adults with inflammatory bowel disease receiving vedolizumab or anti-TNFα treatment as first-line biologics in Canada, Greece, and the USA. Twelve-month outcomes were analyzed in vedolizumab- or infliximab-treated patients with moderate-to-severe CD (and subgroups with complicated and noncomplicated CD) including cumulative rates of clinical response, clinical remission, and mucosal healing, and incidence rates of serious adverse events (SAEs) and serious infections (SIs). Inverse probability weighting (IPW) was used to account for baseline differences between treatment groups.

RESULTS

Data were analyzed from 167 patients. In the IPW dataset (99 vedolizumab-treated and 63 infliximab-treated), adjusted 12-month clinical remission rates were 73.1% and 55.2%, respectively ( P  = 0.31). Overall, effectiveness rates were similar across treatment and complicated/noncomplicated disease subgroups. Adjusted 12-month incidence rates (first occurrence/1000 person-years) of SAEs for vedolizumab vs. infliximab: 43.6 vs. 200.9 [hazard ratio (HR) 0.36 (0.09-1.54)]; SIs: 10.8 vs. 96.0 [HR 0.08 (<0.01-2.64)]. AE incidence was significantly lower in vedolizumab- vs. infliximab-treated patients for complicated [131.6 vs. 732.2; HR 0.19 (0.05-0.65)] and noncomplicated [276.3 vs. 494.8; HR 0.59 (0.35-0.99)] disease subgroups.

CONCLUSION

These real-world data on first-line biologics show no differences in 12-month effectiveness outcomes for vedolizumab- vs. infliximab-treated biologic-naive patients with CD. Vedolizumab may have a more favorable safety profile vs. infliximab in patients with complicated and noncomplicated disease.

Perirectal Mucinous Adenocarcinoma After Subtotal-Colectomy for Crohn's Disease: A Case Report

Colorectal carcinoma (CRC) represents the third most common cancer and the second highest cause of cancer-related death in the United States. CRC is particularly prevalent in patients with underlying inflammatory bowel disease. Adenocarcinoma represents more than 90% of new CRC diagnoses. The mucinous subtype of colorectal adenocarcinoma is found in approximately 10-20% of all colorectal cancer patients and is most frequently located in the proximal colon. We report a case of mucinous adenocarcinoma arising from the rectal stump of a patient who had previously undergone subtotal-colectomy with end ileostomy for Crohn's disease. She initially presented with gradually worsening chronic abdominal pain and gelatinous rectal discharge. She was found to have a complex cystic lesion communicating with her Hartman's pouch. She ultimately underwent a completion proctectomy, radical hysterectomy, and bilateral salpingo-oophorectomy in conjunction with gynecology oncology. To the best of our knowledge, this case represents the first description of a perirectal mucinous adenocarcinoma arising in a patient after subtotal-colectomy for Crohn's disease.

Very Early Onset of Fistulizing Inflammatory Bowel Disease With RIPK1 Mutation: A Case Report

Infantile inflammatory bowel disease (IBD) is a very rare subgroup of IBD that develops in children younger than two years with genetic susceptibility, especially in those with monogenic defects. This type, when compared with IBD in older children, is more resistant to conventional medical treatment and presents with more complications that require more surgical interventions. Our patient is a male with first-degree consanguineous parents. He was 16 months old when he presented with multiple perianal fistulas, fissures, abscesses, diarrhea, fever, and failure to thrive. He underwent a protective double-barrel ileostomy and surgical repair of the perianal disease. Crohn's disease was confirmed after endoscopy and biopsy. A genetic workup was done and revealed receptor-interacting protein kinase 1 (RIPK1) mutations. Conventional pediatric IBD treatment was initiated after surgery, including tumor necrosis factor antagonist adalimumab 40 mg subcutaneously weekly for five months. Despite treatment, he presented with dysuria and a colovesical fistula. The patient underwent secondary surgical repair.

Chronic Myelomonocytic Leukemia-Associated Immune Thrombocytopenic Purpura: A Report of a Rare Case and a Review of Literature

Chronic myelomonocytic leukemia (CMML) presents as a complex hematologic malignancy with myelodysplastic and myeloproliferative features. Our case report explores the rare coexistence of CMML with immune thrombocytopenic purpura (ITP) in a 63-year-old female patient. CMML diagnosis followed World Health Organization criteria, and the patient was classified as having high-risk myelodysplastic syndrome (MDS)-CMML stage 2. Initial treatment with subcutaneous azacytidine for CMML proved partially effective, highlighting persistent severe thrombocytopenia. Subsequent investigations revealed secondary ITP associated with Crohn's disease. Conventional ITP therapies, including high-dose steroids and intravenous immunoglobulin, showed limited efficacy. Eltrombopag, a thrombopoietin receptor agonist, was initiated, resulting in the normalization of platelet counts within six weeks. Our case emphasizes the diagnostic challenges and intricate treatment landscape of CMML-associated ITP, suggesting eltrombopag as a potential therapeutic option in refractory cases. The study contributes to the evolving understanding of the complex interplay between myeloid disorders and immune-mediated hematological conditions, calling for personalized and multidisciplinary approaches to enhance patient outcomes.

Analysis of the risk of future gastrointestinal surgery in Crohn's disease with stricture

BACKGROUND

Stricture in patients with Crohn's disease (CD) carries a high risk of CD-related surgery in the course of the disease. The aim of this study was to assess the rate of occurrence of CD-related surgery and to determine baseline risk factors predicting subsequent surgery in this patient group.

METHODS

Patients registered with stricturing CD were included. All baseline and follow-up data were collected retrospectively. Patients attended the clinic for follow-up at week 14 to assess their response to infliximab (IFX). CD-related surgery was the observational endpoint. Univariate and multivariate Cox regression analyses were used.

RESULTS

A total of 123 patients with stricturing CD were included in this study. The cumulative risk of CD-related surgery for years 1-5 after diagnosis was 18.0%, 26.7%, 32.6%, 40.7%, and 46.4%, respectively. Prior gastrointestinal (GI) surgery, low body mass index (BMI), and high platelet count might be risk factors for future CD-related surgery. With 97 participants treated by IFX, prior GI surgery and primary non-response (PNR) to IFX correlated with future CD-related surgery.

CONCLUSION

Prior GI surgery, BMI, and platelet counts were related to future CD-related surgery. Patients who were PNR to IFX had a higher risk of CD-related surgery in the future.

Matrix gla protein, a potential marker of tissue remodelling and physiological ageing of the gut in crohn's disease

BACKGROUND

The inactive dephosphorylated and uncarboxylated form of the matrix Gla protein (dp-ucMGP) has been shown to be increased in plasma of inflammatory bowel disease (IBD) patients. Our aim was to assess if the plasmatic level of dp-ucMGP could reflect disease endoscopic activity, presence of strictures and cumulative structural bowel damage in Crohn's disease (CD) patients.

METHODS

The plasmatic level of dp-ucMGP was measured in a monocentric cohort of prospectively recruited patients. The analysis was done by chemiluminescent immunoassay on blood samples collected the day of a planned ileocolonoscopy. In addition to classical clinical data (gender, age, body mass index (BMI), disease duration, current treatment), endoscopic data (disease location, Crohn's Disease Endoscopic Index of Severity (CDEIS), mucosal healing (MH), presence of 9 CD lesion types) and biological markers (faecal calprotectin and C-reactive protein (CRP)) were collected. The association between dp-ucMGP level and Lémann index was also investigated. Univariate linear regression was used to investigate the relationship between dp-ucMGP level and different parameters collected.

RESULTS

A total of 82 ileocolonoscopies and dp-ucMGP assays were performed in 75 CD patients (45 females; 37 ileocolonic, 19 ileal and 19 colonic diseases) between October 2012 and November 2019. A total of 24 patients (29.3%) showed MH. The dp-ucMGP levels were not associated with MH, CDEIS, faecal calprotectin or CRP levels. Plasmatic dp-ucMGP levels increased significantly with age (p = 0.0032), disease duration (p = 0.0033), corticosteroids use (p = 0.019) and tended to increase in patients with intestinal strictures (p = 0.086) but not with the Lémann index.

CONCLUSION

The significant increase of plasmatic dp-ucMGP levels with age, disease duration and the trend observed in patients with non-ulcerated strictures may suggest that this extracellular matrix protein could be a marker of tissue remodelling and physiological ageing of the gut.

Risk of malignancy in a high-incidence population-based cohort of Faroese patients with inflammatory bowel disease from 1960 to 2020 - a Faroese IBD cohort study

BACKGROUND

The association between inflammatory bowel disease (IBD) and malignancy remains disputed despite many observational studies. The Faroese population exhibits the highest occurrence of IBD in the world. This study aimed to investigate the cancer risk in Faroese IBD patients in a nationwide IBD cohort.

METHODS

This study included all IBD patients diagnosed in the Faroe Islands between 1960 and 2020. Clinical demographics and cancer diagnoses were retrieved from patient files and the Faroese cancer registry. Cancer risk in IBD patients was calculated as standardized incidence ratios (SIRs) based on the Faroese background population's age- and sex-specific cancer incidence rates, retrievable from NORDCAN.

RESULTS

The cohort consisted of 699 patients with a total follow-up time of 9,629 person-years. Overall, the risk of cancer was not statistically significantly increased compared to the background population. Patients diagnosed with cancer at age 50-59 years had higher overall cancer risk (SIR 1.8; 95% CI, 1.02-2.99) as did UC patients diagnosed with IBD at 50-59 (SIR 2.1; 95% CI, 1.10-3.54). Absolute numbers were small and no estimates for site-specific cancers reached statistical significance, though lung, breast, and cancer of the female reproductive organs were elevated among IBD and UC patients, and colorectal cancer in CD patients.

CONCLUSIONS

This nationwide study found no statistically significantly increased risk of cancer among Faroese patients with CD or UC, except from age 50 to 59 years. While the incidence of IBD is significantly higher in the Faroe Islands than in other countries, risk estimates of cancers are comparable.

Acute Pancreatitis Leading to the Diagnosis of Presymptomatic Crohn's Disease: A Pediatric Case Report

A 14-year-old boy presented with fever and abdominal pain and was diagnosed with acute pancreatitis based on computed tomography findings. The patient had neither diarrhea nor bloody stool but was diagnosed with microcytic anemia. Endoscopic examination revealed a cobblestone pattern and longitudinal ulcer scars in the jejunum. However, no abnormal findings were observed in the ileum or colon. Endoscopic ultrasound-guided fine-needle aspiration was performed from pancreatic body-tail. Pathological examination revealed no evidence of autoimmune pancreatitis (AIP). It was unclear from pathological examination whether idiopathic pancreatitis had self-limitedly improved or whether it was AIP localized to the pancreatic head. The patient was diagnosed with asymptomatic small-bowel Crohn's disease (CD), which may have been two unrelated events of acute pancreatitis. Acute pancreatitis may precede a diagnosis of inflammatory bowel disease. CD with only jejunal involvement (Montreal classification L4) is extremely rare, and we were able to diagnose it early.

Atherosclerosis as a Risk Factor of Inflammatory Bowel Disease: A Population-Based Case-Control Study

INTRODUCTION

Data suggest atherosclerotic-related inflammation may play a role in the pathogenesis of inflammatory bowel disease (IBD), but large-scale studies are missing.

METHODS

In this nationwide case-control study, we used the Swedish Patient Register and the Epidemiology Strengthened by histoPathology Reports in Sweden cohort to identify adult cases of incident IBD between 2002 and 2021, with each case matched to up to 10 general population controls. We used conditional logistic regression to calculate odds ratios (OR) for exposure to an atherosclerotic-related condition (myocardial infarction, thromboembolic stroke, or atherosclerosis itself) before being diagnosed with IBD.

RESULTS

There were a total of 56,212 individuals with IBD and 531,014 controls. Of them, 2,334 (4.2%) cases and 18,222 (3.4%) controls had a prior diagnosis of an atherosclerotic-related condition, corresponding to an OR of 1.30 (95% confidence interval [CI] 1.24-1.37). Results were statistically significant for both Crohn's disease (OR 1.37, 95% CI 1.26-1.48) and ulcerative colitis (OR 1.27, 95% CI 1.20-1.35) and for individuals who developed IBD at 40-59 years of age and 60 years or older. In addition, associations persisted when adjusting for underlying comorbidities, including the presence of immune-mediated diseases and prior aspirin and/or statin use. The highest odds of an atherosclerotic-related condition were seen in the 6-12 months before IBD diagnosis, though odds were increased even ≥5 years before. A higher magnitude of odds was also observed when having 2 or more atherosclerotic-related conditions when compared with having only 1 condition.

DISCUSSION

A history of an atherosclerotic-related condition is associated with increased odds of developing IBD, particularly among older adults. Future studies should investigate whether drugs targeting atherosclerotic-related inflammation may prevent IBD in higher-risk individuals.

Analysis of the Accuracy of Magnetic Resonance Enterography for the Detection of Active Inflammation and Disease Activity in Patients With Crohn's Disease: A Single-Center Experience in Najran, Saudi Arabia

BACKGROUND

Magnetic resonance enterography (MRE) is a non-invasive diagnostic imaging modality that has been used for the detection of active inflammation and disease activity in patients with Crohn's disease. However, its diagnostic accuracy in the Najran population has not been well-studied.

STUDY AIM

This study aimed to assess the diagnostic accuracy of MRE in detecting active inflammation and disease activity in patients with Crohn's disease in the Najran population.

METHODS

The study included 51 patients with Crohn's disease, and their demographic, clinical, radiological, laboratory, and endoscopic data were analyzed.

RESULTS

The results showed that MRE findings, such as the radiological score for active inflammation and the presence of extra-intestinal manifestations, were significantly associated with the final diagnosis of active inflammation. Furthermore, the timing of MRE in relation to symptom activity and the indication for performing MRE were significantly associated with the final diagnosis. The study findings demonstrate the potential of MRE as a valuable tool for diagnosing and assessing disease activity in Crohn's disease patients in the Najran population.

The Potential Association Between Inflammatory Bowel Diseases and Apical Periodontitis: A Systematic Review and Meta-Analysis

Recent literature has suggested a potential association between inflammatory bowel diseases (IBD) and apical periodontitis (AP). The present systematic review and meta-analysis sought to analyse and appraise the available evidence regarding the reported association. Following 2020 PRISMA guidelines, a comprehensive search of multiple online databases (PubMed, Scopus, Web of Science, and Google Scholar) was conducted for all relevant studies published from the date of inception until 27 April 2023 using various relevant keywords. All observational studies that assessed the association between IBD and AP in humans were eligible for inclusion. The quality of the selected studies was carried out independently by two reviewers, and meta-analysis was performed using Comprehensive Meta-Analysis Version 2.2.064. Six studies (five case-control studies and one cohort study) were included. A total of 657 patients (277 with IBD) were included in 5 case-control studies, and 48,223 subjects (35,740 with AP) were included in the cohort study, where 188 developed IBD on follow-up. The pooled data from the five case-control studies revealed that IBD was significantly associated with a higher risk of AP (OR=1.71, 95% CI: 1.21-2.42; I2=10.337%, fixed-effect, p=0.002). The qualitative analysis also showed that most of the included studies found a higher mean number of teeth with AP in IBD groups than the healthy controls. Newcastle-Ottawa Scale (NOS)-based quality appraisal results demonstrated that five studies were of high quality, and one was of moderate quality. The results suggest a potential association between IBD and AP. Large-scale and prospective studies are required to further confirm and elucidate the nature of such an association.

Upadacitinib in Crohn's Disease: A Comprehensive Systematic Review of Efficacy and Safety

Crohn's disease (CD) presents a formidable challenge as a chronic inflammatory condition. This systematic review aimed to comprehensively assess upadacitinib, a novel Janus kinase (JAK) inhibitor, regarding its efficacy, safety, and mechanistic insights in CD treatment. A thorough search of electronic databases identified studies investigating upadacitinib's impact on CD patients. Study characteristics, efficacy outcomes (clinical remission and endoscopic response), safety profiles, and mechanistic insights were extracted and qualitatively synthesized. Methodological quality was assessed using established tools. The synthesis of three studies consistently demonstrated improvements in clinical remission rates and endoscopic outcomes in upadacitinib-treated patients. Adverse events, such as herpes zoster, intestinal perforation, non-melanoma skin cancer, adjudicated cardiovascular events, and anemia, were reported, necessitating vigilant safety monitoring. Upadacitinib emerges as a promising therapeutic option for CD, supported by its observed clinical benefits and mechanistic implications. However, safety concerns underscore the importance of careful patient selection. These findings contribute to the ongoing discussion surrounding personalized treatment approaches for CD, emphasizing the need for further research to confirm its enduring efficacy and safety.

Preoperative Risk Factors for Adverse Events in Adults Undergoing Bowel Resection for Inflammatory Bowel Disease: 15-Year Assessment of the American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION

Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication.

RESULTS

Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16).

DISCUSSION

Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.

JAK inhibitors for the treatment of inflammatory bowel disease: results of an international survey of perceptions, attitudes, and clinical practice

BACKGROUND

Janus kinase inhibitors (JAKi) are small molecule drugs with demonstrated efficacy in inflammatory bowel disease (IBD). However, widespread utilisation may be hindered by safety concerns.

AIMS

This is the first study assessing risk-benefit perceptions and clinical practices of those using JAKi for IBD.

METHODS

A prospective, cross-sectional study was conducted using a 23-item survey distributed to IBD healthcare providers worldwide.

RESULTS

Of 385 respondents from 48 countries, 72% were tertiary-centre based and 50% were gastroenterologists with ≥10 years experience. JAKi were commonly used outside market authorisation (31%), though many (17%) were unconfident discussing JAKi risk-benefit profile and 7% had never prescribed JAKi. If venous thromboembolism risks were present, 15% preferentially referred for surgery than initiate JAKi; 21% would do this even if the patient was already anticoagulated. For patients relapsing on dose reduction, 8% would switch treatment rather than dose escalate. Conversely, 45% felt that cardiovascular safety concerns from post-marketing studies were irrelevant to IBD. Despite the lack of detailed, long-term safety data, safety profiles of JAK1-selective drugs were perceived to be favourable to tofacitinib by most (62%).

CONCLUSION

The study indicates that while clinical practice appears to be in keeping with international guidance, a significant minority remain deterred by safety concerns.

Prevalence of Immunomodulator Use as Combination Therapy With Vedolizumab or Ustekinumab in Inflammatory Bowel Disease

INTRODUCTION

The benefit of adding an immunomodulator to vedolizumab and ustekinumab remains unclear and may compromise the safety of these biologics. We evaluated the prevalence and predictors of immunomodulator use with vedolizumab or ustekinumab in patients with inflammatory bowel disease in a large longitudinal cohort.

METHODS

Clinical information was ascertained from electronic medical records of patients enrolled in TARGET-IBD, a prospective longitudinal observational cohort of patients with inflammatory bowel disease (IBD) at 34 sites. The prevalence of immunomodulator use with vedolizumab, ustekinumab, and antitumor necrosis factor therapies and predictors of immunomodulator use with vedolizumab and ustekinumab were estimated. Rates of combination therapy were additionally stratified by time from drug approval.

RESULTS

Four thousand thirty-nine adults with IBD were identified, of whom 18.8% were treated with vedolizumab and 13.0% were treated with ustekinumab. Combination therapy with vedolizumab and ustekinumab exceeded 30% (30.7% and 36.2%, respectively) and was more likely in those with perianal disease or previous biologic exposure. Age and presence of extraintestinal manifestations did not consistently predict the use of an immunomodulator. Combination therapy decreased in the years after drug approval.

DISCUSSION

Combination therapy with vedolizumab or ustekinumab was common and was associated with perianal disease and greater exposure to other biologics, although the practice is decreasing with time. Further data are needed to determine the efficacy and safety of combination therapy in patients initiating vedolizumab or ustekinumab for IBD.

Serial Changes in Intestinal Stenotic Stiffness in Patients with Crohn's Disease Treated with Biologics: A Pilot Study Using Ultrasound Shear Wave Elastography

BACKGROUND/AIMS

Intestinal strictures represent an important serious complication of Crohn's disease. Shear wave elastography is a promising noninvasive ultrasound technique for assessing tissue stiffness. This study aimed to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease using shear wave elastography and the changes in stiffness after biologics.

MATERIALS AND METHODS

We enrolled 21 Crohn's disease patients having intestinal stricture. The patients consisted of 3 groups, which were the infliximab naïve (n = 6) group, the ustekinumab naïve (n = 8), and the bio-switch from infliximab to ustekinumab (n = 7) group. Bowell wall thickness was examined by ultrasound sonography, and the stiffness of Crohn's disease stricture lesions was evaluated using Shear wave speed before and 1 year after anti-tumor necrosis factor-alpha antibody infliximab, anti-interleukin 12/23 antibody ustekinumab, and bio-switch from infliximab to ustekinumab.

RESULTS

Bowell wall thickness was significantly improved after infliximab, ustekinumab, and the bio-switch. However, shear wave speed indices only in the ustekinumab group significantly decreased after treatment (P = .028), but not in the other group.

CONCLUSIONS

Shear wave elastography might be a useful method to evaluate stiffness in the areas of intestinal stricture in patients with Crohn's disease treated with biologics. However, a prospective randomized study evaluating the development of obstruction after biological treatment is needed to validate the study findings.

Benefits and Challenges of Treat-to-Target in Inflammatory Bowel Disease

There is notable disparity between symptomatology and disease activity in a significant proportion of patients with inflammatory bowel disease (IBD), and escalation of treatment based on symptoms alone can fail to significantly alter the course of disease. The STRIDE-II position statement, published in 2021 by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organisation for the Study of IBD (IOIBD) provides the most current recommendations for a treat-to-target (T2T) approach in IBD. Despite the benefits offered by a T2T approach in IBD, there are numerous drawbacks and current limitations to its widespread implementation in real-world clinical practice. Owing to the lack of a standardised definition of MH, outcome data are heterogeneous and limit the comparability of existing data. Further, studies investigating the likelihood of achieving MH with a T2T approach are limited and largely retrospective. Evidence of the real-world feasibility of tight monitoring is currently minimal and demonstrates sub-optimal adherence among patients. Further, the few studies on the acceptability and uptake of a T2T approach in real-world practice demonstrate the need for increased acceptability on both patients' and clinicians' behalf. Real-world applicability is further limited by the need for repeated endoscopic assessments of MH as well as a lack of guidance on how to incorporate the various treatment targets into therapeutic decision-making. We aim to review the benefits and challenges of the T2T approach and to discuss potential solutions to further patient care.

Anxiety and Depression in Patients With Inflammatory Bowel Disease at King Fahad Specialist Hospital, Qassim Region

Background Inflammatory bowel disease (IBD) includes Crohn's disease (CD) and ulcerative colitis (UC). It carries a risk of annual relapses and multiple intense flares, which require lifelong treatment and, sometimes, surgical interventions. This affects patients negatively in various aspects of their functioning, and they are left with an increased risk of disturbed quality of life and mental illnesses. Aim This study is carried out to describe the prevalence and risk factors of anxiety and depression symptoms among adult patients with IBD at King Fahad Specialist Hospital, Qassim, Saudi Arabia, and to examine the relationship between mental illness and disease activity. Patient and methods This cross-sectional descriptive study targets adult patients with IBD attending a gastroenterology clinic and medical day care unit. A self-administered questionnaire was given to patients with the help of an IBD nurse. The questionnaire includes the patient's demographic data (i.e., age, gender, etc.), symptoms and treatment patterns, the General Anxiety Disorder (GAD) questionnaire to measure anxiety, and the Patient Health Questionnaire (PHQ-9) to measure depression. Results Among the 179 IBD patients, 60.9% were males, and 40.8% were in the age group of 25-35 years. CD was the most prevalent IBD (73.2%). Perineal CD was detected in 45%. The prevalence of patients who were positive for anxiety symptoms was 17.3%, while the prevalence of depressive symptoms was 19.6%. The independent risk factor for anxiety was female gender, while the independent risk factor for depression was extraintestinal manifestation. The preventive factor for depression was treatment with IV medication. Conclusion Almost one-fifth of IBD patients were considered to have either anxiety or depression. Female gender was a risk factor for anxiety while extraintestinal manifestation of IBD was a risk factor for depression. Interestingly, treatment with IV medication was found to be the protective factor for depression. More investigations are warranted to give more insights regarding the prevalence and risk factors of psychological disorders among patients with IBD in our region.

Crohn's disease from past to present: Research trends and global outcomes with scientometric analysis during 1980 to 2022

Currently, there is no comprehensive bibliometric study in the literature on Crohn's disease (CD). The aim of this study was to analyze articles published on CD using bibliometric and statistical methods. The aim was to identify current research trends, show global productivity, and determine important players such as countries, journals, institutions, and authors. A total of 16,216 articles published on CD between 1980 and 2022 were analyzed using various statistical and bibliometric methods. Bibliometric network visualization maps were used to perform trend topic analysis, citation analysis, and international collaboration analysis. Spearman's correlation coefficient was used for correlation analysis. The top 3 contributing countries to the literature were the United States of America (USA) (n = 4344, 26.7%), the United Kingdom (UK) (n = 2036, 12.5%) and Germany (n = 1334, 8.2%). The most active institutions were Udice French Research Universities (n = 696), Assistance Publique Hopitaux Paris (n = 570), and Institut National de la Sante et de la Recherche Medicale Inserm (n = 479). The most productive journals were Inflammatory Bowel Diseases (n = 1100), Journal of Crohn's & Colitis (n = 579), and Gut (n = 510). The most prolific author was Colombel JF. (n = 290). The most frequently researched topics from past to present included infliximab, ulcerative colitis, surgery, pediatrics, adalimumab, magnetic resonance imaging, inflammation, perianal CD/perianal fistula, azathioprine, magnetic resonance enterography, small bowel, stricture/strictureplasty, recurrence, therapy/treatment, ustekinumab, mucosal healing, biomarkers, fistula, quality of life, ultrasonography, epidemiology, capsule endoscopy, laparoscopic surgery/laparoscopy, endoscopy, disease activity, postoperative recurrence, and the Nucleotide Binding Oligomerization Domain Containing 2 gene. We have seen an exponential increase in worldwide publications on CD. In recent years, the major research topics related to CD have been ustekinumab, vedolizumab, fecal calprotectin, therapeutic drug monitoring, biologics, biomarkers, exclusive enteral nutrition, microbiome/microbiota, magnetic resonance enterography, anti-TNF, postoperative complications, and mucosal healing. We determined that countries with large economies, particularly the United States, United Kingdom, Germany, France, Canada, Italy, Japan and China, have taken the lead in research contributions to the development of CD literature.

Role of Biologic Therapies in the Rheumatic Manifestations of Inflammatory Bowel Disease: A Systematic Analysis

In the recent years, there has been a growing recognition of the intricate relationship between inflammatory bowel disease (IBD) and extraintestinal manifestations (EIMs). EIMs of IBD include rheumatological, mucocutaneous, ocular, neurologic, pulmonary, cardiac, renal, hepatobiliary, and hematologic manifestations. Rheumatic manifestations are identified as the most common EIM, including axial and peripheral spondyloarthritis, arthralgia, sacroiliitis, enthesitis, and dactylitis. The convergence of the two distinct yet interconnected medical domains has spurred extensive research into the potential benefits of biological therapies as a treatment approach compared to the traditional method of treatment. This systematic review aims to assess the efficacy and overall impact of biological therapies in managing the rheumatic manifestations associated with IBD. Seventy-five articles from reputed journals published between January 1, 2013 and August 19, 2023 were reviewed. A set of eight papers were chosen for the focused study. The evaluation considered variables, such as rheumatic symptoms, in established IBD patients and compared the available biologic treatment and its benefits in alleviating rheumatic manifestations of IBD. By delving into the available literature and critically evaluating the relevant studies, this review shows insights into the role of biological therapies in the management of rheumatic symptoms in IBD. However, we must also address the limitations in implementing these since newer therapies are on the horizon. Hence, in-depth exploration and refinement of therapeutic strategies are needed to ultimately enhance patient care and quality of life for those affected by IBD. Infact, emerging artificial intelligence (AI) technologies are being used to improve the precision of diagnosis and enhance patient management.

Concomitant Crohn's Disease and Anti-Glutamic Acid Decarboxylase (GAD)-Associated Autoimmune Encephalitis: A Case Report

Crohn's disease is an inflammatory, autoimmune disorder that predominantly affects the intestines but can also affect extraintestinal organs. Certain neurological conditions, such as autoimmune encephalitis, can develop along with this disease. In this case report, we present a case of anti-glutamic acid decarboxylase (GAD) antibody-associated autoimmune encephalitis that occurred shortly after the diagnosis of Crohn's disease and was unrelated to the treatment and nutritional deficiencies. After a significant weight loss (24 kg) and persistent diarrhea, the patient was diagnosed with Crohn's disease by colonoscopy and biopsy. Within two weeks after the diagnosis, he experienced altered consciousness and memory impairment, followed by a rapid deterioration in consciousness and respiratory distress, leading to intubation and admission to the intensive care unit. His brain MRI revealed asymmetrical diffuse cortical diffusion restrictions, hyperintense signals on fluid-attenuated inversion recovery (FLAIR) sequences, and diffuse pachymeningeal contrast enhancement involving both cingulate gyri, bilateral insular cortices, amygdalae, hippocampi, and the right precuneus. Analysis of cerebrospinal fluid (CSF) revealed a slight elevation of CSF proteins, and the patient tested positive for serum anti-GAD antibodies. The patient responded favorably to a seven-day course of intravenous methylprednisolone, five days of intravenous immunoglobulin (IVIG), and oral corticosteroids. Subsequent treatment consisted of monthly IVIG, azathioprine, and vedolizumab, resulting in no neurologic sequelae except mild amnesia. A follow-up MRI at three months showed a nearly complete disappearance of the lesions. This is the first reported case of anti-GAD-associated encephalitis occurring in the presence of Crohn's disease.

Safety of Radiation Therapy in Patients With Prostate Cancer and Inflammatory Bowel Disease: A Systematic Review

PURPOSE

Inflammatory bowel disease (IBD) has historically been considered a relative contraindication for pelvic radiation therapy (RT). To date, no systematic review has summarized the toxicity profile of RT for patients with prostate cancer and comorbid IBD.

METHODS AND MATERIALS

A PRISMA-guided systematic search was conducted on PubMed/Embase for original investigations that reported gastrointestinal (GI; rectal/bowel) toxicity in patients with IBD undergoing RT for prostate cancer. The substantial heterogeneity in patient population, follow-up, and toxicity reporting practices precluded a formal meta-analysis; however, a summary of the individual study-level data and crude pooled rates was described.

RESULTS

Twelve retrospective studies with 194 patients were included: 5 examined predominantly low-dose-rate brachytherapy (BT) monotherapy, 1 predominantly high-dose-rate BT monotherapy, 3 mixed external beam RT (3-dimensional conformal or intensity modulated RT [IMRT]) + low-dose-rate BT, 1 IMRT + high-dose-rate BT, and 2 stereotactic RT. Among these studies, patients with active IBD, patients receiving pelvic RT, and patients with prior abdominopelvic surgery were underrepresented. In all but 1 publication, the rate of late grade 3+ GI toxicities was <5%. The crude pooled rate of acute and late grade 2+ GI events was 15.3% (n = 27/177 evaluable patients; range, 0%-100%) and 11.3% (n = 20/177 evaluable patients; range, 0%-38.5%), respectively. Crude rates of acute and late grade 3+ GI events were 3.4% (6 cases; range, 0%-23%) and 2.3% (4 cases; range, 0%-15%).

CONCLUSIONS

Prostate RT in patients with comorbid IBD appears to be associated with low rates of grade 3+ GI toxicity; however, patients must be counseled regarding the possibility for lower-grade toxicities. These data cannot be generalized to the underrepresented subpopulations mentioned above, and individualize decision-making is recommended for those high-risk cases. Several strategies should be considered to minimize the probability of toxicity in this susceptible population, including careful patient selection, minimizing elective (nodal) treatment volumes, using rectal sparing techniques, and employing contemporary RT advancements to minimize exposure to GI organs at risk (eg, IMRT, magnetic resonance imaging-based target delineation, and high-quality daily image guidance).

The Relationship Between the Endoscopic Healing Index, Fecal Calprotectin, and Magnetic Resonance Enterography in Crohn's Disease

INTRODUCTION

The serum-based endoscopic healing index (EHI) test identifies endoscopic Crohn's disease (CD) activity. Data are lacking on the relationship between EHI with other endpoints. We assessed the relationship between EHI and the simplified Magnetic Resonance Index of Activity.

MATERIALS AND METHODS

Data were prospectively collected on patients with CD with either an EHI or fecal calprotectin (FCAL) within 90 days of magnetic resonance enterography (MRE). Diagnostic accuracy was assessed using area under the receiver operator characteristics. Proportions with any, severe, and terminal ileum MR inflammation were compared above/below identified thresholds for both EHI and FCAL.

RESULTS

A total of 241 MREs paired to either EHI or FCAL from 155 patients were included. Both EHI and FCAL had similar accuracy to diagnose inflammation (area under the receiver operator characteristics: EHI: 0.635 to 0.651, FCAL: 0.680 to 0.708). Optimal EHI values were 42 and 26 for inflammation on MRE and endoscopy, respectively. Patients with EHI ≥42 (100% vs. 63%, P=0.002), FCAL >50 µg/g (87% vs. 64%, P<0.001) and FCAL >250 µg/g (90% vs. 75%, P=0.02) had higher rates of simplified Magnetic Resonance Index of Activity ≥1 compared with lower values. EHI differentiated ileitis numerically more than FCAL (delta: 24% to 25% vs. 11% to 21%). Patients with FCAL ≥50 µg/g had higher rates of severe inflammation compared with FCAL <50 µg/g (75% vs. 47%, P<0.001), whereas smaller differentiation existed for EHI threshold of 42 (63% vs. 49%, P=0.35).

CONCLUSION

Both EHI and FCAL were specific in their confirmation of inflammation and disease activity on MRE in patients with CD. However, MRE-detected inflammation was frequently present in the presence of low EHI and FCAL in similar proportions.

Metastatic Crohn's Disease in External Genitalia With Good Outcome on Adalimumab: A Rare Case of a Saudi Female and a Short Review

Crohn's disease (CD), an inflammatory bowel disease that involves the gastrointestinal tract, is observed in daily hospital practice. On the other hand, metastatic Crohn's disease (MCD) is a rare entity in which cutaneous lesions are found in regions apart from the digestive system. This article describes a rare case of cutaneous CD in a Saudi female, which manifested initially as vulvar and perianal skin lesions. The diagnosis was proven by skin biopsy, and adalimumab offered effective treatment. Although cutaneous MCD is rare, it is an important cutaneous manifestation, as early detection creates the possibility of accessing effective management.

The Impact of Cellular Therapies on Gastrointestinal Diseases: Applications and Challenges

Gastrointestinal diseases are highly prevalent, and their burden significantly impacts the quality of life of affected individuals. Inflammatory and immune-mediated intestinal diseases usually have a chronic course without adequate therapeutic modalities. Although much has been reported to comprehend these diseases, many remain resistant and refractory to conventional treatment approaches. Therefore, recent approaches to cellular therapy using stem cells, like hematopoietic stem cells and mesenchymal stem cells, and other cellular immunosuppressive modalities, like T-regulatory cells, were introduced and investigated in treating gastrointestinal diseases. We aimed to conduct a literature review to discuss the applications and challenges of cellular therapeutics in gastrointestinal diseases. Evidence from published clinical trials supports the safety and efficacy of cellular treatment in different immune-mediated and inflammatory gastrointestinal diseases. They can offer a longer duration of remission, being able to adjust the dysregulated immune system. However, there are various challenges to be considered by future trials, including the limitations of current clinical trials, challenges in retrieval and application of these therapeutics, and their mutagenesis potential.

Sarcopenia and Myosteatosis Assessed by Magnetic Resonance Enterography May Predict Negative Outcomes in Patients with Crohn's Disease

BACKGROUND

Limited research has examined the clinical consequences of sarcopenia and myosteatosis in Crohn's disease. This study aimed to determine the prevalence, risk factors, and effects of sarcopenia and myosteatosis on prognostic outcomes in Crohn's disease patients who underwent magnetic resonance enterography.

MATERIALS AND METHODS

This retrospective observational study included 116 Crohn's disease patients who underwent magnetic resonance enterography between January 2015 and August 2021. Skeletal muscle index was the ratio of the cross-sectional area of skeletal muscles at the L3 vertebral level to the square of the neck in cross-sectional imaging. Sarcopenia was defined as skeletal muscle index <38.5 cm2/m2 in women and <52.4 cm2/m2 in men. Myosteatosis was considered positive if the ratio of the mean signal intensity of the psoas muscle to the mean signal intensity of the cerebrospinal fluid was above 0.107.

RESULTS

Among the negative results in the post-procedure follow-up of the patients, a significant increase was observed in the sarcopenia group regarding abscess and the need for surgery (P < .05). Anti-tumor necrosis factor initiation was found to be significantly higher in the follow-up than in patients without myosteatosis (P = .029). In the multivariate model established with these variables, the presence of sarcopenia in the surgical follow-up was odds ratio = 5.34 (CI: 1.02-28.03, P = .047) and was found to be significantly associated with the increased risk.

CONCLUSIONS

The presence of myosteatosis and sarcopenia detected in magnetic resonance enterography may be a harbinger of negative outcomes in Crohn's disease patients. Nutritional support should be provided to these patients with the potential to alter the course of the disease.

The Effect of Adherence to Mediterranean Diet on Disease Activity in Patients with Inflammatory Bowel Disease

BACKGROUND/AIMS

Mediterranean diet, owing to its infla mmati on-mo dulat ory effects, is considered a beneficial dietary regimen for patients with inflammatory bowel disease. Despite promising results in the literature, studies on this subject are still limited. Therefore, the aim of this study was to evaluate adherence to the Mediterranean diet in patients with inflammatory bowel disease and examine its impact on disease activity and quality of life.

MATERIALS AND METHODS

A total of 83 patients were included in the study. Mediterranean Diet Adherence Scale was used to evaluate adherence to the Mediterranean diet. Crohn's Disease Activity Index was used to evaluate disease activity in Crohn's disease. Disease activity was determined by using the Mayo Clinic score for ulcerative colitis. Quality of Life Scale Short Form-36 was used to evaluate the quality of life of patients.

RESULTS

When the median Mediterranean Diet Adherence Scale score was 7 (1-12), only 18 patients (21.7%) showed strong adherence to the Mediterranean diet. Disease activity scores of patients with ulcerative colitis having low adherence to the Mediterranean diet were found to be higher (P < .05). In addition, some quality of life parameters were relatively higher in patients with ulcerative colitis who showed strong adherence to the Mediterranean diet (P < .05). For Crohn's disease, no significant difference was found in disease activity and quality of life with respect to adherence to the Mediterranean diet (P > .05).

CONCLUSIONS

Stronger adherence to the Mediterranean diet in patients with ulcerative colitis can help improve quality of life and modulate disease activity. However, further prospective studies are needed to investigate the potential use of the Mediterranean diet in inflammatory bowel disease management.

Managing the older adult with inflammatory bowel disease: is age just a number?

PURPOSE OF REVIEW

This review summarizes the most recent literature on older adults with inflammatory bowel diseases (IBD). Additionally, we review geriatric syndromes that may be pertinent to the management of older adults with IBD.

RECENT FINDINGS

Traditionally chronological age has been used to risk stratify older adults with IBD, however physiologic status, including comorbidities, frailty, and sarcopenia, are more closely associated with clinical outcomes for older adults. Delaying care for and undertreating older adults with IBD based upon advanced chronologic age alone is associated with worse outcomes, including increased mortality. Treatment decisions should be made considering physiologic status, with an understanding of the differential risks associated with both ongoing disease and treatment. As such, there is an increasing recognition of the impact geriatric syndromes have on older adults with IBD, which need to be further explored.

SUMMARY

Older adults with IBD are less likely to receive advanced therapies and timely surgery. They are also more likely to have adverse outcomes despite having similar disease courses to younger adults with IBD. Focusing on biological age as opposed to chronological age can shift this trajectory and improve quality of care for this growing population of patients with IBD.

Clostridium difficile in inflammatory bowel disease

PURPOSE OF REVIEW

The chronic inflammatory bowel diseases (IBD), Crohn's disease, and ulcerative colitis, are associated with an increased risk of symptomatic Clostridium difficile infection (CDI). CDI may also masquerade as an IBD flare and complicate IBD management. This review provides a comprehensive overview of the epidemiology, diagnosis, and treatment of CDI in IBD patients.

RECENT FINDINGS

CDI remains common in IBD with complications including flares in disease activity, recurrent CDI episodes, and prolonged hospital stays. Newer IBD therapeutics including vedolizumab, ustekinumab, and tofacitinib are less likely to cause severe CDI. A high index of suspicion, rapid testing via a two-step method, and prompt treatment with vancomycin or fidaxomicin are paramount to managing CDI in IBD patients. Strategies to prevent recurrent CDI (rCDI) include the monoclonal antibody bezlotoxumab as well as fecal microbiota transplantation (FMT). FMT has a robust profile of safety and effectiveness in preventing rCDI in adults and children.

SUMMARY

Clinicians must remain vigilant in the prompt diagnosis and treatment of CDI in IBD patients. Corticosteroids, unnecessary antibiotics, and ongoing colonic inflammatory disease are modifiable risk factors. Improved infection control measures, newer IBD medications, and using effective CDI treatments will facilitate a reduced burden of severe CDI and complications for IBD patients.

Growth Failure and Primary Amenorrhea: Endocrine Dysfunction as a Late Presentation of Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory bowel disease involving entire gastrointestinal tract, most commonly affecting terminal ileum and colon. It usually presents with gastrointestinal symptoms like bloody diarrhea, fever and loss of weight. The clinical course of CD includes gastrointestinal complications like fistulas, abscesses and perianal disease. Inflammatory bowel diseases (IBD) are usually diagnosed during childhood and adolescence, majority during puberty and pubertal growth spurt. Various extraintestinal manifestations may be a presentation of CD that poses a diagnostic challenge. Growth failure is an important complication of IBD rather than a manifestation. Herein we present a case of a 16-year-old Sri Lankan girl presenting with growth failure and primary amenorrhea. She had minimal gastrointestinal symptoms. She also had microcytic anemia with marginally elevated inflammatory markers and hormonal profile. She underwent colonoscopy and was diagnosed to have Crohn's disease confirmed by ileal biopsy. On initiation of treatment with immunosuppressants, she attained menarche, although no improvement in height was observed.

Pediatric IBD patients show medication and disease activity dependent changes in NK cell and CD4 memory T cell populations

Objectives

CD4+ memory T cells facilitate long-termed adaptive immune responses while NK cells are predominately rapid effector cells with significant functions for both intestinal homeostasis and inflammation. We wanted to study both populations in health and pediatric inflammatory bowel disease (IBD) and correlate them with disease activity and medication.

Methods

We performed flow cytometric analyses of peripheral blood CD4 + CD45RO+ memory T cells and CD3-CD16 + CD56+ NK cells in 30 patients with IBD and 31 age-matched controls and correlated percentages of subsets with disease activity (PUCAI/PCDAI) and medication.

Results

We found a significant reduction of peripheral NK cells in overall IBD patients with both clinical remission and disease activity, which was even more pronounced in patients treated with azathioprine. Otherwise, circulating CD4+ memory T cell populations were significantly enhanced in active IBD compared to controls. Enhancement of memory T cells was particularly found in new onset disease and correlated with disease activity scores.

Discussion

Our single center cohort confirms previous results showing enhanced memory T cell populations in pediatric IBD patients, which correlate with disease activity scores. CD4+ memory T cells are a relevant pathogenic leukocyte population for disease development and perpetuation in IBD. In addition, we found a decrease of NK cells in IBD patients, which was pronounced by use of azathioprine. Surveillance of both cellular populations could possibly serve as biomarker for therapy control in pediatric IBD.

Public Knowledge of Inflammatory Bowel Diseases in Saudi Arabia: A Cross-Sectional Survey Study

BACKGROUND

Lack of public understanding and perception may lead to a general downplaying of inflammatory bowel disorder (IBD) symptoms as they affect a less socially acceptable area of the body, which may be a significant component in the everyday struggles of an individual with IBD.

AIM

The aim is to assess the public knowledge of Crohn's disease and ulcerative colitis in Saudi Arabia.

METHOD

This was an online survey study that examined public knowledge of IBD in Saudi Arabia for the duration between February and March 2023. Participants were invited to participate in this study using social media websites. The questionnaire tool comprised three sections: a sociodemographic characteristics section (seven questions), an awareness section (two questions), and a knowledge section (24 questions). A binary logistic regression analysis was utilized to identify the factors that influenced the participants' knowledge of Crohn's disease and ulcerative colitis.

RESULTS

A total of 630 individuals participated in this study. Around 28% of the participants reported that they had never heard of, read about, or dealt with Crohn's disease. Around 16% of them reported that they had never heard of, read about, or dealt with ulcerative colitis. The mean overall knowledge score of the study participants was 8.3 (standard deviation: 2.4) out of 24, which is equal to 34.6% and represents a weak level of knowledge of IBD. The participants showed a weak level of knowledge for all sub-scales of knowledge related to IBD general knowledge, diet, treatments, and complications. The knowledge sub-scale level ranged between 30% and 36.7%. Females, the participants in the moderate and high-income category, those who lived in urban areas, those with a higher level of education, and those who reported having osteoarthritis were more likely to be knowledgeable about IBD compared to others (p≤0.001).

CONCLUSION

In Saudi Arabia, a low level of IBD awareness was identified among the general population, supporting findings from other countries. Future research should aim to identify effective educational interventions to increase public awareness of this group of diseases, which would ultimately facilitate early diagnosis and improve patient outcomes.

Clinical value of fecal calprotectin for evaluating disease activity in patients with Crohn's disease

Objective: To explore the clinical value of fecal calprotectin (FC) for evaluating disease activity in patients with Crohn's disease (CD) and its relationship with disease location. Methods: Patients with CD were enrolled retrospectively, and clinical data, including FC levels, were collected. Clinical activity was assessed using the Crohn's disease activity index (CDAI). Endoscopic activity was assessed using a simple endoscopic score for Crohn's disease (SES-CD). The partial SES-CD (pSES-CD) was scored for the size of ulcers in each segment as defined by the SES-CD and was calculated as the sum of segmental ulcer scores. Results: This study included 273 CD patients. The FC level was significantly positively correlated with the CDAI and SES-CD, with correlation coefficients of 0.666 and 0.674, respectively. The median FC levels in patients with clinical remission and mildly active and moderately-severely active disease were 41.01, 164.20, and 444.45 μg/g. These values were 26.94, 66.77, and 327.22 μg/g during endoscopic remission and mildly and moderately-severely active stages, respectively. Compared with c-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and other biomarker parameters, FC was better at predicting disease activity for CD patients. For an FC <74.52 μg/g, the area under the curve (AUC) for predicting clinical remission was 0.86, with a sensitivity of 89.47% and a specificity of 71.70%. Moreover, endoscopic remission was predicted with a sensitivity of 68.02% and a specificity of 85.53%. The AUC was 0.83, and the cutoff value was 80.84 μg/g. In patients with ileal and (ileo) colonic CD, FC was significantly correlated with the CDAI, SES-CD, and pSES-CD. The correlation coefficients were 0.711 (CDAI), 0.473 (SES-CD), and 0.369 (pSES-CD) in patients with ileal CD and 0.687, 0.745, and 0.714 in patients with (ileo) colonic CD, respectively. For patients in remission, those in the active stage, and those with large or very large ulcers, differences in FC levels were not significant between patients with ileal and (ileo) colonic CD. Conclusion: FC is a reliable predictor of disease activity in patients with CD, including those with ileal CD. FC is thus recommended for the routine follow-up of patients with CD.

Ocular Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic disease connected to the immune system, with a predilection for the gastrointestinal tract. However, a large proportion of the patients have extraintestinal manifestations (EIM), and the ocular system is affected in some patients. The clinical presentation of ocular pathology is broad, ranging from asymptomatic cases to blindness, leading to high morbidity. Ocular complications can be primary and, in general, are associated with episodes of acute flare-ups that subside with immunological management of the digestive disease. Secondary complications arise from the primary ones and as adverse effects of immunological treatment. In addition, on many occasions, the ocular manifestation may appear prior to the presentation of digestive symptoms. The presence of a multidisciplinary team that includes a gastroenterologist and an ophthalmologist is important in order to achieve early diagnosis of ocular complications, thereby preventing, treating, and avoiding unfavorable and irreversible long-term ocular sequelae.

Mucosal Healing and Clinical Efficacy of Adalimumab in Small Intestinal Crohn's Disease (SIMCHA Study): Final Results From a Prospective, Open-Label, Single-Arm Study

BACKGROUND

Endoscopic healing is a key treatment target in inflammatory bowel disease; few data are available on the clinical and endoscopic efficacy of biological therapy in upper gastrointestinal Crohn's disease. This study aimed to investigate small bowel mucosal healing and clinical efficacy of adalimumab therapy by video capsule endoscopy in patients with endoscopically active upper gastrointestinal Crohn's disease.

METHODS

This prospective, open-label, single-arm study included Crohn's disease patients with moderate-severe endoscopic proximal small bowel involvement, defined by a Lewis score >790. Patients were treated with adalimumab monotherapy for 24 weeks. Co-primary outcomes were endoscopic healing, defined as Lewis score <350, and endoscopic response, defined as >50% decrease in Lewis score. Secondary outcomes included clinical (Harvey-Bradshaw index <4) and biomarker remission (fecal calprotectin <250 μg/g, and C-reactive protein <5 mg/L).

RESULTS

A total of 59 Crohn's disease patients were screened; 17 patients have met eligibility criteria and were enrolled. Endoscopic healing was observed in 8 patients (47.1%) and endoscopic response in additional 5 patients (29.4%) at 24 weeks. Median Lewis score was significantly decreased compared to baseline (1912 vs. 337, P = .0005). Eleven of 13 patients (84.6%) with clinical activity achieved clinical remission (baseline: 13/17 vs. week 24: 2/17, P < .0001). Nine of 10 patients with elevated C-reactive protein achieved normal C-reactive protein after treatment and the median C-reactive protein significantly decreased from 7.4 to 1.6 mg/L, P = .032. In contrast, no change was observed in fecal calprotectin pre- and posttreatment.

CONCLUSIONS

Adalimumab induced endoscopic healing and clinical remission in patients with active small bowel Crohn's disease, with approximately half of the patients achieving endoscopic healing.

An Unusual Presentation of Primary B-cell Lymphoma of the Small Bowel in an Immunosuppressant-Naive Patient With Newly Diagnosed Crohn's Disease

Inflammatory bowel disease (IBD) consists of two primary conditions: ulcerative colitis (UC) and Crohn's disease (CD). UC primarily impacts the colon, leading to inflammation of the mucosal layer. Conversely, CD involves transmural inflammation and can affect any segment of the gastrointestinal tract, ranging from the oral cavity to the perianal region. Patients with CD can have symptoms for many years prior to diagnosis, or they may present acutely. We present the case of a 31-year-old male with a recent CD diagnosis and otherwise, no past medical history presenting with a week-long history of bilateral lower extremity swelling that started in the thighs and progressed downward, accompanied by a heavy sensation in the legs and intermittent numbness. Less than 24 hours into his hospital course, the patient experienced progressive bilateral numbness, saddle anesthesia, and urinary incontinence. Subsequently, the patient was taken for STAT MRI and emergent neurosurgery to alleviate the spinal cord compression and remove/biopsy a mass at the T6-T7 level that was later defined as a B-cell lymphoma. Our objectives are to describe the etiology of IBD complicated by lymphoma, to analyze the association between IBD and lymphoma, and to investigate the role that immunosuppressants play in the development of lymphoma from IBD, which we achieve through retrospective case analysis and associated literature review on symptom constellation. There is good evidence that malignant lymphoma of the bowel is a rare but significant complication of IBD in immunosuppressant-naive patients, apparently being more common in chronic UC. We suggest increased surveillance for this disease in immunosuppressant-naive patients, as the prognosis of lymphoma depends on the time of diagnosis.

Impact of Anti-CD20 therapies on the immune homeostasis of gastrointestinal mucosa and their relationship with de novo intestinal bowel disease in multiple sclerosis: a review

Multiple sclerosis (MS) and inflammatory bowel disease (IBD) are autoimmune disorders characterized by inflammatory episodes affecting the brain and the gastrointestinal (GI) tract, respectively. The frequent association between MS and IBD suggests that both conditions may share common pathogenic mechanisms. However, different responses to biological therapies indicate differences in immune mechanisms of inflammation. Anti-CD20 therapies are high efficacy treatments increasingly used to control inflammatory bursts in MS, but they may alter GI homeostasis and promote the development of bowel inflammation in susceptible individuals. This review analyzes the mechanistic association between immunity in MS and IBD, the effect of anti-CD20 therapies on the gut microenvironment, and provides recommendations for early detection and management of GI toxicities in the context of B-cell depletion in MS patients.

Identification of CD8 + T-Cell-Immune Cell Communications in Ileal Crohn's Disease

INTRODUCTION

Crohn's disease (CD) is a major subtype of inflammatory bowel disease (IBD), a spectrum of chronic intestinal disorders caused by dysregulated immune responses to gut microbiota. Although transcriptional and functional changes in a number of immune cell types have been implicated in the pathogenesis of IBD, the cellular interactions and signals that drive these changes have been less well-studied.

METHODS

We performed Cellular Indexing of Transcriptomes and Epitopes by sequencing on peripheral blood, colon, and ileal immune cells derived from healthy subjects and patients with CD. We applied a previously published computational approach, NicheNet, to predict immune cell types interacting with CD8 + T-cell subsets, revealing putative ligand-receptor pairs and key transcriptional changes downstream of these cell-cell communications.

RESULTS

As a number of recent studies have revealed a potential role for CD8 + T-cell subsets in the pathogenesis of IBD, we focused our analyses on identifying the interactions of CD8 + T-cell subsets with other immune cells in the intestinal tissue microenvironment. We identified ligands and signaling pathways that have implicated in IBD, such as interleukin-1β, supporting the validity of the approach, along with unexpected ligands, such as granzyme B, which may play previously unappreciated roles in IBD.

DISCUSSION

Overall, these findings suggest that future efforts focused on elucidating cell-cell communications among immune and nonimmune cell types may further our understanding of IBD pathogenesis.

[Imaging Techniques and Differential Diagnosis for Inflammatory Bowel Disease]

The two main types of inflammatory bowel disease (IBD) are Crohn's disease and ulcerative colitis. Currently, when IBD is suspected, CT enterography is widely used as an initial imaging test because it can evaluate both the bowel wall and the outside of the bowel, helping to differentiate IBD from other diseases. When IBD is suspected, it is necessary to distinguish between Crohn's disease and ulcerative colitis. In most cases this is not difficult; however, in some cases, it is difficult and such cases are called IBD-unclassified. CT findings are often non-specific for ulcerative colitis, making it difficult to differentiate it from other diseases using imaging alone. In contrast, characteristic CT findings for Crohn's disease are often helpful in diagnosis, although diseases, such as tuberculous enteritis can mimic Crohn's disease. Recently, mutations in the gene encoding a prostaglandin transporter called SLCO2A1 have been discovered as the cause of the disease in some patients with multiple ulcers and strictures, similar to Crohn's disease. Therefore, genetic testing is being used to make a differential diagnosis.

Rare Oral Crohn's Disease: A Case Report

Crohn's disease is an inflammatory granulomatous and chronic disease characterized by inflammation of the gastrointestinal mucosa with extra-intestinal manifestations. Oral lesions seem to occur as specific lesions like lip swelling, cobblestone or tag lesions, or nonspecific lesions like ulcers. The present case report describes an orofacial Crohn's disease case, a rare presentation of Crohn's disease, managed with infliximab. Oral Crohn's disease refers to the spread of manifestations of Crohn's disease and could precede other signs. Physicians have to be aware of oral mucosal changes. The treatment options are based on the use of corticosteroids, immune-modulators and biologics. The best plan and therapy to control oral Crohn's disease requires early and precise diagnosis.

[Perianal Fistula: An Overview]

Perianal fistula is a common inflammatory condition in the general population and affects the area around the anal canal. Although most cases are benign, they cause serious morbidity and require surgical treatment due to a high risk of recurrence. MR imaging is a gold standard technique for the evaluation of perianal fistulas and provides accurate information on the anatomy of the anal canal, its relationship to the anal sphincter complex, accurate identification of secondary tracts or abscesses, and reporting associated complications. MR imaging can help monitor treatment effects and determine treatment methods. Crohn's disease-related fistulas often require medical rather than surgical treatment. The radiologist is required to know the anatomy and MR imaging findings of the perianal fistula to present an accurate diagnosis to the clinician.

Interleukin-4 Gene Polymorphisms in Romanian Patients with Inflammatory Bowel Diseases: Association with Disease Risk and Clinical Features

1.

INTRODUCTION

Multiple cytokines have been studied for their role in the propagation of the inflammatory process related to inflammatory bowel diseases (IBD), but the role of interleukin-4 remains controversial. The aim of this study was to evaluate the role of two IL-4 gene single nucleotide polymorphisms (SNPs) in disease susceptibility and phenotypic expression. 2.

MATERIALS AND METHODS

A group of 160 patients with IBD (86CD/74UC) and 160 healthy controls were genotyped for IL-4 rs2243250/-590C/T and rs2070874/-34C/T using real-time polymerase chain reaction with TaqMan assay. 3.

RESULTS

The analysis of IBD patients and controls revealed a significantly reduced frequency of the minor allele T of both SNPs in CD patients (p = 0.03, OR 0.55 and p = 0.02, OR 0.52) and for the entire IBD group (p = 0.01, OR 0.57 and p = 0.01, OR 0.55). Haplotype analysis identified the most frequent haplotype (rs2243250/rs2070874 CC) associated with a high risk for developing IBD (either UC or CD) (p = 0.003). IBD patients with extraintestinal manifestations had significantly increased frequency of the minor alleles T. We also found an association between the presence of allele C of rs2070874 and response to antiTNF treatment. 4.

CONCLUSIONS

This is the first study to investigate the IL-4 gene's relation to IBD susceptibility conducted in Romania. Both SNPs were found to be associated with disease susceptibility and phenotypic features, such as extraintestinal manifestations and response to antiTNF agents.

Basidiobolomycosis Mimicking Fistulizing Crohn's Disease: A Case Report From Saudi Arabia

Gastrointestinal basidiobolomycosis (GIB) is a rare, emerging fungal infection caused by Basidiobolus ranarum, which requires a high index of clinical suspicion for early diagnosis and management. It is prevalent in hot and humid regions, and its clinical manifestations may mimic inflammatory bowel disease (IBD), malignancy, and tuberculosis (TB). This often results in the disease being missed or incorrectly diagnosed. We present the case of a 58-year-old female patient from the southern region of Saudi Arabia who presented with persistent non-bloody diarrhea for four weeks and was found to have GIB. This condition is associated with significant morbidity and mortality if not diagnosed and treated in a timely manner. The optimal therapeutic strategy for managing this rare infection has not yet been established. Most patients described in the literature have received a combination of pharmaceutical and surgical therapy. Including GIB in the differential diagnosis of gastrointestinal disorders that do not fit the diagnosis may help with its early diagnosis and management.