Journal of Crohn's & colitis最新文献

Surgery is a pivotal component of the management of Crohn's disease (CD), particularly in cases of disease-related complications or failure of medical therapy. However, the risk of short bowel syndrome following multiple large resections makes bowel preservation strategies a major therapeutic priority. This review gathers insights from a diverse group of inflammatory bowel disease specialists, exploring the full spectrum of bowel-preserving strategies, from conservative surgical techniques and peri-operative optimization to emerging innovations in robotic surgery. The therapeutic paradigm of treat-to-target and tight disease monitoring is shifting the focus from reactive interventions to proactive and personalized care. Looking ahead, the evolving implementation of multi-omics profiling and artificial intelligence holds promise to reshape the role of surgery in CD. Surgery should no longer be viewed solely as a response to complications, but rather as an individualized, biology-driven strategy that prioritizes bowel preservation. In this rapidly advancing field, innovation is measured not only by clinical outcomes but also by every centimeter of bowel preserved.

Background and aims: The necessity of diverting loop-ileostomy after a staged ileoanal pouch for ulcerative colitis (UC) remains unclear. This study aimed to compare postoperative outcomes between modified-two-stage and three-stage ileoanal pouch procedures for UC.

Methods: This retrospective cohort study included patients ≥18 years with UC or unclassified inflammatory bowel disease who underwent modified-two-stage or three-stage ileoanal pouch surgery from 2016 to 2021 in six European centers, with a follow-up of more than 12 months. The primary outcome was stoma-free rate at the end of follow-up. Secondary outcomes included perioperative practise, length of hospital stay, anastomotic leakage rate, and timing of diagnosis and treatment.

Results: Overall, 370 patients were included, of whom 228 (61.6%) underwent a modified-two-stage approach and 142 (38.4%) a three-stage approach. The median length of follow-up was 3.6 years (range: 1.0-7.7). Stoma-free rate was 93.8% (213/227) in modified-two-stage patients and 91.5% (130/142) in three-stage patients (P = .404). Notably, 78.4% of modified-two-stage patients never required an ileostomy, while the remaining 21.6% did receive a secondary ileostomy. While the median length of hospital stay for pouch surgery was longer in the modified-two-stage group, total median length of hospital stay after 1 year was shorter (median 7.0 days [IQR 6.0-11.0] vs 9.0 days [IQR 7.0-12.5], P = .015). The Clavien-Dindo score was higher than II in 22.6% of modified-two-stage patients and in 8.7% of three-stage patients (P < .001). Anastomotic leakage rate was higher after the modified-two-stage procedure (18% vs 5%, P < .001), but diagnosis and treatment occurred earlier (86% within 21 days vs 43%, P = .009).

Conclusions: Both approaches have comparable high stoma-free rates at the end of follow-up. Modified-two-stage avoids a temporary stoma in more than 75% of patients, but has a significantly higher rate of anastomotic leakages. Active and early surveillance of the anastomosis after three-stage procedures could improve postoperative outcomes in this group.

Introduction: ESGE have recently defined important performance measures for endoscopy in IBD. The role of patient experience in quality assessment of endoscopy in IBD is yet to be defined. We undertook an observational study based on analysis of a large multi-centre dataset with national coverage in Ireland. The aim was to analyse individual and composite metrics that reflect patients' experience with endoscopic procedures for IBD.

Methods: Anonymised data was extracted from electronic procedure records of patients who underwent colonoscopy in 24 Irish hospitals. The Performance Indicator of colonic intubation (PICI), a novel composite score reflecting sedation rates and patient comfort, and IBD-specific endoscopic domains were evaluated.

Results: Data from 261,524 colonoscopies were analysed from 2014-2020. CD patients had significantly lower OR of achieving PICI compared to non-IBD patients (0.69, 0-65-0.74 p < 0.001). Severe colitis was also associated with a significantly lower OR of achieving PICI (OR 0.53 (0.38-0.74, p,0.001). 80.2% of CD patients had a comfort score ≤2 compared to 87.8% of those with UC and 84.2% without IBD. 60.7% of patients with CD required Midazolam dose of 3 mg or more compared to 50.4% of those with UC and 76.7% of those without IBD. . 50% of CD patients required Fentanyl doses >50mcg compared to 34% of UC patients and 30.3% of patients without IBD.

Conclusion: This analysis of a large national endoscopy dataset highlights variability in quality metrics for IBD endoscopy and underscores the need for a metric like PICI to more accurately capture and reflect patient endoscopic experience with IBD.

Background and aims: Upadacitinib (UPA)-an oral, reversible selective Janus kinase inhibitor-has a favorable benefit-risk profile for patients with Crohn's disease (CD) and ulcerative colitis (UC). We evaluated the benefit-risk of UPA in select subgroups with CD or UC.

Methods: Patients were randomized to UPA 45 mg (UPA45) once daily (QD) or placebo (PBO) induction for 12 (CD: U-EXCEED, U-EXCEL) or 8 weeks (UC: U-ACHIEVE, U-ACCOMPLISH). Clinical responders were re-randomized to QD UPA 15 mg (UPA15), UPA 30 mg (UPA30), or PBO for 52-week maintenance (CD: U-ENDURE; UC: U-ACHIEVE). This exploratory post hoc analysis assessed efficacy and safety outcomes (adverse events of special interest [AESIs]: serious infections, major adverse cardiovascular [CV] events, malignancies, and venous thromboembolic events) by CV risk, prior treatment failure, and age.

Results: This analysis included 1021 patients with CD and 1097 with UC during induction, and 673 with CD and 746 with UC during maintenance. Improved efficacy outcomes comparable to the overall study populations were observed with UPA versus PBO across subgroups. Patients receiving UPA30 generally showed numerically higher rates of improvements versus UPA15. AESI rates were generally comparable between UPA and PBO across subgroups except for numerically higher rates of herpes zoster and serious infections in CD with UPA.

Conclusions: UPA resulted in consistent benefit versus placebo across CV risk, prior treatment failure, and age subgroups. No treatment differences were seen in AESIs across subgroups except herpes zoster and serious infections, reinforcing the favorable benefit-risk profile for UPA in CD and UC seen in the overall study populations.

Clinical trial numbers: NCT02819635, NCT03653026, NCT03345836, NCT03345849, NCT03345823.

Background: Achieving endoscopic remission is a key therapeutic goal in inflammatory bowel disease (IBD) that is associated with improved disease outcome. Transmural and intestinal barrier healing represent emerging targets, as they have similarly been associated with favourable disease behaviour. To date, no study has compared these novel end-points and their impact on avoiding deleterious disease outcome.

Methods: Clinically remittent IBD patients underwent ileocolonoscopy with assessment of intestinal barrier function by endomicroscopy. Transmural healing was assessed by magnetic resonance imaging or intestinal ultrasonography. Endoscopic and histologic disease activity were prospectively assessed along established scores. During subsequent follow-up (FU), patients were closely monitored for disease activity and major adverse outcomes (MAO): Disease flares, IBD-related hospitalization/surgery, initiation or escalation of systemic steroid, immunosuppressive or targeted advanced therapy.

Results: Eighty patients (47 Crohn's disease [CD], 33 ulcerative colitis [UC]) were included. During a mean FU of 34 (CD) and 18 (UC) months, 72% of CD and 85% of UC patients experienced MAO. Intestinal barrier healing exhibited the highest accuracy for predicting MAO-free survival in UC and CD patients and outcompeted transmural healing for predicting the further disease course. Both barrier healing and transmural healing showed higher diagnostic accuracy in forecasting the future course of disease when compared to endoscopic and histologic remission.

Conclusion: Intestinal barrier healing is superior to transmural healing to prevent disease progression in clinical remittent IBD patients while both barrier and transmural healing showed superiority over endoscopic and histologic remission. Hence, barrier and transmural healing are emerging end-points potentially refining disease monitoring and outcome prediction.

Demyelinating diseases, particularly multiple sclerosis (MS), present a unique therapeutic challenge in the management of inflammatory bowel disease (IBD). Although rare, the co-occurrence of IBD and demyelinating disorders is well-documented and may reflect shared immune, genetic, and environmental risk factors. As the therapeutic landscape of IBD expands to include biologics and small molecules that target immune pathways also implicated in MS, concerns around neurological safety have grown. In particular, anti-tumor necrosis factor agents have been consistently linked to new-onset or worsening demyelinating events, while other treatments such as sphingosine-1-phosphate receptor modulators and natali-zumab are licensed for both IBD and MS, though real-world data in patients with coexisting disease remain limited. This review synthesizes current evidence regarding the neurological safety and efficacy of IBD therapies in the context of demyelinating disease. It proposes a practical framework for clinicians, addressing management strategies for patients with confirmed MS, those at increased risk, and individuals who develop neurological symptoms during treatment. In the absence of formal guidelines, multidisciplinary collaboration, early recognition of symptoms, and careful treatment selection are important to optimize both gastrointestinal and neurological outcomes.

Background and aims: Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. While infliximab (IFX) offers significant benefits, 10%-30% of patients remain non-responders initially. This study employs artificial intelligence with multimodal integration to improve treatment response prediction and advance precision medicine.

Methods: We conducted a retrospective analysis of clinical data from patients with CD. The endpoint event was defined as primary non-response within 14 weeks of treatment. The multimodal dataset included laboratory indices, computed tomography enterography (CTE), and endoscopic histopathology based on whole-slide biopsy images. A TabNet model, originally designed for tabular data and here applied to clinical and laboratory features, was developed using a multi-instance learning framework to incorporate this multimodal information for predicting primary non-response to IFX. Finally, the multimodal model was validated in an independent external test cohort.

Results: The study included 188 patients, with 93 in the internal training set, 38 in the internal validation set, and 57 in the test set from an independent external cohort. The model utilizing pathological features achieved an area under the receiver operating characteristic (AUC) of 0.789 in internal validation. When combining pathological and radiological features, the AUC was 0.844. The optimal multimodal model integrating histology, radiology, and clinical features achieved an AUC of 0.852 in the internal validation set and 0.858 in the external test set.

Conclusions: The study developed a multimodal deep learning model accurately predicting IFX primary non-response, offering a tool to guide individualized therapy and improve CD outcomes.

Objective: To critically evaluate the evidence and mechanistic basis for combining exclusive enteral nutrition (EEN) with biologics in adults with Crohn's disease (CD), addressing the gap between strong theory and limited clinical proof.

Methods: We conducted a literature review up to May 2025, focusing on studies combining EEN with biologics (anti-TNF agents, vedolizumab, or Ustekinumab). We assessed methodological quality and bias.

Results: The current literature-mainly small, retrospective cohort studies-indicates that adding EEN to biologic therapy may increase clinical and endoscopic remission rates by 30-50% compared to biologic monotherapy. This effect is believed to be attributed to enhanced mucosal healing, alterations in the microbiome, and improved pharmacokinetics. However, these findings are based on studies with significant limitations, including selection bias, varying protocols, and lack of blinding.

Conclusion: Combined therapy with Exclusive Enteral Nutrition (EEN) and biologics shows promise in managing complex Crohn's Disease (CD), with studies reporting improved remission rates. This clinical benefit may be attributed to a synergistic effect supported by a plausible biological basis. However, these favorable outcomes are based on low-certainty evidence from limited clinical studies. Robust randomized controlled trials are needed to establish the effectiveness, safety, and best use of this combination approach. Keywords: Crohn's disease; Exclusive enteral nutrition; Combination therapy; Biologics; Mucosal healing.

Background and aims: Data on the management of acute severe ulcerative colitis (ASUC) in patients with prior anti-tumor necrosis factor (anti-TNF) exposure are limited. We compared medical management, colectomy risk, and mortality between anti-TNF-exposed and bio-naive patients.

Methods: This retrospective, multicenter GETECCU study included two ASUC cohorts (2010-2020): anti-TNF-exposed (cohort 1) and bio-naive (cohort 2). Patients previously treated with other advanced therapies were excluded. Steroid response was defined by reduced bowel movements and C-reactive protein. Rescue therapies were used for steroid failure. Maintenance therapy was initiated post-ASUC. Clinical effectiveness was assessed using the partial Mayo score (remission ≤2). Colectomy rates were analyzed through survival analysis and Cox regression. Mortality at 12 months was also evaluated.

Results: A total of 461 patients were included: 149 in cohort 1 and 312 in cohort 2. Steroid use was lower in cohort 1 (82% vs 97%, P < .001), but clinical response rates were similar. Rescue therapy rates were comparable (52% vs 57%, P = .88); infliximab use was lower in cohort 1 (25% vs 54%, P < .01). At 12 months, cohort 1 showed lower remission (44% vs 59%, P = .03) and higher colectomy (17% vs 8.7%, P = .01). Overall colectomy was higher in cohort 1 (34% vs 17%; hazard ratio 2.46, P = .001). One-year mortality was 1.52% (no significant differences between cohorts).

Conclusion: ASUC management in anti-TNF-exposed patients is heterogeneous and differs from that of bio-naive patients, with increased risk of treatment failure and colectomy.

Background and aims: Microscopic colitis (MC) is a chronic gastrointestinal disease with disabling symptoms and associated comorbidities. Yet, the economic impact of MC has not been studied. In this cost-of-illness study, we estimated the economic burden of MC.

Methods: We used histopathology reports from all of Sweden's 28 pathology departments to identify 11 517 adult patients with biopsy-proven MC as of January 1, 2017. Each patient was compared to up to five general-population comparators matched on sex, age, and county of residence. Mean costs for the calendar year of 2016 were calculated based on nationwide register data encompassing healthcare use, dispensed medications, and work loss derived from sick leave and disability leave. The number of budesonide treatments following MC diagnosis was used as a proxy for disease activity. Mean differences were further adjusted for education level.

Results: Compared with the general population, patients with MC had an annual mean excess cost of $4805 (USD; adjusted mean difference [95% CI], $4974 [$4650; $5298]), corresponding to a cost ratio of 1.84 (95% CI, 1.74; 1.95). Based on an estimated disease prevalence of ∼0.1%, the economic burden of MC was $1.2 million per 100 000 inhabitants. No significant cost differences were seen based on subtype or sociodemographic factors. However, a high disease activity was associated with higher costs driven by excess work loss.

Conclusion: Compared with the general population, patients with MC had almost twice as high annual mean costs. Excess costs were particularly high in patients with a high disease activity at onset, mainly driven by work loss.