Pre-Diagnosis Diet Predicts Response to Exclusive Enteral Nutrition and Correlates with Microbiome in Pediatric Crohn Disease

Exclusive enteral nutrition (EEN) is effective in inducing remission in pediatric Crohn disease (CD). EEN alters the intestinal microbiome, but precise mechanisms are unknown. We hypothesized that pre-diagnosis diet establishes a baseline gut microbiome, which then mediates response to EEN. We analyzed prospectively recorded food frequency questionnaires (FFQs) for pre-diagnosis dietary patterns. Fecal microbiota were sequenced (16SrRNA) at baseline and through an 18-month follow-up period. Dietary patterns, Mediterranean diet adherence, and stool microbiota were associated with EEN treatment outcomes, disease flare, need for anti-tumor necrosis factor (TNF)-α therapy, and long-term clinical outcomes. Ninety-eight patients were included. Baseline disease severity and microbiota were associated with diet. Four dietary patterns were identified by FFQs; a "mature diet" high in fruits, vegetables, and fish was linked to increased baseline microbial diversity, which was associated with fewer disease flares (p < 0.05) and a trend towards a delayed need for anti-TNF therapy (p = 0.086). Baseline stool microbial taxa were increased (Blautia and Faecalibacterium) or decreased (Ruminococcus gnavus group) with the mature diet compared to other diets. Surprisingly, a "pre-packaged" dietary pattern (rich in processed foods) was associated with delayed flares in males (p < 0.05). Long-term pre-diagnosis diet was associated with outcomes of EEN therapy in pediatric CD; diet-microbiota and microbiota-outcome associations may mediate this relationship.

Letting go of control: A qualitative descriptive study exploring parents' perspectives on their child's transition from pediatric to adult care for inflammatory bowel disease

Parents of young adults with chronic disease are important stakeholders in their child's transition from pediatric to adult care. There remains a gap in characterizing the parent experience during transition. This study describes the experiences of 13 mothers of young adults with inflammatory bowel disease during their child's transition. Most parents expressed fear and sadness about their child transitioning. Themes relating to involvement in their child's adult care included: direct involvement (sub-themes: disease management; logistics of care); and indirect involvement. Reasons for involvement included themes of parent's feelings and child's circumstances. Themes of involvement were discussed in terms of previous research on parenting of children with chronic disease. We suggest that future efforts focus on improving empathy and understanding toward parents of transitioning children and providing resources on how they can best support their child during transition and transfer to adult care.

Dichotomous effect of dietary fiber in pediatrics: a narrative review of the health benefits and tolerance of fiber

Dietary fibers are associated with favorable gastrointestinal, immune, and metabolic health outcomes when consumed at sufficient levels. Despite the well-described benefits of dietary fibers, children and adolescents continue to fall short of daily recommended levels. This gap in fiber intake (i.e., "fiber gap") might increase the risk of developing early-onset pediatric obesity and obesity-related comorbidities such as type 2 diabetes mellitus into adulthood. The structure-dependent physicochemical properties of dietary fiber are diverse. Differences in solubility, viscosity, water-holding capacity, binding capability, bulking effect, and fermentability influence the physiological effects of dietary fibers that aid in regulating appetite, glycemic and lipidemic responses, and inflammation. Of growing interest is the fermentation of fibers by the gut microbiota, which yields both beneficial and less favorable end-products such as short-chain fatty acids (e.g., acetate, propionate, and butyrate) that impart metabolic and immunomodulatory properties, and gases (e.g., hydrogen, carbon dioxide, and methane) that cause gastrointestinal symptoms, respectively. This narrative review summarizes (1) the implications of fibers on the gut microbiota and the pathophysiology of pediatric obesity, (2) some factors that potentially contribute to the fiber gap with an emphasis on undesirable gastrointestinal symptoms, (3) some methods to alleviate fiber-induced symptoms, and (4) the therapeutic potential of whole foods and commonly marketed fiber supplements for improved health in pediatric obesity.

Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study

AIM

To assess contemporary outcomes in children with acute severe ulcerative colitis [ASUC] at initial presentation.

METHODS

Between April 2014 and January 2019, children aged <17 years, with new onset ASUC (Paediatric Ulcerative Colitis Activity Index [PUCAI ≥65) were prospectively followed in a Canadian inception cohort study. 16S rRNA amplicon sequencing captured microbial composition of baseline faecal samples. Primary endpoint was corticosteroid-free clinical remission with intact colon at 1 year [PUCAI <10, no steroids ≥4 weeks].

RESULTS

Of 379 children with new onset UC/IBD-unclassified, 105 [28%] presented with ASUC (42% male; median [interquartile range; [IQR]) age 14 [11-16] years; extensive colitis in all). Compared with mild UC, gut microbiome of ASUC patients had lower α-diversity, decreased beneficial anaerobes, and increased aerobes; 54 [51%] children were steroid-refractory and given infliximab [87% intensified regimen]. Corticosteroid-free remission at 1 year was achieved by 62 [61%] ASUC cohort (by 34 [63%] steroid-refractory patients, all on biologics; by 28 [55%] steroid responders,13 [25%] on 5- aminosalicylic acid [5-ASA], 5 [10%] on thiopurines, 10 [20%] on biologics). By 1 year, 78 [74%] escalated to infliximab including 24 [47%] steroid-responders failed by 5-ASA and/or thiopurines. In multivariable analysis, clinical predictors for commencing infliximab included hypoalbuminaemia, greater PUCAI, higher age, and male sex. Over 18 months, repeat corticosteroid course[s] and repeat hospitalisation were less likely among steroid-refractory versus -responsive but -dependent patients (adjusted odds ratio [aOR] 0.71 [95% CI 0.57-0.89] and 0.54 [95% CI 0.45-0.66], respectively).

CONCLUSION

The majority of children presenting with ASUC escalate therapy to biologics. Predictors of need for advanced therapy may guide selection of optimal maintenance therapy.

Precision nutrition in pediatric IBD: A position paper from the ESPGHAN special interest group for basic science and translational research, the IBD Porto group, and allied health professionals

Stratified and precision nutrition refers to disease management or prevention of disease onset, based on dietary interventions tailored to a person's characteristics, biology, gut microbiome, and environmental exposures. Such treatment models may lead to more effective management of inflammatory bowel disease (IBD) and reduce risk of disease development. This societal position paper aimed to report advances made in stratified and precision nutritional therapy in IBD. Following a structured literature search, limited to human studies, we identified four relevant themes: (a) nutritional epidemiology for risk prediction of IBD development, (b) food-based dietary interventions in IBD, (c) exclusive enteral nutrition (EEN) for Crohn's disease (CD) management, and (d) pre- and probiotics for IBD management. There is scarce literature upon which we can make recommendations for precision or stratified dietary therapy for IBD, both for risk of disease development and disease management. Certain single-nucleotide polymorphisms related to polyunsaturated fatty acid (PUFA) metabolism may modify the effect dietary PUFA have in increasing the risk of IBD development. Non-colonic CD, mild-to-moderate CD, and high microbiota richness may predict success of EEN and may be used both for prediction of treatment continuation, but also for early cessation in nonresponders. There is currently insufficient evidence to make recommendations for precision or stratified dietary therapy for patients with established IBD. Despite the great interest in stratified and precision nutrition, we currently lack data to support conclusive recommendations. Replication of early findings by independent research groups and within structured clinical interventions is required.

The Crohn's Disease Exclusion Diet: A Comprehensive Review of Evidence, Implementation Strategies, Practical Guidance, and Future Directions

Dietary therapy is increasingly recognized for the management of Crohn's disease (CD) over recent years, including the use of exclusive enteral nutrition (EEN) as first-line therapy for pediatric CD according to current guidelines. The Crohn's disease exclusion diet (CDED) is a whole-food diet designed to reduce exposure to dietary components that are potentially pro-inflammatory, mediated by negative effects on the gut microbiota, immune response, and the intestinal barrier. The CDED has emerged as a valid alternative to EEN with cumulative evidence, including randomized controlled trials, supporting use for induction of remission and possibly maintenance in children and adults. We gathered a group of multidisciplinary experts, including pediatric and adult gastroenterologists, inflammatory bowel diseases (IBD) expert dietitians, and a psychologist to discuss the evidence, identify gaps, and provide insights into improving the use of CDED based on a comprehensive review of CDED literature and professional experience. This article reviews the management of CDED in both children and adults, long-term aspects of CDED, indications and contraindications, selecting the best candidates, identifying challenges with CDED, globalization, the role of the multidisciplinary team, especially of dietitian, and future directions. We concluded that CDED is an established dietary therapy that could serve as an alternative to EEN in many pediatric and adult cases, especially with mild to moderate disease. In severe disease, complicated phenotypes, or with extraintestinal involvement, CDED should be considered on a case-by-case basis, according to physician and dietitians' discretion. More studies are warranted to assess the efficacy of CDED in different scenarios.

Inflammatory Bowel Disease Among Canadian Children: Comparison Between Children of Non-European Descent and Children of European Descent

BACKGROUND

Inflammatory bowel disease (IBD) phenotypes may differ between countries and ancestral groups. The study aim was to examine ancestry and subtype variations of children newly diagnosed with IBD.

METHODS

Children newly diagnosed with IBD enrolled into the Canadian Children Inflammatory Bowel Disease Network inception cohort study were categorized into 8 ancestral groups. Prospectively collected data at diagnosis and follow-up were compared between ancestral groups.

RESULTS

Among 1447 children (63.2% Crohn's disease, 30.7% ulcerative colitis), 67.8% were European, 9.4% were South Asian, 3.8% were West Central Asian and Middle Eastern, 2.3% were African, 2.2% were East/South East Asian, 2.0% were Caribbean/Latin/Central/South American, 9.9% were mixed, and 2.6% were other. Children of African descent with ulcerative colitis had an older age of diagnosis compared with children of European descent (median 15.6 years vs 13.3 years; P = .02). Children of European descent had a higher proportion of positive family history with IBD (19.3% vs 12.1%; P = .001) compared with children of non-European descent. Children of European descent also had a lower proportion of immigrants and children of immigrants compared with children of non-European descent (9.8% vs 35.9%; P < .0001; and 3.6% vs 27.2%; P < .0001, respectively) .

CONCLUSIONS

Important differences exist between different ancestral groups in pediatric patients with IBD with regard to age of diagnosis, family history, and immigrant status. Our study adds to the knowledge of the impact of ancestry on IBD pathogenesis.

A Potential Role for Gut Microbes in Mediating Effects of Omega-3 Fatty Acids in Inflammatory Bowel Diseases: A Comprehensive Review

Omega-3 polyunsaturated fatty acids (ω-3 PUFAs) have been associated with several inflammatory conditions, including inflammatory bowel diseases (IBDs), and found to have an impact on gut microbiota. In fact, some randomized controlled studies suggest benefits to IBD patients, but others do not. Our aim was to review recent evidence on the effects of omega-3 on IBD and establish the contribution of the gut microbiome. Omega-3 mediate anti-inflammatory effects in IBD through various mechanisms, including suppression of NLR family pyrin domain-containing 3 (NLRP3) inflammasome, Toll-like receptor-4 (TLR4), and nucleotide-binding oligomerization domain 2 (NOD2) signaling; this results in the repression of the nuclear factor-kappa B (Nf-kB) pathway and the secretion of pro-inflammatory cytokines. Omega-3 can also affect gut microbiota and revert the bacterial community to patterns associated with healthy status by increasing short-chain fatty acid (SCFA)-producing bacteria and enhancing the mucosal gut barrier, thus promoting homeostasis. The combination of these immunoregulatory effects and anti-inflammation properties with the promotion of a balanced gut microbiome environment could suggest that omega-3 might benefit IBD patients. Considering the microbiota of IBD patients while using omega-3 might predict and improve omega-3 effectiveness. Combining omega-3 with bacteria-altering therapy, such as probiotics and fecal microbiota transplantation, may further enhance its efficacy; however, further studies are required to elucidate mechanisms and potential preventive or treatment roles of omega-3 in IBD.

ADALIMUMAB VERSUS INFLIXIMAB IN LUMINAL PEDIATRIC CROHN'S DISEASE: COMPARABLE OUTCOMES IN A PROSPECTIVE MULTICENTER COHORT STUDY

BACKGROUND

This study compared real-world effectiveness between adalimumab (ADA) and infliximab (IFX) in children with Crohn's disease (CD).

METHODS

Children enrolled into the prospective Canadian Children Inflammatory Bowel Disease Network (CIDsCaNN) National Inception Cohort between 2014 and 2020 who commenced ADA or IFX as first anti-tumor necrosis factor (antiTNF) agent for luminal CD were included. Multivariate logistic regression modelled the propensity of commencing ADA; propensity score matching was used to match IFX-treated children to ADA-treated children. The primary outcome at one year was steroid-free clinical remission (SFCR). Secondary outcomes at one year were I) combined SFCR and c-reactive protein (CRP) remission; II) treatment intensification; and III) antiTNF durability. Odds ratios (aOR) and hazard ratio (aHR) adjusted for concomitant immunomodulator use with 95% confidence interval (CI) are reported.

RESULTS

In the propensity score matched cohort of 147 ADA-treated and 147 IFX-treated children, 92 (63%) ADA- and 87 (59%) IFX-treated children achieved SFCR at one year (aOR: 1.4, 95% CI 0.9-2.4); 75 of 140 (54%) ADA- and 85 of 144 (59%) IFX-treated children achieved combined SFCR and CRP remission (aOR: 1.0, 95% CI 0.6-1.6). ADA-treated children less frequently underwent treatment intensification (21 [14%]) compared to IFX-treated children (69 [47%]) (P<0.0001). Discontinuation of antiTNF occurred in 18 (12%) ADA-treated and 15 (10%) IFX-treated children (aHR: 1.2, 95% CI 0.6-2.2).

CONCLUSION

Children with Crohn's disease achieved favourable outcomes at one year with either ADA or IFX as first antiTNF agents. Those receiving IFX did not have significantly superior outcomes compared to clinically similar children receiving ADA.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Special Populations-Children and Adolescents with IBD

Rates of inflammatory bowel disease (IBD) in Canadian children and adolescents are among the highest in the world, and the incidence is rising most rapidly in children under five years of age. These young children may have either a typical form of IBD with multi-factorial aetiology, or they may have a monogenic form. Despite the growing number of children in Canada living with this important chronic disease, there are few available medical therapies approved by Health Canada due to the omission of children from most clinical trials of newly developed biologics. As a result, off-label use of medications is common, and physicians have learned to use existing therapies more effectively. In addition, most Canadian children are treated in multidisciplinary, specialty clinics by physicians with extra training or experience in IBD, as well as specialist nurses, dietitians, mental health care providers and other allied health professionals. This specialized clinic approach has facilitated cutting edge research, led by Canadian clinicians and scientists, to understand the causes of IBD, the optimal use of therapies, and the best ways to treat children from a biopsychosocial perspective. Canadians are engaged in work to understand the monogenic causes of IBD; the interaction between genes, the environment, and the microbiome; and how to address the mental health concerns and medical needs of adolescents and young adults transitioning from paediatric to adult care.

Use of fiber-containing enteral formula in pediatric clinical practice: an expert opinion review

INTRODUCTION

Children who require enteral nutrition often report gastrointestinal symptoms. There is a growing interest in nutrition formulas that meet nutritional requirements and also maintain gut ecology and function. Fiber-containing enteral formulas can improve bowel function, promote the growth of healthy gut microbiota, and improve immune homeostasis. Nonetheless, guidance in clinical practice is lacking.

AREAS COVERED

This expert opinion article summarizes the available literature and collects the opinion of eight experts on the importance and use of fiber-containing enteral formulas in pediatrics. The present review was supported by a bibliographical literature search on Medline via PubMed to collect the most relevant articles.

EXPERT OPINION

The current evidence supports using fibers in enteral formulas as first-line nutrition therapy. Dietary fibers should be considered for all patients receiving enteral nutrition and can be slowly introduced from six months of age. Fiber properties that define the functional/physiological properties of the fiber must be considered. Clinicians should balance the dose of fiber with tolerability and feasibility. Introducing fiber-containing enteral formulas should be considered when initiating tube feeding. Dietary fiber should be introduced gradually, especially in fiber-naïve children, with an individualized symptom-based approach. Patients should continue with the fiber-containing enteral formulas they tolerate best.

Transition Readiness in Youth with Inflammatory Bowel Disease

OBJECTIVES

To examine readiness of adolescents and young adults (AYAs) with inflammatory bowel disease (IBD) to transition to adult care.

STUDY DESIGN

A cross-sectional multicenter study evaluating transition readiness in individuals with IBD 16-19 years old prospectively recruited from 8 Canadian IBD centers using the validated ON Taking Responsibility for Adolescent to Adult Care (ON TRAC) questionnaire. Secondary aims included (1) screening for depression and anxiety using the 8-item Personal Health Questionnaire Depression Scale and The Screen for Child Anxiety Related Emotional Disorders questionnaires, respectively; (2) evaluating the association between depression and anxiety with readiness and disease activity; and (3) subjectively evaluating AYA readiness based on physician and parent assessments.

RESULTS

In total, 186 participants (139 adolescent, 47 young adult) were enrolled, mean age 17.4 years (SD, 0.87). ON TRAC scores determined that 26.6% of AYAs at pediatric and 40.4% at adult centers reached the threshold of readiness. On multivariable linear regression analysis age was positively (P = .001) and disease remission negatively (P = .03) associated with ON TRAC scores. No statistically significant differences were determined across centers. A significant percentage of AYAs reported moderate-to-severe depression (21.7%) and generalized anxiety (36%); however, neither were significantly associated with ON TRAC scores. Notably, physician and parental assessment of AYA readiness correlated poorly with ON TRAC scores (⍴ = 0.11, ⍴ = 0.24, respectively).

CONCLUSIONS

Assessment of transition readiness in AYAs with IBD highlighted that a large proportion do not have adequate knowledge or behavior skills needed for transition to adult care. This study infers that readiness assessment tools are essential during transition to identify deficits in knowledge and behavior skills that could be specifically targeted by the youth, caregivers, and multidisciplinary team.

Novel Biomarkers for Inflammatory Bowel Disease and Colorectal Cancer: An Interplay between Metabolic Dysregulation and Excessive Inflammation

Persistent inflammation can trigger altered epigenetic, inflammatory, and bioenergetic states. Inflammatory bowel disease (IBD) is an idiopathic disease characterized by chronic inflammation of the gastrointestinal tract, with evidence of subsequent metabolic syndrome disorder. Studies have demonstrated that as many as 42% of patients with ulcerative colitis (UC) who are found to have high-grade dysplasia, either already had colorectal cancer (CRC) or develop it within a short time. The presence of low-grade dysplasia is also predictive of CRC. Many signaling pathways are shared among IBD and CRC, including cell survival, cell proliferation, angiogenesis, and inflammatory signaling pathways. Current IBD therapeutics target a small subset of molecular drivers of IBD, with many focused on the inflammatory aspect of the pathways. Thus, there is a great need to identify biomarkers of both IBD and CRC, that can be predictive of therapeutic efficacy, disease severity, and predisposition to CRC. In this study, we explored the changes in biomarkers specific for inflammatory, metabolic, and proliferative pathways, to help determine the relevance to both IBD and CRC. Our analysis demonstrated, for the first time in IBD, the loss of the tumor suppressor protein Ras associated family protein 1A (RASSF1A), via epigenetic changes, the hyperactivation of the obligate kinase of the NOD2 pathogen recognition receptor (receptor interacting protein kinase 2 [RIPK2]), the loss of activation of the metabolic kinase, AMP activated protein kinase (AMPKα1), and, lastly, the activation of the transcription factor and kinase Yes associated protein (YAP) kinase, that is involved in proliferation of cells. The expression and activation status of these four elements are mirrored in IBD, CRC, and IBD-CRC patients and, importantly, in matched blood and biopsy samples. The latter would suggest that biomarker analysis can be performed non-invasively, to understand IBD and CRC, without the need for invasive and costly endoscopic analysis. This study, for the first time, illustrates the need to understand IBD or CRC beyond an inflammatory perspective and the value of therapeutics directed to reset altered proliferative and metabolic states within the colon. The use of such therapeutics may truly drive patients into remission.

A164 IDENTIFYING THE MOST IMPORTANT PREDICTORS TO CORRELATE SERUM METABOLITES WITH MRE CHANGES IN PATIENTS WITH PEDIATRIC CROHN DISEASE

Background

Endoscopy has been the gold standard for assessing activity in Pediatric Crohn disease (pCD); however, it is limited by its invasiveness and partial assessment of small intestine and transmural inflammation. To that end, the Pediatric Inflammatory Crohn's MRE Index (PICMI) is a valid, reliable, non-invasive, and responsive index that includes transmural inflammation when assessing disease activity.

The pathogenesis of pCD remains poorly understood, but evidence suggests that endogenous metabolites produced in the intestinal tract might mediate pathogenesis. Despite the important applicability of metabolomics in increasing the understanding of pCD, there has been limited research on this topic.

Purpose

Serum metabolomic profiles are linked to disease activity in pediatric Crohn disease.

Method

ImageKids is a multicenter, prospective, observational cohort study, designed to develop PICMI for pCD. The study was conducted over 18 months with paired serum specimens collected at study initiation and completion for 56 pCD patients. Due to the long time between the visits and the fact that during the study variables that highly affect serum metabolites were not controlled, we considered each patient visit as an individual measure point. Metabolites were identified using a quantitative metabolomics approach through The Metabolomics Innovation Centre (TMIC; University of Alberta). Disease activity was determined by the cutoff values in the total PICMI score of each patient.

The most relevant serum metabolites were identified by medium-level and high-level variable selection analysis. Pearson correlation and hypothesis testing were used to select important metabolites. Decision trees, regularization techniques, and support vector machines were used to assess explicit importance of metabolites in disease activity.

Result(s)

This work provides a strategy to reduce a dimensional dataset from a metabolomic experiment. By medium-level selection analysis we were able to identify 117 statistical important metabolites for disease activity. The high-level selection analysis allowed to indicate the importance of the top 10 metabolites trough disease activity (defined by PICMI index). Results, also show that the evaluation of importance of metabolites through multivariate statistical models is dependent of the intrinsic variable selection model.

Figure 1 reveals that Tryptophan ranked highest in the feature importance scoring. Histidine, Methylhistidine, Citric acid, Isoleucine, and Decanoylcarnitine also correlated well with disease severity.

Image

Conclusion(s)

This work uses a unique approach of multivariate statistical analyses, to identify metabolites associated with pCD disease activity. Tryptophan has been previously identified as significantly altered in the blood of IBD patients compared to controls. Histidine is known to be involved in the mediation of oxidative stress, potentially influencing intestinal inflammation. These metabolites could serve as biomarkers and help define pCD pathogenesis.

Disclosure of Interest

None Declared

A14 TRANSABDOMINAL BOWEL ULTRASOUND AND CLINICAL OUTCOMES OVER ONE YEAR IN CHILDREN WITH NEWLY DIAGNOSED CROHN’S DISEASE

Background

Transabdominal bowel ultrasound (TABUS) is an emerging non-invasive tool for monitoring inflammatory bowel disease (IBD). Its use is particularly increasing in pediatric IBD, given the need for anesthesia during endoscopy. The assessment of TABUS in pediatric IBD has been limited to small numbers of patients with no long-term follow-up.

Purpose

To describe TABUS findings and its relationship with clinical, biochemical, and endoscopic assessments in pediatric patients with Crohn’s disease up to one year post-diagnosis.

Method

Patients (0-18 years) with suspected IBD were prospectively enrolled through the Edmonton Pediatric IBD Clinic. Those with Crohn’s disease were included. Patients underwent repeated TABUS, clinical assessments, blood work, fecal calprotectin (FCP) (baseline, 1-, 3-, 6-, 12-months), and endoscopy (baseline and 6-12 months). The weighted Pediatric Crohn’s Disease Activity Index (wPCDAI), Simple Endoscopic Score for Crohn’s Disease (SES-CD; rectum excluded), and Simple Ultrasound Activity Score for Crohn’s Disease (SUS-CD; rectum excluded) were used. Remission was defined as FCP&lt;250mg/kg, CRP&lt;4mg/L, wPCDAI&lt;12, no upcoming surgery, and SES-CD score ≤2 for any bowel segment.

Result(s)

Fifty-six patients (68% male), median age 12.5 years (range 6-17), were followed for 6 months. Forty (71%) were followed up to 12 months. Median TABUS bowel wall thickness (BWT) and SUS-CD total scores improved in all bowel segments over time. SUS-CD total scores significantly correlated with SES-CD (baseline, 6-, 12-months), wPCDAI (baseline, 1-, 6-, 12-months), CRP (baseline, 1-, 3-, 6-months), ESR (baseline, 1-, 3-, 6-, 12-months), and FCP (baseline, 1-, 6-, 12-months) (rho ranged 0.302-0.732, p&lt;0.05). Patients in remission had sustained significantly thinner BWT of their most affected bowel segment (Figure 1) starting at 1-month (median 3.1mm (IQR 2.7-3.7) vs. 4.1mm (IQR 2.9-5.6; p&lt;0.05), and sustained significantly lower SUS-CD total scores starting at 6 months (median 0 (IQR 0-1) vs. median 2 (IQR 1-3); p&lt;0.05). Seven patients had surgery (n=7/7 ileocecal, n=2/7 jejunal resection). All 7 patients had complex TI disease (n=6 strictures, n=1 long-segment disease &gt;25cm) and proximal small bowel disease (n=2/2) on TABUS. Those with baseline ultrasound findings of a stricture with upstream bowel dilatation (n=7/56) had increased odds (OR=288, p&lt;0.01) and relative risk (RR=42, p&lt;0.01) of needing surgery (n=6/7 with baseline obstructive findings, n=1/49 without) within the first year.

Image

Conclusion(s)

TABUS had significant correlations with clinical, biochemical, and endoscopic markers of Crohn’s disease activity in pediatric patients over one year. Bowel wall thickness of the most affected bowel segment is a helpful measurement, becoming significantly thinner as soon as 1-month post-diagnosis in those who obtain remission. Baseline findings of bowel narrowing and upstream dilation increase the odds and relative risk of needing surgery in the first year.

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None

Disclosure of Interest

None Declared

A50 THE EFFECTS OF SHORT-CHAIN FATTY ACIDS ON EPITHELIAL AND MACROPHAGE RESPONSE TO BACTEROIDES FRAGILIS

Background

Patients with IBD have an altered microbiome and gut microenvironment leading to changes in their Short-Chain Fatty Acid (SCFA) profile. Pathobionts are commensal organisms that become pathogenic under specific conditions, likely related to microenvironmental gut changes. This is especially relevant to children given that early life exposures are critical to microbiome development and impact immune response.

Purpose

The objectives of our study were to: 1) determine if microbes from IBD patients are more proinflammatory compared to non-IBD microbes; and 2) define how SCFAs affect host-response to potential pathobionts.

Method

Fructooligosaccharide (FOS) fermentation and SCFA production were assessed by HPLC-RID using whole-intestinal microbe culture collected as mucosal washes from pIBD (n=10) and non-IBD patients (n=8). Individual anaerobic bacteria were isolated from individual patients and screened for proinflammatory response [interleukin (IL)-1ß] using THP-1 macrophages. Caco-2 (epithelial) or THP-1 cells were pre-exposed to individual SCFAs (50 mM acetate or formate; 10 mM succinate; or 1 mM butyrate or propionate), then infected with Bacteroides fragilis, isolated from patients. Microscopy (bacterial staining with HEMA 3), qPCR, ELISA, TransEpithelial Electrical Resistance (TEER), and culturing were used to determine invasion potential, cytokine expression, barrier, and secretion.

Result(s)

FOS fermentation by microbes from IBD patients led to increased acetate and decreased butyrate production. Microbes from IBD patients were more proinflammatory, with increased IL-1ß secretion and reactive oxygen species generation, compared to those from non-IBD patients. B. fragilis isolated from an IBD patient was found to be a potential pathobiont with increased invasion and cytokine production in both epithelial and macrophage cells. Invasion was further increased when cells were exposed to SCFAs, particularly acetate and butyrate. Furthermore, the strain isolated from the IBD patient was observed (by microscopy) to be more adherent to the epithelial barrier, causing a loss of membrane integrity (TEER). The inflammasome pathway were significantly upregulated in Caco-2 cells infected with IBD-isolated B. fragilis and incubated with acetate or butyrate.

Conclusion(s)

The altered microbiome in IBD patients leads to an increased acetate and decreased butyrate, which likely affects host response to microbes and promotes inflammation. This changed microenvironment promotes the development of pathobionts, such as the identified B. fragilis strain we isolated from an IBD patient. The observation that acetate and butyrate increased host susceptibility to this strain indicates that understanding diet and SCFA production are instrumental in treating chronic conditions such as IBD. The role of diet as both a treatment and potential cause of inflammation in IBD is becoming more apparent; therefore, it is crucial that we understand the complex role diet has in host-microbe interactions.

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CIHR, Other

Please indicate your source of funding;

Mitacs- Weston Foundation

Disclosure of Interest

None Declared

A187 DIETARY FIBERS ELICIT GUT IMMUNE AND EPITHELIAL BARRIER MODIFYING EFFECTS IN INFLAMMATORY BOWEL DISEASES BASED ON FOOD SOURCE AND FIBER CHEMICAL FEATURES

Background

Dietary fibers are not digested in the bowel; they are fermented by microbes, typically promoting gut health. However, IBD patients experience sensitivity to consumption of fibers. Our previous findings offered the first mechanistic evidence demonstrating that unfermented dietary β-fructans (inulin and oligofructose) can induce pro-inflammatory cytokines and altered epithelial barrier integrity in a subset of pediatric IBD colonic biopsies cultured ex vivo, and in the SYNERGY-1 (β-fructan) clinical study of adult remission UC patients. Fermentation of β-fructan by whole-microbiota intestinal washes from non-IBD or remission IBD patients (but not non-IBD microbes) reduced pro-inflammatory responses.

Purpose

Here we aimed to expand our findings to uncover the physiologically relevant gut immune and epithelial responses to over 50 unfermented and partially fermented dietary fibers (arabinoxylans, β-glucans, β-mannans, galatooligosaccharides, inulins, oligofructoses, pectins, raffinooligosaccharides, xyloglucans) sourced from commonly consumed fruits, grains, and vegetables to better understand which foods are safe for IBD patients, and in which disease state settings.

Method

Colonic biopsies cultured ex vivo, peripheral blood mononuclear cells (PBMCs), colonic organoids, and cell lines were incubated with individual dietary fibers or mixture of fibers extracted from commonly consumed fruits, grains, and vegetables. Epithelial barrier integrity (TEER, microscopy, FITC-dextran) and immune responses (cytokine secretion [ELISA/MSD] and expression [qPCR]) were assessed. Structural features of the different fibers (e.g., degree of polymerization, phenolic/phytic content, branching, sugar content) were measured by HPLC and gas chromatography and correlated to host cell responses.

Result(s)

Most significantly unfermented inulin, oligofructose, and arabinoxylan induced pro-inflammatory responses, particularly in myeloid cells. Pectin and galatooligosaccharides were either non-inflammatory or anti-inflammatory depending on the food source. The epithelial barrier response to select dietary fibers correlated more significantly with the chemical properties of the fibers; longer fibers (greater degree of polymerization; e.g., inulin) displayed improved barrier integrity while shorter dietary fibers with higher phenolic content displayed reduced barrier integrity. Fiber structural properties varied significantly between different fiber subtypes along with the same fiber subtype sourced from different foods.

Conclusion(s)

Our findings suggest that intolerance and avoidance of fibers in select IBD patients occurs in patients whose gut microbiota do not support fermentation of fibers resulting in increased presence of unfermented dietary fibers in the gut. Here we show which specific dietary fibers from specific food items can elicit gut barrier damage and inflammation in the gut dependent on fiber structural features, suggesting mechanisms underlying IBD patient avoidance of specific high-fiber foods.

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Other

Please indicate your source of funding;

Weston Family Foundation, MMSF, NSERC, CRC

Disclosure of Interest

None Declared

A171 INTESTINAL INTERFERON-LAMBDA RECEPTOR 1 EXPRESSION AND RESPONSES ARE SIGNIFICANTLY DECREASED IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

Background

While interferon-lambdas (IFN-λs) were initially discovered for their role in antiviral immunity at mucosal barriers such as the lung and gut, there are many unanswered questions for how IFN-λs uniquely dampen inflammatory immune responses. In mouse colitis models, IFN-λs were shown to play a significant role in promoting epithelial barrier integrity and mucosal healing. Microbes present in the gut naturally induce IFN-λs, but how chronic inflammation, such as in patients with inflammatory bowel diseases (IBD), affects IFN-λ biology has not been well studied, especially in humans.

Purpose

Here, we tested the hypothesis that children with active, more severe IBD would present with lower intestinal IFN-λR levels and IFN-λ responses which could contribute to IBD pathology through exacerbated inflammation, decreased mucosal healing and impaired barrier function.

Method

We screened 14 novel antibodies to find the optimal clone that accurately stains the unique IFN-λ receptor subunit (IFN-λR1) protein in human intestinal tissue and IFN-λR1 levels were quantified by immunohistochemistry and flow cytometry in biopsy samples from children without IBD, Crohn’s disease, or ulcerative colitis (n=35 total). Fresh patient biopsies (ascending colon or terminal ileum) were also treated in media +/- IFN-λ for 24hrs using our novel ex vivo biopsy assay and changes in gene expression were quantified by RT-qPCR. Intestinal washes were also collected and microbes profiled by shotgun metagenomics.

Result(s)

We identified 2 new antibodies that accurately stained human cell lines and immune cells known to express IFN-λR1 protein (gut epithelial cells and B cells). We found that IFN-λ receptor (IFN-λR) levels are significantly reduced in gut epithelial and immune cells within pediatric IBD intestinal tissue, even at non-inflamed sites (p<0.01, 30-50% reduction) and this was even more pronounced when comparing moderate/severe disease compared to children with no disease activity. This led to lower IFN-λ responsiveness in IBD compared to non-IBD biopsies when investigating IFN-stimulated gene expression (p<0.05, up to 7-fold reduction). Paired patient gut microbe analyses identified specific species that correlated with changes in IFN-λ receptor expression.

Conclusion(s)

Together, our findings demonstrate pediatric IBD patients may be less able to induce critical IFN-λ-mediated antimicrobial responses and protective anti-inflammatory pathways. This work supports the goal to restore and promote IFN-λ responses as a novel therapeutic strategy for pediatric IBD.

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Children's Hospital Research Institute of Manitoba

Disclosure of Interest

None Declared

A98 ASSOCIATIONS BETWEEN DISTANCE TO CLINIC AND PATIENT CHARACTERISTICS FOR YOUNG ADULTS WITH IBD AT THE TIME OF PEDIATRIC TO ADULT TRANSFER OF CARE

Background

Patients with inflammatory bowel disease (IBD) in childhood are a vulnerable population. Compared to patients diagnosed in adulthood, they may present more often with extensive disease, delayed growth, and more frequently have perianal disease. Eventually, these patients will transfer care from the pediatric to the adult system, which has been associated with medication nonadherence and increase in health care utilization. Within the literature, travel distance has been cited as a barrier to accessing health care; however, understanding its’ impact on this vulnerable patient population has not been well-established.

Purpose

The study objective was to characterize differences between patients transferring from pediatric to adult care based on distance from an IBD center. To achieve this, the study aims to measure associations between distance to clinic and smoking status, anxiety and depression, history of surgery, and biologics at the time of first appointment in adult care.

Method

A retrospective cross-sectional study is ongoing using electronic medical charts for patients who transferred from pediatric to adult care from January 1, 2014 – October 4, 2022. Transfer was defined as the patient’s first appointment in adult care at the University of Alberta’s IBD clinic. Distance was measured by driving distance from the patient’s postal code to the postal code of the IBD clinic. Distance was categorized as being <50km from IBD clinic and >50km. Binary outcome variables collected at time of transfer included reported biologic use, anxiety and depression, smoking status, and history of surgeries. Descriptive and inferential statistics were used to analyze data.

Result(s)

Of the 185 electronic medical charts were reviewed, 46 (24.9%) patients lived >50km from clinic. The median age at diagnosis for the >50km group was 14.5 (IQR: 15.9-13.6), 41% were female sex, 54% had Crohn disease, 41% had ulcerative colitis (UC), and 26% had completed a fecal calprotectin within the last 6 months. The median age at diagnosis of the 139 patients living <50km from clinic was 14.3 (IQR:15.9-12.5), 45% were female sex, 60% had Crohn disease, 32% had UC, and 59% had completed a fecal calprotectin. Of those who had a fecal calprotectin, in group 1, 26% had a result over >250 ug/g, compared to 60% in the reference group. Univariate analysis (Table 1) showed that those living further than 50 km were more likely than those closer to engage in daily smoking (OR~4.7). Weaker and lack of associations were seen with anxiety and depression (OR~1); being on biologics (OR~0.7); history of surgical intervention (OR~2.2).

Image

Conclusion(s)

When smoking status was reported, patients > 50km away from clinic were 4.7 times more likely to engage in daily smoking at time of transfer compared to those patients within 50km from the clinic. By acknowledging and understanding potential differences and similarities between patients characterized by geographical location, we can use this research to inform personalized care plans.

Disclosure of Interest

None Declared

A199 BIOFILMS IN THE APPENDIX AND OTHER NON-INFLAMED SECTIONS OF THE COLON IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

Biofilms, aggregated bacteria colonizing the extracellular polymeric substances matrix, are associated with the mucosa of inflammatory bowel diseases (IBD) patients with some studies showing a mean density of the mucosal biofilms 2-fold higher in IBD patients than in controls. The appendix, which is a highly immune organ, seems to be involved in IBD pathogenesis.

Purpose

In this study we aimed to evaluate biofilms in the appendix and other non-inflamed regions of the colon in pediatric IBD patients. We hypothesized that biofilms composed of pathobionts in these sections could drive inflammation in IBD patients.

Method

Tissues from the appendix, peri-appendicular region, cecum, and ascending colon (ASC), collected from the resected colons of 9 pediatric IBD patients and one pediatric non-IBD patient, preserved in methanol Carnoy’s solution were processed and paraffin embedded. Combined fluorescence in situ hybridization (FISH) for biofilms (probe: EUB338) and immunofluorescence (IF) mucin staining (MUC2) identified biofilms and their location. Biofilm formation capacity of culturable bacteria (identified through 16S DNA Sanger sequencing) from these sections was measured. Interleukin (IL)-8 (pro-inflammatory chemokine) and IL-10 (anti-inflammatory cytokine) expressions were assessed by tissue qPCR.

Result(s)

FISH demonstrated biofilms in these sections, in close proximity to epithelial cells. We used a biofilm formation assay to assess the ability of the identified bacteria from these sections to form biofilms, illustrating their potential to colonize and evade host defense and potential antibiotics. We found that Enterococcus avium has a significantly higher ability to form biofilms than the negative control. IL-8 and IL-10 both had the highest expression level in the appendix and peri-appendicular region and the lowest in the ASC among all the patients, suggesting an active immune response. Mechanistic experiments are in progress to investigate the type of bacteria involved in the biofilms and their effects on the gut barrier integrity.

Conclusion(s)

Biofilms adjacent to the epithelium, especially in the appendix and peri-appendix, could interact with or invade epithelial cells. The elevated chemokine transcript level in the appendix could reflect the recruitment of immune cells to this section following bacterial invasion, resulting in the activation of the immune system. Identifying the bacteria involved in the biofilms and clarifying their characteristics will aid us in developing novel microbe-altering treatment strategies or personalized medicine.

Disclosure of Interest

None Declared

Mouse mammary tumor virus is implicated in severity of colitis and dysbiosis in the IL-10-/- mouse model of inflammatory bowel disease

BACKGROUND

Following viral infection, genetically manipulated mice lacking immunoregulatory function may develop colitis and dysbiosis in a strain-specific fashion that serves as a model for inflammatory bowel disease (IBD). We found that one such model of spontaneous colitis, the interleukin (IL)-10 knockout (IL-10^-/-) model derived from the SvEv mouse, had evidence of increased Mouse mammary tumor virus (MMTV) viral RNA expression compared to the SvEv wild type. MMTV is endemic in several mouse strains as an endogenously encoded Betaretrovirus that is passaged as an exogenous agent in breast milk. As MMTV requires a viral superantigen to replicate in the gut-associated lymphoid tissue prior to the development of systemic infection, we evaluated whether MMTV may contribute to the development of colitis in the IL-10^-/- model.

RESULTS

Viral preparations extracted from IL-10^-/- weanling stomachs revealed augmented MMTV load compared to the SvEv wild type. Illumina sequencing of the viral genome revealed that the two largest contigs shared 96.4-97.3% identity with the mtv-1 endogenous loci and the MMTV(HeJ) exogenous virus from the C3H mouse. The MMTV sag gene cloned from IL-10^-/- spleen encoded the MTV-9 superantigen that preferentially activates T-cell receptor Vβ-12 subsets, which were expanded in the IL-10^-/- versus the SvEv colon. Evidence of MMTV cellular immune responses to MMTV Gag peptides was observed in the IL-10^-/- splenocytes with amplified interferon-γ production versus the SvEv wild type. To address the hypothesis that MMTV may contribute to colitis, we used HIV reverse transcriptase inhibitors, tenofovir and emtricitabine, and the HIV protease inhibitor, lopinavir boosted with ritonavir, for 12-week treatment versus placebo. The combination antiretroviral therapy with known activity against MMTV was associated with reduced colonic MMTV RNA and improved histological score in IL-10^-/- mice, as well as diminished secretion of pro-inflammatory cytokines and modulation of the microbiome associated with colitis.

CONCLUSIONS

This study suggests that immunogenetically manipulated mice with deletion of IL-10 may have reduced capacity to contain MMTV infection in a mouse-strain-specific manner, and the antiviral inflammatory responses may contribute to the complexity of IBD with the development of colitis and dysbiosis. Video Abstract.

Unfermented β-fructan Fibers Fuel Inflammation in Select Inflammatory Bowel Disease Patients

BACKGROUND & AIMS

Inflammatory bowel diseases (IBD) are affected by dietary factors, including nondigestible carbohydrates (fibers), which are fermented by colonic microbes. Fibers are overall beneficial, but not all fibers are alike, and some patients with IBD report intolerance to fiber consumption. Given reproducible evidence of reduced fiber-fermenting microbes in patients with IBD, we hypothesized that fibers remain intact in select patients with reduced fiber-fermenting microbes and can then bind host cell receptors, subsequently promoting gut inflammation.

METHODS

Colonic biopsies cultured ex vivo and cell lines in vitro were incubated with oligofructose (5 g/L), or fermentation supernatants (24-hour anaerobic fermentation) and immune responses (cytokine secretion [enzyme-linked immunosorbent assay/meso scale discovery] and expression [quantitative polymerase chain reaction]) were assessed. Influence of microbiota in mediating host response was examined and taxonomic classification of microbiota was conducted with Kraken2 and metabolic profiling by HUMAnN2, using R software.

RESULTS

Unfermented dietary β-fructan fibers induced proinflammatory cytokines in a subset of IBD intestinal biopsies cultured ex vivo, and immune cells (including peripheral blood mononuclear cells). Results were validated in an adult IBD randomized controlled trial examining β-fructan supplementation. The proinflammatory response to intact β-fructan required activation of the NLRP3 and TLR2 pathways. Fermentation of β-fructans by human gut whole microbiota cultures reduced the proinflammatory response, but only when microbes were collected from patients without IBD or patients with inactive IBD. Fiber-induced immune responses correlated with microbe functions, luminal metabolites, and dietary fiber avoidance.

CONCLUSION

Although fibers are typically beneficial in individuals with normal microbial fermentative potential, some dietary fibers have detrimental effects in select patients with active IBD who lack fermentative microbe activities. The study is publicly accessible at the U.S. National Institutes of Health database (clinicaltrials.gov identification number NCT02865707).

Sustained Diet-Induced Remission in Pediatric Crohn's Disease Is Associated With Kynurenine and Serotonin Pathways

BACKGROUND

Both the Crohn's disease exclusion diet combined with partial enteral nutrition (CDED+PEN) and exclusive enteral nutrition (EEN) can induce remission in mild-to-moderate pediatric Crohn's disease and are associated with a marked decrease in fecal kynurenine levels. This suggests a link between clinical outcome of dietary therapy and changes in tryptophan metabolism pathways. Here, we characterize the changes in several fecal tryptophan metabolites induced by CDED+PEN or EEN and their association with remission.

METHODS

A total of 21 tryptophan metabolites were quantified in fecal samples from a 12-week prospective randomized trial with CDED+PEN or EEN for induction of remission in mild to moderate pediatric Crohn's disease. Tryptophan metabolites at week 0 (W0), W6, and W12 of 73 samples were quantitatively measured by liquid chromatography coupled with triple quadrupole mass spectrometry, and data were analyzed according to clinical groups of baselines (W0), induced remission at W6, no remission, sustained remission at W12, and nonsustained remission.

RESULTS

Reduction in components of the kynurenine pathway, such as kynurenine and quinolinic acid, were strongly associated with induced remission with both CDED+PEN and EEN, which were maintained in sustained remission. Specific serotonin pathway metabolites, such as melatonin, N-acetylserotonin, and 5-OH-tryptophan, were significantly increased in fecal samples from patients maintaining remission at W12 with both CDED+PEN and EEN. Importantly, in samples from patients failing to sustain remission, no changes were observed. Remission induction with EEN differs from CDED+PEN, particularly the moderate effects on indole pathway metabolites. The ratios of kynurenine and melatonin and quinolinic acid and melatonin perform well as markers for sustained remission.

CONCLUSIONS

The reduction in specific kynurenine pathway compounds and the increase in serotonin pathway compounds are associated with diet-induced and sustained remission. Further studies are warranted to assess causality and the association of these metabolites with specific diet and lifestyle factors, affecting sustained clinical remission.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early Infliximab Clearance Predicts Remission in Children with Crohn's Disease

BACKGROUND AND AIMS

Children with Crohn's disease have lower response rates to infliximab, lower infliximab levels, and higher infliximab clearance on weight-based dosing than adults. We hypothesize infliximab clearance is a predictive of later outcomes on infliximab in children with Crohn's disease.

METHODS

In this single-center retrospective study, data were collected from charts on diagnosis, anthropometry, routine labs, infliximab therapeutic drug monitoring, infliximab dosing, disease activity, and other treatments. With these data we generated a population pharmacokinetic model using non-linear mixed effects modeling and calculated infliximab clearance for each patient over time. Patients were classified as in remission, responder-only or non-responder at 5, 10 and 16 months. Regression and ROC analyses were used to assess for early predictors of remission and response to infliximab.

RESULTS

Eighty-five subjects were included, with a median follow-up of 22.3 months (IQR 10.1-36.8). Our pharmacokinetic model showed infliximab clearance was positively associated with CRP and weight, while negatively associated with albumin. In regression analyses, early infliximab clearance was the only significant, consistent predictor of remission. A 0.1 L/day increase in infliximab clearance predicted remission with an OR between 0.179 and 0.426. Differences in dosing did not account for differences in outcome. Infliximab clearance alone had moderate predictive accuracy of remission, with an AUC between 0.682 and 0.738.

CONCLUSIONS

Early infliximab clearance is strongly associated with remission in children with Crohn's disease. It may be useful as a marker of response in proactive therapeutic drug monitoring to guide early dose optimization and/or changes in treatment for betterment of long-term outcomes.

Metabolome Changes With Diet-Induced Remission in Pediatric Crohn's Disease

BACKGROUND & AIMS

The Crohn's disease (CD) exclusion diet (CDED) plus partial enteral nutrition (PEN) and exclusive enteral nutrition (EEN) both induce remission in pediatric CD. CDED+PEN is better tolerated and able to sustain remission. We characterized the changes in fecal metabolites induced by CDED+PEN and EEN and their relationship with remission.

METHODS

A total of 216 fecal metabolites were measured in 80 fecal samples at week (W) 0, W6, and W12, of children with mild to moderate CD in a prospective randomized trial comparing CDED+PEN vs EEN. The metabolites were measured using liquid chromatography coupled to mass spectrometry. Metagenome Kyoto Encyclopedia of Genes and Genomes Orthology analysis was performed to investigate the differential functional gene abundance involved in specific metabolic pathways. Data were analyzed according to clinical outcome of remission (W6_rem), no remission (W6_nr), sustained remission (W12_sr), and nonsustained (W12_nsr) remission.

RESULTS

A decrease in kynurenine and succinate synthesis and an increase in N-α-acetyl-arginine characterized CDED+PEN W6_rem, whereas changes in lipid metabolism characterized EEN W6_rem, especially reflected by lower levels in ceramides. In contrast, fecal metabolites in EEN W6_nr were comparable to baseline/W0 samples. CDED+PEN W6_rem children maintained metabolome changes through W12. In contrast, W12_nsr children in the EEN group, who resumed a free diet after week 6, did not. The metabolome of CDED+PEN differed from EEN in the purine, pyrimidine, and sphingolipid pathways. A significant differential abundance in several genes involved in these pathways was detected.

CONCLUSION

CDED+PEN- and EEN-induced remission are associated with significant changes in inflammatory bowel disease-associated metabolites such as kynurenine, ceramides, amino acids, and others. Sustained remission with CDED+PEN, but not EEN, was associated with persistent changes in metabolites.

CLINICALTRIALS

gov, Number NCT01728870.

Successful Dietary Therapy in Paediatric Crohn's Disease is Associated with Shifts in Bacterial Dysbiosis and Inflammatory Metabotype Towards Healthy Controls

BACKGROUND AND AIMS

Nutritional therapy with the Crohn's Disease Exclusion Diet + Partial Enteral Nutrition [CDED+PEN] or Exclusive Enteral Nutrition [EEN] induces remission and reduces inflammation in mild-to-moderate paediatric Crohn's disease [CD]. We aimed to assess if reaching remission with nutritional therapy is mediated by correcting compositional or functional dysbiosis.

METHODS

We assessed metagenome sequences, short chain fatty acids [SCFA] and bile acids [BA] in 54 paediatric CD patients reaching remission after nutritional therapy [with CDED + PEN or EEN] [NCT01728870], compared to 26 paediatric healthy controls.

RESULTS

Successful dietary therapy decreased the relative abundance of Proteobacteria and increased Firmicutes towards healthy controls. CD patients possessed a mixture of two metabotypes [M1 and M2], whereas all healthy controls had metabotype M1. M1 was characterised by high Bacteroidetes and Firmicutes, low Proteobacteria, and higher SCFA synthesis pathways, and M2 was associated with high Proteobacteria and genes involved in SCFA degradation. M1 contribution increased during diet: 48%, 63%, up to 74% [Weeks 0, 6, 12, respectively.]. By Week 12, genera from Proteobacteria reached relative abundance levels of healthy controls with the exception of E. coli. Despite an increase in SCFA synthesis pathways, remission was not associated with increased SCFAs. Primary BA decreased with EEN but not with CDED+PEN, and secondary BA did not change during diet.

CONCLUSION

Successful dietary therapy induced correction of both compositional and functional dysbiosis. However, 12 weeks of diet was not enough to achieve complete correction of dysbiosis. Our data suggests that composition and metabotype are important and change quickly during the early clinical response to dietary intervention. Correction of dysbiosis may therefore be an important future treatment goal for CD.

Appendix and Ulcerative Colitis: a Key to Explaining the Pathogenesis and Directing Novel Therapies?

The vermiform appendix is generally considered a redundant organ, but recent evidence suggests that the appendix could contribute to the pathogenesis of inflammatory bowel diseases, in particular ulcerative colitis (UC), and may even have a therapeutic role; however, mechanisms of the appendix involvement remain unclear. Here, we highlight current evidence on the link between the appendix and UC and consider plausible therapeutic implications. A literature search was conducted using PubMed and PubMed Central from inception to Nov 2021 using the terms "Appendix", "UC", "Appendix & UC," "Appendectomy", and "Peri-appendicular patch," including only articles published in English. Reference lists from the selected studies were manually searched and reviewed to gather additional related reports. Inflammation around the appendix ("peri-appendicular patch") has been frequently observed in UC patients without other cecal involvement, and this inflammation can even precede the onset of UC. Epidemiologic studies propose that appendectomy reduces the risk of developing UC or even the risk of flare after UC is diagnosed, although this remains controversial. We reviewed studies showing altered host-microbe interactions in the appendix in UC, which suggest that the appendix could act as a priming site for disease via alterations in the immune response and changes in microbiota carried distally to the colon. In summary, recent literature suggests a possible role for microbes and immune cells within the appendix; however, the role of the appendix in the pathogenesis of UC remains unclear. Further research could clarify the therapeutic potential related to this organ.

A237 VIRULENCE POTENTIAL OF BACTERIA ISOLATED FROM NON-INFLAMED COLON IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background

As inflammation can impact microbes, our lab has focused on non-inflamed bowel sections of patients with inflammatory bowel diseases (IBD) and found bacterial alterations in the terminal ileum. We are also interested in the appendix given the involvement of the peri-appendicular region and effects of appendectomy in ulcerative colitis.

Aims

In this study, we aimed to identify and evaluate microbes from the appendix and non-inflamed regions of the colon in IBD patients. We hypothesized that microbes originating from the non-inflamed sections of the colon or appendix are more invasive and could trigger inflammation in IBD patients.

Methods

16S DNA Sanger sequencing was performed on bacteria, aerobically and anaerobically cultured from tissues of the appendix, peri-appendicular region, cecum, and ascending colon, collected from the resected colons of 5 pediatric IBD patients. The invasive capacity of the identified bacteria was evaluated by gentamicin protection assays on Caco-2 intestinal epithelial cells in vitro. Presence of select invasive or adhesive genes in the bacteria was assessed by PCR.

Results

Escherichia coli was the most frequently cultured species in the aerobic cultures; additional aerobic species included Enterococcus and Klebsiella. Bifidobacterium and Erysipelatoclostridium were identified among the anaerobic cultures. Gentamicin protection assays indicated that Klebsiella isolated from the peri-appendicular region was significantly more invasive (mean ~3000 CFU/ml) than HB101 (~1000 CFU/ml; non-invasive control; P<0.05). Enterococcus avium and Enterococcus faecalis were also more invasive than HB101 in the peri-appendicular region (~10000 CFU/ml) and cecum (~4000 CFU/ml; P<0.05), respectively. E. coli isolated from the appendix showed a higher invasive potential (~3000 CFU/ml) than E. coli isolated from other sections. Additionally, PCR showed that E. coli obtained from different sections, except the ascending colon of one the patients, had the fimH gene while the other types of bacteria did not. None of the isolated bacteria had Hemolysin ( hlyA) or attaching and effacing ( eaeA) genes.

Conclusions

Bacteria, especially E. coli, from non-inflamed bowel in IBD (including the appendix) appear to have increased invasive potential. This suggests that the microenvironment in these regions could be altered, resulting in increased invasion of bacteria or the gut harboring more invasive microbial populations in IBD patients. As a result, inflammation could be triggered or exacerbated through this reservoir of pathobionts.

Funding Agencies

CIHR

A176 UTILITY OF MACHINE LEARNING FOR SERUM METABOLOMIC DATA ANALYSIS IN PEDIATRIC CROHN DISEASE

Background

The pathogenesis of pCD remains poorly understood, but evidence suggests roles for genetics, environment, immune response, and gut microbes. Microbial changes can contribute to chronic inflammation and correlate with disease severity. Metabolomics reflects interactions between host immune and gut microbial function by quantifying compounds in biological samples. Therefore, metabolomics provides a unique opportunity to gain insight into pCD pathogenesis.

Aims

To correlate disease severity, metabolites, and clinical data by applying machine learning algorithms in pediatric Crohn Disease (pCD).

Methods

ImageKids is a multicenter, prospective, cohort observational study, conducted to develop magnetic resonance enterography (MRE) indices for pCD. Paired serum specimens were collected at study initiation (Visit One; V1) and completion (Visit Four; V4; 18 months) for 120 pCD patients. Serum from patients with representative clinical scenarios and paired samples was analyzed at The Metabolomics Innovation Centre (TMIC; University of Alberta) and 131 metabolites were identified. Metabolites were analyzed via Unsupervised (U.ML) and Supervised (S.ML) Machine Learning algorithms based on Scikit-learn library in Python. Principal Component Analysis (PCA) was used to identify the variation pattern of the patients’ metabolome. Classifiers and regression algorithms were trained to assess correlation with disease activity.

Results

Results were available for the 56 paired samples. U.ML demonstrated distinct metabolome profiles with V1 clustering mainly attributed to aspartic acid, glutamic acid, and kynurenine. V4 clustering was mainly attributed to spermidine, spermine, total dimethylarginine. Furthermore, demographics was found as an important environmental factor driving distinct patterns of the metabolomics profile.

After training different classifiers and regressors with S. ML algorithms, metabolome data were correlated with disease severity (defined by C-reactive protein and fecal calprotectin). Isoleucine, p-hydroxyhippuric acid, and putrescine were the top three compounds associated with disease severity. The accuracy of our classification models was of 80% and the coefficient of determination of our regression models was 0.5

Conclusions

Metabolomic analysis can provide insight into disease pathogenesis and help predict disease severity among pCD patients. The correlation between metabolomics and disease severity might allow a better understanding of changes in host-microbe interactions and introduce new diagnostic or therapeutic options.

Funding Agencies

CIHR

A50 IMPACT OF SHORT CHAIN FATTY ACIDS ON PATHOGENICTY OF COMMENSAL BACTERIA IN PEDIATRIC INFLAMMATORY BOWEL DISEASES

Background

Dietary fibers are fermented by microbiota into many different compounds including short-chain fatty acids (SCFA). The gut microenvironment is essential not only for human health but also in maintaining a rich biodiversity of bacterial species. It is well known that the microbiome is altered in Inflammatory Bowel Diseases (IBD), which likely changes the microenvironment and has other health effects on individuals with IBD. Pathobionts are organisms that can induce pathology under specific conditions, and several have already been associated with IBD, such as adherent invasive Escherichia coli (AIEC) and Helicobacter hepaticus. Although these bacteria have been associated with IBD, it is still largely unknown what conditions make these bacteria become pathogenic.

Aims

Determine the role of SCFA composition on the pathogenic potential of commensal bacteria isolated from non-IBD and IBD pediatric patients.

Methods

Anaerobic bacteria were isolated during colonoscopy from pediatric IBD and non-IBD patients and identified using 16S sequencing. PMA-activated human monocytes (THP-1) and colonic epithelial cells (Caco2) were grown in the presence of SCFA (acetate, butyrate, formate, propionate, and succinate). The ability of commensal bacteria ( Bacteroides fragilis, Clostridium innocuum, Ruminococcus, Parabacteroides merdae, Bifidobacterium infantis and E. coli HB101) and the pathobiont AIEC to invade cells was assessed using a gentamicin protection assay. Immune activation was quantified with IL-1b and IL-6 by ELISA, as well as reactive oxygen species (ROS) using DCFDHA.

Results

The SCFA propionate and formate significantly decreased invasion for HB101 and LF82 into macrophages but not epithelial cells. Bacteria isolated from an IBD environment had a higher invasion potential independent of the addition of SCFA, compared to bacteria from a non-IBD environment. However, butyrate was found to significantly increase invasion of non-IBD B. fragilis into Caco2 cells but not macrophages. Bacteria isolated from IBD patients tended to have a higher inflammatory response with both elevated IL-1b as well as ROS production.

Conclusions

Microenvironment changes, such as in SCFA concentrations, during a disease state can affect the host response to microbes including commensals. Commensal bacteria from IBD patients tend to be more proinflammatory, suggesting that they play a role in driving inflammation. SCFA are beneficial factors for gut health; however, what is still unknown is the interaction between microbes and the host after microenvironmental shifts that likely causes bacterial stress. Understanding the host-microbe interactions and the role diet can have on this dynamic relationship has the potential for discovering new therapeutic options for those suffering from IBD.

Funding Agencies

CIHRWeston Family Foundation

A65 PREDICTING TRANSITION SUCCESS IN YOUNG ADULTS WITH INFLAMMATORY BOWEL DISEASE: PRELIMINARY RESULTS

Background

Patients diagnosed with inflammatory bowel disease (IBD) in childhood present more often with extensive disease, are more likely to be admitted to hospital and are less adherent with clinic appointments. Due to these risks, a smooth, uninterrupted transition from pediatric to adult care should be a priority. We have conducted interviews with providers, patients, and parents about their opinions on indicators of successful transition. Themes of successful transition that emerged included independence in seeking care and disease management. Characterizing successful transition based on stakeholder input makes it possible to monitor its achievement and identify its determinants.

Aims

This study aims to: 1) describe the frequency of success indicators in transitioned patients and 2) identify predictors associated with success indicators. We hypothesize that patients with more experience in pediatric care (e.g., younger age at diagnosis or on biologics) are more likely to achieve success.

Methods

We conducted a retrospective medical chart review to obtain data on patients who transitioned to adult care between January, 2014 - September, 2019 at the University of Alberta. We abstracted potential predictors, including social and disease factors, at first adult appointment which had notes on pediatric history. We chose available success indicators related to two themes: independence in seeking care (e.g., attending appointments, communicating for oneself) and disease management (e.g., lab work frequency and medication adherence). We abstracted selected success indicators within a two-year period from first appointment in adult care. We used Poisson and logistic regression to estimate incidence rate ratios (IR) and odds ratios (OR) for the association of potential predictors with success indicators.

Results

We reviewed medical charts of 99 patients. At first adult appointment, the median age at diagnosis was 14.5 years old (IQR: 13.2 – 15.9) and 57.6% of patients were on biologic agents. Within two years, 42.4% of patients required a change to a different therapy, 22.2% had at least two instances where a parent called on their behalf, and 16.2% had notes of medication nonadherence in adult care. Regression analysis (Table 1) estimated that patients who lived > 100km from clinic had a lab work incidence rate in the first year that was two-thirds that of patients who lived closer. Strong predictors of non-adherence in adult care included chart notes on pediatric medication non-adherence (OR~12) and, inversely, taking biologics (OR=0.34).

Conclusions

These results identified factors that could be used to identify patients likely to have poor outcomes following transition to adult care. These are preliminary results; we plan to analyze a total of 350 medical charts.

Funding Agencies

None

A47 MICROBIAL FUNCTIONS AS BIOMARKERS OF PRO-INFLAMMATORY RESPONSE TO SELECT DIETARY FIBERS IN IBD

Background

Dietary fibers are not digested in the bowel; they are fermented by microbes, typically promoting gut health. However, IBD patients experience sensitivity to consumption of fibers. Our previous findings offered the first mechanistic evidence demonstrating that unfermented dietary β-fructans (inulin and FOS) can induce pro-inflammatory cytokines in a subset of pediatric IBD colonic biopsies cultured ex vivo, and in the SYNERGY-1 (β-fructan) clinical study of adult remission UC patients. Incubating FOS with whole-microbiota intestinal washes from non-IBD or remission IBD patients improved fermentation and reduced pro-inflammatory responses, but not from patients with active disease. Fibre-induced immune responses correlated with microbe functions, luminal metabolites, and fibre avoidance.

Aims

Here we aimed to expand on our findings and define the role of microbial functions in mediating host response to β-fructans.

Methods

Colonic biopsies cultured ex vivo and cell lines in vitro were incubated with FOS (5g/L), or fermentation supernatants (24hr anaerobic fermentation). Immune responses (cytokine secretion [ELISA/MSD] and expression [qPCR]) were assessed. Taxonomic classification of microbial fermentation cultures was conducted with Kraken2 and metabolic profiling by HUMAnN2. HPLC and gas chromatography volatile fatty acid (CG-VFA) analysis were used to identify concentrations of remaining fibre and SCFAs following anaerobic fermentation.

Results

7 microbial enzymes were identified to be predictive of cytokine (IL-1β, IL23, IL-5, IL-8, MIP-1α) secretion in ex vivo colonic biopsies from pediatric Crohn disease (CD; n=38), ulcerative colitis (UC; n=20), and non-IBD (n=21) patients, in response to β-fructans; their use as biomarkers of response was determined in patient stool from the SYNERGY-1 clinical study cohort. Fermentation of FOS by whole-microbe intestinal washes from only non-IBD or remission IBD patients reduced cytokine secretion, and our findings demonstrate that this was due to a combination of reduction of β-fructan present and production of a precise combination of anti-inflammatory SCFAs.

Conclusions

Our findings suggest that intolerance and avoidance of fibers in select IBD patients is associated with the inability to ferment these fibers, mediated by altered microbial functions (enzymes), leading to worsened inflammation. Data indicate that gut microbial function, not composition, predicts patient pro-inflammatory response to β-fructans, supporting our hypothesis that overall community function impacts fibre fermentation and affects associated pro-inflammatory effects. Our work highlights select disease state scenarios in which administration of fermentable fibers should be avoided and tailored dietary interventions considered.

Funding Agencies

CIHRWeston Foundation, Mitacs

Clinical Features and Outcomes of Paediatric Patients With Isolated Colonic Crohn Disease

OBJECTIVES

Adult studies suggest that patients with isolated colonic Crohn disease (L2 CD) exhibit unique characteristics differentiating them from patients with ileo-caecal (L1) CD and ulcerative colitis (UC). We aimed to characterize clinical features and outcomes of paediatric patients with L2.

METHODS

Retrospective data was collected through the Porto Inflammatory Bowel Disease group of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) on Paediatric patients with L2, L1 or UC at different time-points. Outcome measures included time to first flare, hospital admissions, initiation of anti-tumor necrosis factor-alpha (TNFα) drug, stricture and surgery.

RESULTS

Three hundred patients were included: 102 L1, 94 L2 and 104 UC. Rates of hematochezia at presentation were 14.7%, 44.7% and 95.2%, while rates of fever were 12.7%, 26.6% and 2.9%, for patients with L1, L2 and UC, respectively (P < 0.001 for all comparisons). Skip lesions were identified in 65% of patients with L2, and granulomas in 36%, similar to L1 patients. Rates of anti-Saccharomyces cerevisiae antibodies (ASCA) and perinuclear antineutrophil cytoplasmic (pANCA) positivity significantly differed between the three groups: 25.4% and 16.7% for patients with L2, compared with 55.2% and 2.3%, and 1.8% and 52.9% for patients with L1 and UC, respectively. Response rates to exclusive enteral nutrition were comparable between L1 and L2 (78.3-82.4%), as was the response to oral steroids (70.4-76.5%) in the three groups. While times to first flare and admission were similar between groups, patients with L1 were commenced on anti-TNFα earlier. Moreover, stricturing phenotype and need for colectomy were very rare in patients with L2.

CONCLUSIONS

Significant differences are observed in the clinical presentation and outcomes of Paediatric patients with L2, compared to patients with L1 and UC.

OUP accepted manuscript

Background

The transition from pediatric to adult care is associated with changes centered around the patient taking responsibility for their health. As the incidence of childhood-onset inflammatory bowel disease (IBD) is increasing, it is important to address gaps in transition literature—specifically, the indicators signifying achievement of transition success. The study objective was to define transition success according to patients, parents, and health care providers involved in IBD transition.

Methods

This study used the method of qualitative description to conduct semi-structured interviews with patients, parents, and health care providers. During interviews, demographic information was collected, and interviews were recorded and transcribed. Data analysis was conducted independently of each group using latent content analysis. Participant recruitment continued until thematic saturation was reached within each group.

Results

Patients, parents, and health care providers all defined transition success with the theme of independence in one’s care. The theme of disease management emerged within parent and provider groups, whereas the theme of relationship with/ trust in adult care team was common to patients and parents. Additional themes of care team management, general knowledge, care stability, and health outcomes emerged within specific groups.

Conclusion

This study demonstrated differences between how patients, parents, and health care providers view transition success. This finding reveals the value of using a multifaceted definition of transition success with input from all stakeholders. Further research should prioritize the identification of factors common to patients who do not reach transition success as defined by patients, their parents, and providers.

Nutritional Therapies and Their Influence on the Intestinal Microbiome in Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder of the gastrointestinal tract with numerous genetic and environmental risk factors. Patients with Crohn’s disease (CD) or ulcerative colitis (UC) often demonstrate marked disruptions of their gut microbiome. The intestinal microbiota is strongly influenced by diet. The association between the increasing incidence of IBD worldwide and increased consumption of a westernized diet suggests host nutrition may influence the progression or treatment of IBD via the microbiome. Several nutritional therapies have been studied for the treatment of CD and UC. While their mechanisms of action are only partially understood, existing studies do suggest that diet-driven changes in microbial composition and function underlie the diverse mechanisms of nutritional therapy. Despite existing therapies for IBD focusing heavily on immune suppression, nutrition is an important treatment option due to its superior safety profile, potentially low cost, and benefits for growth and development. These benefits are increasingly important to patients. In this review, we will describe the clinical efficacy of the different nutritional therapies that have been described for the treatment of CD and UC. We will also describe the effects of each nutritional therapy on the gut microbiome and summarize the strength of the literature with recommendations for the practicing clinician.

The Phenotypic Spectrum of New-onset IBD in Canadian Children of South Asian Ethnicity: A Prospective Multi-Centre Comparative Study

BACKGROUND

Canadian-born children of South Asian [SA] ethnicity develop inflammatory bowel disease [IBD] at similar rates to those among Caucasian children. We evaluated the variation in phenotypic spectrum of IBD in SA and Caucasian children in a national paediatric inception cohort of new-onset IBD.

METHODS

Patients aged <17 years, enrolled in a Canadian nationwide inception cohort study, were included. Baseline demographic and IBD phenotypic features were compared between SA and Caucasian children. Longitudinal outcomes through 18 months of follow-up were compared matched by propensity scores.

RESULTS

Of 1156 children enrolled over 2014 to 2019, 623 were Caucasian [98% and 88% parents Canadian born] and 114 SA [79% Canadian born, 87% parents SA born]. Fewer SAs have a first-degree relative with IBD, 6% vs 19% in Caucasians, p = 0.002. SAs present at a younger age, median age 11.4 years (interquartile range [IQR] 9.2-14.3) vs 13 years [IQR 10.9-15 years], p = 0.03 and more commonly with a UC/IBD-U [ulcerative colitis/IBD-unclassified] subtype [ratio of UC/IBD-U to CD 1.2:1 vs 1:1.8 for Caucasians, p <0.001]. Additionally, a greater proportion of SA CD patients present with colonic-only disease [colonic-only CD/UC/IBD-U in SAs 67% vs 57% for Caucasians, p = 0.001], and among those with CD, colonic CD in SAs 31% vs 23% in Caucasians, p = 0.20]. Perianal fistulising disease was also numerically more common in SAs (14 [27%] vs 64 [18%], p = 0.06]. Adjusting for differences in phenotypic presentation, anti-tumour necrosis factor [TNF] exposure, and time to initiation was similar, and two-thirds of children, whether anti-TNF exposed or naïve, were in corticosteroid-free clinical remission at 18 months irrespective of ethnicity.

CONCLUSIONS

The phenotypic spectrum of new-onset IBD in SA children differs from that of Caucasian children, but treatment and clinical course are similar within phenotypic subgroups.

Shared decision making in pregnancy in inflammatory bowel disease: design of a patient orientated decision aid

Background

Research has indicated a lack of disease-specific reproductive knowledge among patients with Inflammatory Bowel Disease (IBD) and this has been associated with increased “voluntary childlessness”. Furthermore, a lack of knowledge may contribute to inappropriate medication changes during or after pregnancy. Decision aids have been shown to support decision making in pregnancy as well as in multiple other chronic diseases. A published decision aid for pregnancy in IBD has not been identified, despite the benefit of pre-conception counselling and patient desire for a decision support tool. This study aimed to develop and test the feasibility of a decision aid encompassing reproductive decisions in the setting of IBD.

Methods

The International Patient Decision Aid Standards were implemented in the development of the Pregnancy in IBD Decision Aid (PIDA). A multi-disciplinary steering committee was formed. Patient and clinician focus groups were conducted to explore themes of importance in the reproductive decision-making processes in IBD. A PIDA prototype was designed; patient interviews were conducted to obtain further insight into patient perspectives and to test the prototype for feasibility.

Results

Issues considered of importance to patients and clinicians encountering decisions regarding pregnancy in the setting of IBD included fertility, conception timing, inheritance, medications, infant health, impact of surgery, contraception, nutrition and breastfeeding. Emphasis was placed on the provision of preconception counselling early in the disease course. Decisions relating to conception and medications were chosen as the current focus of PIDA, however content inclusion was broad to support use across preconception, pregnancy and post-partum phases. Favourable and constructive user feedback was received.

Conclusions

The novel development of a decision aid for use in pregnancy and IBD was supported by initial user testing.