Inpatient Nutritional Considerations in Inflammatory Bowel Disease

PURPOSE OF REVIEW

This review aims to explain the causes, diagnosis, and treatment of malnutrition in hospitalized patients with inflammatory bowel disease (IBD), focusing on both adults and children.

RECENT FINDINGS

Malnutrition is common among IBD patients, affecting up to 85% of individuals, and is linked to higher rates of illness, death, and longer hospital stays. Recent studies highlight the importance of early detection using tools like the Subjective Global Assessment (SGA) and handgrip strength tests. Nutritional interventions-such as exclusive enteral nutrition (EEN) and parenteral nutrition (PN)-have proven effective in inducing remission and improving patient outcomes, especially in pediatric Crohn's disease. New evidence suggests that optimizing nutrition before and after surgery, as well as using immunonutrition, may reduce postoperative complications. Early identification and management of malnutrition in hospitalized IBD patients may be important for improving clinical outcomes. Using appropriate nutritional screening tools and creating personalized nutrition plans can help with recovery, decrease hospital stays, and improve quality of life. Further research is needed to develop standard protocols for nutritional assessment and treatment in this patient population.

Anti-vaccine antibodies against measles, rubella, parotitis and hepatitis B in children with inflammatory bowel disease and healthy controls

BACKGROUND

Patients with inflammatory bowel diseases (IBD) often miss the scheduled vaccines and have a higher risk of infection susceptibility, including vaccine-prevented diseases.

AIM

To evaluate the vaccine coverage and levels of the post-vaccine antibodies against measles, mumps, rubella, and hepatitis B in children with IBD.

METHODS

Total 98 patients: 46 females (47.2%) and 52 males (52.8%) with IBD (Crohn’s disease-75% and ulcerative colitis-25%) with disease onset age-11.0 (6.0; 14.0) years whom clinical data, vaccination status and levels of the post-vaccination antibodies (IgG) for measles, rubella, mumps, hepatitis B, measured with ELISA were prospectively evaluated. The control group consisted of 88 healthy peers from the biobank data.

RESULTS

Patients with IBD had lower levels of measles, rubella, and hepatitis B, except mumps, compared to controls. Incomplete vaccination/non-protective titer of the antibodies against measles, mumps rubella, and hepatitis B had 33 (33.7%)/52.3%, 21 (21.4%)/50.4%, 26 (25.8)/25.6% and 26 (25.8%)/55.2%, respectively. Patients with incomplete vaccination had a lower age at the diagnosis for all vaccines. The age of the IBD diagnosis ≤ 6 years was the predictor of incomplete vaccination for measles [odds ratio (OR) = 4.6, P = 0.001], mumps (OR = 5.0, P = 0.001), rubella (OR = 5.4, P = 0.0005) and hepatitis B (OR = 5.4, P = 0.0005) and corticosteroid treatment for measles (OR = 2.2, P = 0.074) and mumps (OR = 3.0, P = 0.047) vaccines. Incomplete vaccination was the predictor of non-protective titer of antibodies against rubella (OR = 6.8, 95%CI: 2.3-19.9, P = 0.0002)/mumps (OR = 7.0, 95%CI: 2.4-20.8; P = 0.0002).

CONCLUSION

Patients with IBD had low vaccine coverage and lower levels of anti-vaccine antibodies against measles, rubella, and hepatitis B. Nearly half of the IBD patients require revaccination.

ECCO Topical Review on Predictive Models on Inflammatory Bowel Disease Disease Course and Treatment Response

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) poses a clinical challenge due to its variable progression and treatment response. Despite the development of predictive models, their clinical application remains limited due to validation and methodological inconsistencies. The current topical review examines existing predictive models, assesses their relevance, and discusses the barriers to their clinical implementation.

METHODS

An expert panel formed by European Crohn's and Colitis Organisation, including gastroenterologists, surgeons, and clinical epidemiologists, reviewed predictive models on IBD disease course and treatment response. Delphi methodology was applied to develop practice position statements. A practice position was set when at least 80% of participants reached agreement on a recommendation.

RESULTS

Fourteen practice positions and 2 perspective points were developed, highlighting factors included in models predicting IBD disease course and treatment response identified in the literature and barriers to clinical implementation. The appropriate methodological approaches for model development and validation have been defined, while methodological barriers to tackle have been identified. Perspectives on the inclusion of relevant biomarkers, and flexible study design have been outlined.

CONCLUSIONS

This topical review offers practice recommendations and guidance for future predictive models on IBD disease course and treatment response including their implementation in clinical practice.

Real-World Treatment Patterns Among Pediatric and Adult Patients with Crohn's Disease in the United States

BACKGROUND

The advent of biologics has expanded treatment options for Crohn's disease (CD). This study assessed treatment patterns in pediatric and adult patients with CD in the United States during 1- and 3-year follow-up periods.

METHODS

This retrospective, claims-based cohort study utilized the Merative™ MarketScan® Research Databases from January 1, 2014, to December 31, 2021. The index date was the date of the first CD diagnosis during the identification period. Among pediatric and adult CD cohorts, patients were stratified into two subgroups: (a) previously diagnosed (presence of a CD claim) and (b) newly diagnosed (absence of a CD claim) in the 12-month pre-index period. Results were summarized descriptively.

RESULTS

Data from 2809 pediatric and 25,940 adult patients were analyzed at 1-year follow-up. Mean age in years was 13.5 for pediatric and 46.0 for adult patients. Combination therapies were more common in pediatric versus adult patients, especially among those newly diagnosed with CD (38.2% vs 13.9%). A higher percentage of pediatric patients were prescribed biologics than adults (35.1% vs 24.3%). Numerically shorter time from diagnosis to corticosteroid initiation was observed in pediatric versus adult patients (9.5 vs 35 days). Higher persistence to biologics was observed in pediatric versus adult patients (94.6% vs 87.1%).

CONCLUSIONS

Combination therapies with biologics were more frequent among pediatric patients than adults. Although the overall treatment pattern among pediatric and adult patients was similar, early initiation of corticosteroids and adoption of biologics were more frequently observed in pediatric than adult patients, consistent with pediatric CD presenting with more aggressive disease.

Safety and immunogenicity of the measles-mumps-rubella vaccine in immunocompromised children with inflammatory bowel disease, or after liver transplantation: An observational study

Safety of live vaccines is questioned in children with inflammatory bowel diseases and after liver transplantation receiving immunosuppressive therapy. The objective was to monitor the immunogenicity and safety of attenuated live vaccines against measles, mumps and rubella (MMR) in children receiving immunosuppressive therapy. In this prospective multicenter observational study (DRKS00014569) 22 children and adolescents with incomplete MMR vaccination status were identified. Following individual assessment of vaccination readiness with stable immunosuppressive therapy in the last three months with no evidence of underlying disease activity, a risk-benefit assessment regarding vaccination with live-attenuated vaccines was performed. A checklist was used to assess the immune status based on thresholds for leukocyte, lymphocyte and CD4+ T cell counts, serum immunoglobulin G and M levels and detectable in vitro T cell activation. Sixteen patients were vaccinated against MMR, eleven after liver transplantation and five with inflammatory bowel disease. At the time of vaccination, four patients were receiving moderate (e.g., tacrolimus drug level below 5 ng/ml), eleven were receiving high-intensity immunosuppression (e.g. anti-tumor-necrosis factor agents, mycophenolate mofetil) and one child had previously discontinued immunosuppressive treatment. There were no serious adverse events or complications related to the vaccination. In children receiving immunosuppressive medications, the seroconversion rate for measles after the first MMR vaccination was 73.3 % (11/15) and after the second vaccination 80 % (12/15). Specific in vitro lymphocyte reactivity to measles antigen was detectable in three out of four patients after vaccination. This study shows that MMR vaccination can be carried out under immunosuppressive therapy in selected patients without relevant side effects, and a specific humoral and cellular immune response could be achieved.

Multiomics-Based Profiling of the Fecal Microbiome Reveals Potential Disease-Specific Signatures in Pediatric IBD (PIBD)

Inflammatory bowel disease (IBD), which includes Crohn's Disease (CD) and Ulcerative Colitis (UC), is a chronic gastrointestinal (GI) disorder affecting 1 in 100 people in the United States. Pediatric IBD (PIBD) is estimated to impact 15 per 100,000 children in North America. Factors such as the gut microbiome (GM), genetic predisposition to the disease, and certain environmental factors are thought to be involved in pathogenesis. However, the pathophysiology of IBD is incompletely understood, and diagnostic biomarkers and effective treatments, particularly for PIBD, are limited. Recent work suggests that these factors may interact to influence disease development, and multiomic approaches have emerged as promising tools to elucidate the pathophysiology. We employed metagenomics, metabolomics- and metatranscriptomics-based approaches to examine the microbiome, its genetic potential, and its activity to identify factors associated with PIBD. Metagenomics-based analyses revealed pathways such as octane oxidation and glycolysis that were differentially expressed in UC patients. Additionally, metatranscriptomics-based analyses suggested enrichment of glycan degradation and two component systems in UC samples as well as protein processing in the endoplasmic reticulum, ribosome, and protein export in CD and UC samples. In addition, metabolomics-based approaches revealed patterns of differentially abundant metabolites between healthy and PIBD individuals. Interestingly, overall microbiome community composition (as measured by alpha and beta diversity indices) did not appear to be associated with PIBD. However, we observed a small number of differentially abundant taxa in UC versus healthy controls, including members of the Classes Gammaproteobacteria and Clostridia as well as members of the Family Rikenellaceae. Accordingly, when identifying potential biomarkers for PIBD, our results suggest that multiomics-based approaches afford enhanced potential to detect putative biomarkers for PIBD compared to microbiome community composition sequence data alone.

Lactitol may improve the prognosis of hepatocellular carcinoma through the proliferation of Megasphaera as well as Bifidobacterium

Background

Increasing evidence suggests that gut microbiota and their metabolites can modulate antitumor immunity. However, sufficient evidence from human studies is lacking. We evaluated the association of lactitol and lactulose as prebiotics with the progression of hepatocellular carcinoma (HCC).

Methods

In Study 1, the effects of lactitol and lactulose on overall survival (OS) of patients with HCC with Child-Pugh scores of B or C were investigated in patients diagnosed at the Nagasaki Medical Center between 2003 and 2020. In Study 2, the effects of these substances on the gut microbiota of patients with cirrhosis were analyzed. Study 3 examined the effect of these substances on serum albumin levels in patients with cirrhosis.

Results

In Study 1, a total of 321 patients were evaluated, and 55 pairs of Lactitol and Non-Lactitol groups and 80 pairs of Lactulose and Non-Lactulose groups were created using one to one propensity score matching. The Lactitol group showed a significant improvement (p < 0.05) in OS compared to the Non-Lactitol group, but the Lactulose group did not show any significance compared to the Non-Lactulose group. In Study 2, the number of Bifidobacterium was higher in the Lactitol group and the Lactulose group than in the Control group, but the number of Megasphaera was significantly higher only in the Lactitol group. In addition, in a study of 10 cases in which the gut microbiota was examined before and after lactitol use, an increase in Bifidobacterium and Megasphaera was observed after lactitol use. Study 3 found that lactitol had no beneficial effect on serum albumin levels.

Conclusion

Lactitol may improve the prognosis of HCC through the proliferation of Megasphaera as well as Bifidobacterium.

From traditional to artificial intelligence-driven approaches: Revolutionizing personalized and precision nutrition in inflammatory bowel disease

Inflammatory bowel disease (IBD), comprising ulcerative colitis and Crohn's disease, is a chronic inflammatory condition with global prevalence and varying incidence. The IBD pathogenesis involves intricate interactions among genetic, host and environmental factors, leading to dysregulated immune responses and chronic intestinal inflammation. Alongside elevated levels of inflammatory cytokines and altered miRNAs expression, more studies highlight significant dysbiosis in both fecal and ileal microbiota of IBD patients. This dysbiosis is characterized by an increase in pro-inflammatory and mucin-degrading bacteria (e.g., Fusobacterium spp., Escherichia spp.) and a decline in short-chain fatty acids (SCFAs) -producing microbes (e.g., Roseburia spp., Faecalibacterium spp.) which play a protective role in gut health. Diet emerges as a key environmental factor influencing IBD onset and progression and recent advancements in"omics" technologies, such as genomics, transcriptomics, and metabolomics, provide a deeper understanding of the molecular interactions between genes, gut microbiota (GM) and nutrition. Finally, new technologies like artificial intelligence (AI), further enhance findings by enabling data integration and personalized dietary strategies. In this scenario, this review aims to summarize accumulating data on the effects of dietary interventions in IBD patients and introduce the role of artificial intelligence (AI) in facilitating precision dietary approaches to improve IBD management.

Long-Term Outcome of Paediatric Crohn's Disease Patients With Deep Ulcerations at Diagnosis

AIM

Presence of deep ulcerations (DU) at diagnosis seems to be predictive of a more severe phenotype in adult Crohn's disease (CD). The aim of our study was to investigate if the presence of DU at diagnosis was associated with a more severe disease course over time in children.

METHODS

In this monocentric retrospective study, we analysed data from paediatric patients with a new diagnosis of CD from 2009 to 2017. Clinical, laboratory data, treatments and complications were recorded for each patient at diagnosis and at 1, 3 and 5 years of follow-up. Patients were compared according to the presence or absence of DU on colonoscopy.

RESULTS

Among the 116 patients included in the study, 52 patients had DU at diagnosis. Comparison showed an increased risk for patients with DU to develop abdominal abscesses (p = 0.045) and to experience more relapses (p = 0.013) at 1 year. At 3 and 5 years, there was no longer any difference between groups. The time from diagnosis to first anti-TNF alpha was shorter in DU patients.

CONCLUSION

The presence of DU at diagnosis is associated with more complications during the first year of follow-up but not after, due to a more active therapeutic management.

Bioimpedance Phase Angle as a Diagnostic Tool of Nutritional Status in Children with Crohn's Disease on Exclusive Enteral Nutrition Therapy: One-Year Follow-Up Study

Exclusive enteral nutrition (EEN) is highly effective in achieving remission and improving nutritional status in pediatric Crohn's disease (CD), commonly associated with altered body mass composition (BC). Bioimpedance analysis (BIA) with phase angle (PA) assessment is a noninvasive, reliable tool in screening for BC alterations. In the present study we aimed to assess the PA's usefulness in the detection of malnutrition in newly diagnosed pediatric CD, ongoing EEN treatment, and during 1-year follow-up. Patients and study design: Fourty-three patients with CD, qualified for EEN, were enrolled in the study. Additionally, 22 healthy children, being in the same age category, served as controls. Fat-free mass (FFM), fat-free mass index (FFMI), and BIA-derived PA were assessed at diagnosis, after EEN completion, and at week 52. The same parameters were obtained in the control group once. The majority of patients presented with normal body mass index at diagnosis. PA values were lower than 5 degrees in 65% of the study group. FFMI deficiencies were observed in 74% of patients. After EEN completion, an increase in FFM (P < .001) was observed. The highest mean of FFM (P < .001) and PA (P < .001) were observed at week 52. A strong correlation between PA and FFM at CD diagnosis (Spearman's rho = 0.671, r = 0.702, P < .001), after EEN completion (Spearman's rho = 0.781, P < .00) and at week 52 (Spearman's rho = 0.657, P < .001) was present. PA has been observed as positively associated with albumin concentrations both at diagnosis and after EEN. Our study provides some support that PA may be a reliable tool for screening alteration in BC, especially FFM and lean tissue mass (LTM). Moreover, PA has been observed as positively associated with albumin levels at CD diagnosis, which provides some evidence that it may be considered as a risk indicator of malnutrition and protein deficiency in newly diagnosed CD pediatric patients.

Saudi consensus guidance for the diagnosis and management of inflammatory bowel disease in children and adolescents

ABSTRACT

The management of inflammatory bowel disease (IBD) in children and adolescents is challenging. Clear evidence-based guidelines are required for this population. This article provides recommendations for managing IBD in Saudi children and adolescents aged 6-19 years, developed by the Saudi Ministry of Health in collaboration with the Saudi Society of Clinical Pharmacy and the Saudi Gastroenterology Association. All 57 guideline statements are based on the most up-to-date information for the diagnosis and management of pediatric IBD.

British Society of Gastroenterology guidelines on colorectal surveillance in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) remain at increased risk for colorectal cancer and death from colorectal cancer compared with the general population despite improvements in inflammation control with advanced therapies, colonoscopic surveillance and reductions in environmental risk factors. This guideline update from 2010 for colorectal surveillance of patients over 16 years with colonic inflammatory bowel disease was developed by stakeholders representing UK physicians, endoscopists, surgeons, specialist nurses and patients with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological support.An a priori protocol was published describing the approach to three levels of statement: GRADE recommendations, good practice statements or expert opinion statements. A systematic review of 7599 publications, with appraisal and GRADE analysis of trials and network meta-analysis, where appropriate, was performed. Risk thresholding guided GRADE judgements.We made 73 statements for the delivery of an IBD colorectal surveillance service, including outcome standards for service and endoscopist audit, and the importance of shared decision-making with patients.Core areas include: risk of colorectal cancer, IBD-related post-colonoscopy colorectal cancer; service organisation and supporting patient concordance; starting and stopping surveillance, who should or should not receive surveillance; risk stratification, including web-based multivariate risk calculation of surveillance intervals; colonoscopic modalities, bowel preparation, biomarkers and artificial intelligence aided detection; chemoprevention; the role of non-conventional dysplasia, serrated lesions and non-targeted biopsies; management of dysplasia, both endoscopic and surgical, and the structure and role of the multidisciplinary team in IBD dysplasia management; training in IBD colonoscopic surveillance, sustainability (green endoscopy), cost-effectiveness and patient experience. Sixteen research priorities are suggested.

Hepatosplenic T-cell lymphoma in children and adolescents

ABSTRACT

Hepatosplenic T-cell lymphoma (HSTCL) is an aggressive mature T-cell lymphoma characterized by significant hepatosplenomegaly, bone marrow involvement, and minimal or no lymphadenopathy. Primarily affecting young adults, it is exceptionally rare in children and adolescents. This makes diagnosis and treatment particularly challenging for pathologists and pediatric oncologists. Diagnosis typically relies on bone marrow, spleen, or liver biopsy, with histopathologic features including small/medium lymphoid cells with irregular nuclear contours that obstruct the sinuses or sinusoids of the spleen or liver. Immunophenotyping usually reveals CD2/3/7 positivity and CD4/8 negativity, with γδ T-cell receptor rearrangements in most cases. Some genetic distinctions described in pediatric and adolescent patients include chromosome 7 and 8 abnormalities and mutations involving SETD2 and STAT5B. Given the lack of standardized approaches, childhood and adolescent patients with HSTCL are often treated with adult protocols, such as intensive cytotoxic chemotherapy regimens followed by allogeneic hematopoietic stem cell transplantation. Despite these highly intensive treatments, the prognosis for HSTCL remains poor in children and adolescents, with an estimated 5-year overall survival of <15%. HSTCL's rarity in children and adolescents limits accurate epidemiological estimates, clinical experience, data collection, treatment advances, and surveillance recommendations. Data on relapsed/refractory disease are even more limited. This review summarizes known clinical and histopathologic features as well as outcomes specific to children and adolescents with HSTCL, highlighting potential distinctions from adults. We will also discuss future strategies to acquire additional biologic and molecular data, streamline diagnosis, and advance treatment approaches to ultimately improve outcomes for young patients with this deadly disease.

Clinical outcomes of maintenance therapy with sulfasalazine compared to 5-aminosalicylates in children with ulcerative colitis

OBJECTIVES

Sulfasalazine (SZ) and 5-aminosalicylates (5-ASA) have been widely used treatments for ulcerative colitis (UC). Although some studies suggest SZ may be superior, limited data exists comparing the two in children. This study aimed to describe real-world data on their comparative safety and efficacy in children and the impact of switching between SZ and 5-ASA before treatment escalation.

METHODS

We retrospectively reviewed the electronic medical records of children diagnosed with UC between June 1999 and December 2019 at Boston Children's Hospital. We described outcomes at 1 year and long-term in patients treated with SZ or 5-ASA as a first-line maintenance agent.

RESULTS

Among 433 patients (age 0-19 years), 124 started on SZ and 309 on 5-ASA. Forty-eight patients switched between the two drugs within the first year, and 74 switched during long-term follow-up. The main reason for switching from SZ to 5-ASA was adverse reactions. At 1 year, 54%, 44.3%, and 36.6% of patients on SZ, 5-ASA, and those who switched, respectively, were in steroid-free remission (p = 0.13). Patients who switched due to lack of efficacy or adverse reactions were four times more likely to escalate treatment compared to nonmedical reasons. Patients with Pediatric Ulcerative Colitis Activity Index >65 at the diagnosis are more likely to require treatment escalation (p = 0.0043).

CONCLUSIONS

SZ and 5-ASA are effective first-line treatments for mild to moderate pediatric UC. SZ tends to have more minor adverse reactions. Switching between SZ and 5-ASA does not offer therapeutic benefits, and disease severity at diagnosis predicts early treatment escalation.

Invasive Therapeutic Strategies for Stricturing Crohn's Disease in Childhood: A Systematic Review and Meta-Analysis

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. Current drugs are not effective for treating the primary fibrotic component of CD. Recommended invasive treatments include endoscopic balloon dilation, surgery with resection, or strictureplasty. This meta-analysis compared invasive treatment techniques for CD-related strictures in the pediatric population.

METHODS

The MEDLINE, EMBASE, and LILACS databases were searched from inception to December 2023. This meta-analysis was performed as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome was measured by the rate of stenosis recurrence and the adverse events of the techniques. Eligibility criteria were studies that involved the analysis of the recurrence rate of stenosis in pediatric patients with CD requiring surgical intervention after undergoing any of the previously proposed therapies. Additionally, adverse events were analyzed.

RESULTS

Three studies comprising a total of 106 endoscopic balloon dilations demonstrated a combined rate of stricture recurrence in patients with CD requiring surgical intervention of 0.171 (95% confidence interval [CI], 0.110-0.255). Three studies comprising a total of 49 surgical resections demonstrated a pooled event rate of 0.100 (95% CI, 0.038-0.240). Finally, 2 studies comprising a total of 38 strictureplasties demonstrated a pooled event rate of 0.347 (95% CI, 0.070-0.789). Concerning adverse events, the most common occurrences were found after surgical resection.

CONCLUSIONS

Surgical resection is the best option for treating strictures in pediatric CD patients in terms of recurrence rate, compared with endoscopic balloon dilation and strictureplasty. Nevertheless, surgical resection is associated with more adverse events.

Hormonal therapy for impaired growth due to pediatric-onset inflammatory bowel disease: a systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Inflammatory bowel diseases (IBDs) have an increasing incidence in the pediatric population. The dysabsorptive effects of this condition often lead to a decrease in linear growth. However, the effectiveness and safety of growth hormone (GH) therapy in this population is still a topic of debate, with studies showing conflicting results.

CONTENT

MEDLINE, Embase, and Cochrane Library databases were systematically searched according to the PRISMA guidelines. All experimental studies featuring children with IBD receiving GH therapy were included. In addition, a trial sequential analysis (TSA) was conducted to determine the sample size required for each outcome. The prospective registry was carried out under protocol CRD42024563079. The total data set comprised eight studies involving 127 patients with IBD, 78 (61.41 %) of whom received GH therapy, with a mean follow-up duration of 1.3 years. A statistically significant effect of GH was found in increasing the height standard deviation score (HtSDS) of children with IBD (standardized mean difference - SMD=1.07; CI=0.58, 1.56; p<0.0001). When comparing children who received GH with controls, no significant improvement in HtSDS was observed (SMD=0.18; CI=-0.73, 1.08; p=0.70). However, meta-regression analysis indicated that a longer follow-up was associated with a greater improvement in the HtSDS (p=0.04). Regarding height velocity (HV), a significant increase was found when comparing measurements before and after the initiation of hormone therapy (mean difference - MD=4.09; CI=2.58, 5.60; p<0.0001). An increase in HV was also noted in children receiving GH compared to the control group (MD=4.47; CI=2.03, 6.90; p=0.0003). No significant changes in the Pediatric Crohn's Disease Activity Index (PCDAI) were detected, comparing values before and after the start of treatment (MD=-10.09; CI=-22.29, 2.10; p=0.10). The overall prevalence of any adverse effect was estimated at 15.51 % (95 % CI: 2.32-58.70 %). Most common reaction was itching at injection sites. TSA indicated a low risk of overestimating or underestimating the intervention's effect on the analyzed outcomes.

SUMMARY

Our study points to the effectiveness and safety of GH therapy in children with IBD and growth impairment.

OUTLOOK

Further randomized controlled trials (RCT) with standardized methodologies and extended follow-up periods are necessary to confirm these findings.

Tailoring therapy to the individuals of Crohn's disease

For decades, increasing incidence and prevalence of Crohn's disease (CD) have attracted more attention. Some severe complications such as perforations, fistulas, and abscesses have significantly impaired patients' quality of life. Though the emergence of biologic agents has improved disease course and prognosis to a great extent, different disease manifestations and the economic burden of disease make biologic agents not suitable for all CD patients. The ultimate goal of achieving clinical and endoscopic remission, and even transmural healing is same for every CD patient, but therapeutic decision is so difficult for individual differences. Making a personalized approach based on disease behavior, drug response and other related factors is critical for disease management. This review attempts to summarize the existing clinical trials and data for better tailoring personalized therapy of CD.

Elevating fungal care: bridging Brazil's healthcare practices to global standards

Brazil faces unique challenges in managing invasive fungal infections (IFIs) due to diverse ecosystems, a rural workforce, and prevalent health conditions. In Europe, IFIs are primarily associated with transplantation, intensive care, and chronic diseases. Inspired by initiatives in the Caribbean and Latin America in 2019, efforts to map global diagnostic and treatment resources expanded to Africa, Europe, and Asia/Pacific. This study conducts a comparative analysis, mainly drawing data from Brazil and Europe, to investigate IFI epidemiology and management. Data were collected through online surveys distributed to Brazilian and European institutions, with collaborations from scientific organizations. Surveys covered institutional profiles, IFI diagnoses, accessibility to diagnostic techniques, and antifungal drugs. A comparative survey involving 96 Brazilian and 388 European institutions revealed variations in the perception and practices related to fungal pathogens. Differences in ranking and prevalence were observed, along with variations in diagnostic procedures, fluorescence dye usage, culture practices, antifungal medication availability, and technological approaches. Europe exhibited higher utilization rates for molecular diagnostic approaches, including PCR tests, and therapeutic drug monitoring (TDM) was more widespread in Europe compared with Brazil, indicating substantial differences in understanding and managing fungal infections. Customized IFI management is crucial, considering regional differences and addressing technological gaps like underutilized PCR. The study advocates for increased international collaboration, targeted training, and enhanced resources to foster a unified global approach in preventing, diagnosing, and treating IFI.

IMPORTANCE

This work is significant as it highlights the unique challenges Brazil faces in managing invasive fungal infections (IFIs) due to its diverse ecosystems and public health landscape. By comparing Brazil's situation with Europe-where IFIs are mainly linked to transplantation and intensive care-this study identifies key disparities in diagnostic and treatment practices. The findings reveal substantial differences in the availability and use of molecular diagnostics, antifungal drugs, and therapeutic drug monitoring, with Europe demonstrating more advanced practices. By mapping these variations, the study underscores the importance of tailored approaches to IFI management that consider regional differences and technological gaps. Ultimately, it calls for enhanced international collaboration, targeted training, and resource allocation to improve IFI outcomes globally, particularly in regions with limited access to advanced diagnostic tools and treatments.

Specialized and standard nutritional formulas for the dietary management of pediatric patients with Crohn's disease: a systematic literature review

INTRODUCTION

This systematic literature review (SLR) aims to compare the clinical, humanistic, and economic outcomes associated with specialized and standard nutritional formulas for the treatment of mild-to-moderate pediatric Crohn's disease.

METHODS

Search strategies were applied across MEDLINE, Cochrane and Web of Science (January 2000-October 2023) and recent congress proceedings (January 2021-October 2023). PRISMA-P guidelines were followed. Quality assessment evaluated risk of bias.

RESULTS

Twenty-three unique studies met the inclusion criteria. Nineteen studies (754 patients) evaluated specialized formula, 10 assessed standard formula (246 patients). Mucosal healing (7 studies), induction (20 studies) and maintenance of remission (9 studies) were reported over various timeframes. High proportions of patients who received specialized formula achieved mucosal healing (63-89% 8 weeks; 25-74% 10 weeks), and remission (50-100% 8 weeks). Specialized formula sustained remission (34-62.5% 6 months and 24-87.5% 1 year). Results were not directly comparable with standard formula due to significant heterogeneity in study methodology, patient populations, and remission definition.

CONCLUSIONS

The evidence predominantly supports the benefits of specialized formula in inducing mucosal healing, remission, and sustaining positive outcomes across multiple timepoints. Direct comparison of nutritional interventions is required to further support the findings of this SLR.Protocol registration: PROSPERO CRD42023472370.

The Impact of Endoscopic Healing on Disease-Related Outcomes in Patients With Ulcerative Proctitis

BACKGROUND AND AIMS

Ulcerative proctitis (UP) is a limited form of ulcerative colitis. While achieving endoscopic healing (EH) in ulcerative colitis improves long-term outcomes, the benefit of EH in UP is uncertain. This study aimed to assess the impact of EH on outcomes in UP.

METHODS

This single-center retrospective study included adults with UP and ≥2 endoscopies, with active inflammation (Mayo endoscopic score [MES] 1-3) at index. EH was defined as MES 0-1 at follow-up procedure. The relationship of EH to inflammatory bowel disease (IBD)-related outcomes was assessed using univariate analysis and multivariable logistic regression assessed the effect of EH on IBD-related outcomes.

RESULTS

Among 200 UP patients, 109 (54.5%) had EH at follow-up endoscopy at median 19 months (interquartile range: 7, 32). EH was associated with fewer IBD-related emergency department (ED) visits (EH: 8.3%, no EH: 21%, P = .01), hospitalizations (5.5% vs 18%), and GI visits (mean: 1.47/year [SD: 1.40], vs 2.96/year [2.52], P < .001). Patients with EH were less likely to have iron deficiency anemia (23% vs 41%, P = .007), Clostridioides difficile (0.9% vs 6.6%, P = .048), or initiate new biologic therapy after relapse (15% vs 33%, P = .034). Patients with EH had a greater time to clinical relapse (21 [24] vs 9 months [14]; P = .006) and lower odds of an IBD-related ED visit (OR: 0.32, 95% CI: 0.13, 0.73) or hospitalization (0.26 [0.09, 0.67]). Baseline presence of a cecal patch did not impact outcomes.

CONCLUSIONS

UP patients with EH had less IBD-related healthcare utilization, fewer IBD-related complications, and were less likely to escalate therapy after relapse than patients without EH. Using a treatment target of EH may therefore be desirable in UP.

Magnetic resonance imaging for suspected perianal Crohn's disease in children: a multi-reader agreement study

OBJECTIVES

We aimed to assess inter-radiologist agreement when interpreting pelvic MRI in children with newly diagnosed perianal Crohn's disease (CD).

MATERIALS AND METHODS

In this retrospective multi-reader study, we identified pediatric patients (< 18 years of age) who underwent a pelvic MRI examination for newly diagnosed perianal CD. Images were de-identified and uploaded to a cloud-based image platform for review by 13 fellowship-trained pediatric radiologists The reviewers assessed for the presence of a fistula and abscess, categorization of different imaging findings, and classification using the Parks and St James' University Hospital systems. Fleiss' kappa (κ) statistics and intra-class correlation coefficients (ICC) were used to measure inter-reader agreement, along with 95% confidence intervals (CI).

RESULTS

Forty-six patients were included in our study (median age = 13.0 years [IQR: 10.5 to 16.0 years]); thirty-five (76.1%) were boys. Most imaging features showed fair agreement (κ = 0.21 to 0.35). There was moderate agreement for categorical fistula length (κ = 0.42 [95% CI: 0.32 to 0.53]), involvement of the genitalia (κ = 0.45 [95% CI: 0.26 to 0.63]), and presence of an abscess/collection (κ = 0.52 [95% CI: 0.31 to 0.73]). Maximum abscess/collection length had good agreement (ICC = 0.81 [95% CI: 0.41, 1.00]). There was an almost equal split (yes vs. no: 50.7% vs. 49.3%) regarding whether postcontrast T1-weighted images added value compared to T2-weighted images alone across all radiologists and examinations.

CONCLUSION

Inter-radiologist agreement when interpreting pelvic MRI for perianal CD in children is fair for most imaging features, with fewer features demonstrating moderate or good agreement.

KEY POINTS

Question Pelvic magnetic resonance imaging (MRI) is used for diagnosing and monitoring children with perianal Crohn's disease (CD). Limited information is known about inter-radiologist agreement. Findings Agreement between pediatric radiologists when interpreting MRI for perianal CD in children is only fair for most imaging features (κ = 0.21 to 0.35). Clinical relevance Understanding MRI inter-radiologist agreement is crucial to improve the reliability of pelvic MRI in children with perianal Crohn's disease since it may affect patient management (e.g., surgery); further radiologist education and improved imaging feature definitions may help improve inter-radiologist agreement.

Treatment of IL-10RA deficiency of pediatric patients with very early onset inflammatory bowel disease by allogeneic haematopoietic stem cell transplantation

Very early onset inflammatory bowel disease (VEO-IBD) with interleukin-10 receptor-A (IL-10RA) defects is characterised by severe and unmanageable intestinal inflammation, perianal lesions, and a high mortality rate, with the onset of the disease occurring at a very early age. Currently, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is one of the most effective treatments for VEO-IBD patients with IL-10 signaling deficiency. The objective of this study was to evaluate the clinical effectiveness of allo-HSCT in the treatment of children with VEO-IBD and IL-10RA deficiency, and to provide further clinical insights. A retrospective analysis and summary of the clinical data of seven patients with VEO-IBD and IL-10RA deficiency from January 2021 to December 2023 was performed. These patients subsequently underwent allo-HSCT after receiving a reduced-intensity conditioning regimen followed by a cyclosporine-based regimen for the prevention of graft versus host disease (GVHD). Hematopoietic reconstruction was performed on seven children with VEO-IBD combined with IL-10RA deficiency. Four patients developed grade I-II GVHD, while three patients developed grade III-IV GVHD after undergoing allo-HSCT. At a median follow-up of 518 days after allo-HSCT (range: 210-1072 days), six patients were alive, while one patient died 16 months after the procedure because of chronic GVHD and severe infections. The 3-year cumulative overall survival (OS) probability rate was 80.0% (95% CI: 44.7-100.0). All VEO-IBD patients demonstrated weight gain following HSCT, with substantial improvements observed in severe malnutrition and growth retardation associated with IL-10RA deficiency post-transplantation. Allo-HSCT is thus identified as the optimal curative therapy for VEO-IBD patients with IL10-RA deficiency. The importance of early multidisciplinary intervention and co-management of VEO-IBD is paramount in improving HSCT outcomes.

Elemental Formulas: Indications of Use in Pediatric Clinical Practice

Background: Elemental or amino-acid-based formulas play a crucial role in pediatric nutrition, offering a therapeutic alternative when human milk is poorly tolerated or in specific disease states. Mostly used in various cases of allergy, maldigestion, or malnutrition, elemental formulas serve as a special therapeutic regimen in clinical practice to promote growth and development. Methods: This narrative review briefly surveys the literature of the past decade available on PubMed, Scopus, and Google Scholar, encompassing original research, review articles, and position papers. Results: The indications for using elemental formulas in pediatric clinical practice extend beyond cow's milk allergy to conditions such as eosinophilic esophagitis, intestinal failure, Crohn's disease, hepatic failure, chronic pancreatitis, and various neurological and other malnutrition-related disorders. Conclusions: Elemental formulas are associated with potential health benefits for pediatric patients in certain conditions, either as a first-line feeding option or under conditional use. Despite their drawbacks, they are regarded as a therapeutic tool with numerous indications, requiring careful implementation by a multidisciplinary team of healthcare experts. Future expert guidelines, including dosage, timing, and long-term effects of elemental diets, are needed for pediatric clinical practice.

Bibliometric analysis of Crohn's disease in children, 2014-2024

Background

In recent years, the incidence of Crohn's disease has risen significantly in the pediatric population, and its prolongation has had a major impact on children's physical and mental health as well as on the quality of life of their families, and has therefore received extensive attention from scholars around the world. A large number of articles have been published on Crohn's disease in children; however, there is still a lack of studies that use visualization methods for bibliometric analysis of relevant literature. The purpose of this paper is to statistically analyze the published literature in the field of Crohn's disease in children in order to help in the future diagnosis and treatment of Crohn's disease in children.

Methods

Literature meeting the inclusion criteria was screened from the Web of Science Core Collection database. Literature was visualized and analyzed by author, country, institution, journal, reference, and keyword using Citespace (6.2.R4) and VOSviewer (1.6.18).

Results

A total of 3,177 eligible publications were included. There is an overall increasing trend in the number of annual publications.Turner, Dan published the most number of articles with 78 and has a high impact in the field of CD. The most cited author was Levine, A. Among countries and institutions, the United States and Tel Aviv University had the highest number of publications. The journal with the most publications is Journal Of Pediatric Gastroenterology And Nutrition. The most co-cited journal was Inflammatory Bowel Diseases. The most cited document was ESPGHAN Revised Porto Criteria for the Diagnosis of Inflammatory Bowel Disease in Children and Adolescents, and the most cited document with the highest outbreak intensity was The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update.The most frequent keyword was "inflammatory bowel disease".

Conclusion

This study provides a visual summary of information for the field of pediatric Crohn's disease and contributes to international collaboration to promote research in the field of pediatric Crohn's disease.

Mucosal and Transmural Healing and Long-term Outcomes in Crohn's Disease

BACKGROUND

Healing in Crohn's disease is complex and difficult to measure due to incongruencies between clinical symptoms and disease states. Mucosal healing (MH) and transmural healing (TH) are increasingly used to measure clinical improvement in Crohn's disease, but definitions of MH and TH can vary across studies, and their relationship to long-term outcomes is not clear. To address this knowledge gap, we performed a systematic literature review (SLR) to examine studies measuring MH and TH in Crohn's disease.

METHODS

Database records from 2012 to 2022 were searched for real-world evidence and interventional studies that reported the association of MH or TH with clinical, economic, or quality of life outcomes of adult patients with Crohn's disease.

RESULTS

A total of 46 studies were identified in the systematic literature review, representing a combined patient population of 5530. Outcomes of patients with MH were reported by 39 studies; of these, 14 used validated scales for endoscopic assessment. Thirteen studies reported outcomes of patients with TH. Among studies that examined the outcomes of patients with and without MH or TH, patients with healing generally experienced improved clinical outcomes and reduced healthcare resource utilization, including fewer hospitalizations and surgeries and improved rates of clinical remission. This was especially true for patients with TH.

CONCLUSIONS

Mucosal and transmural healing are associated with positive long-term outcomes for adult patients with Crohn's disease. The adoption of standardized measures and less invasive assessment tools will maximize the benefits of patient monitoring.

Maintenance treatment with vedolizumab in paediatric inflammatory bowel disease (VEDOKIDS): 54-week outcomes of a multicentre, prospective, cohort study

BACKGROUND

Infliximab and adalimumab are the only biologics thus far approved for paediatric patients with inflammatory bowel disease (IBD), so other biologics, such as vedolizumab, are prescribed off-label. Despite its frequent use, prospective data for vedolizumab treatment in children are available only for short-term induction outcomes. We aimed to evaluate the long-term efficacy and safety of maintenance therapy with vedolizumab in paediatric patients with IBD.

METHODS

In this multicentre, prospective, cohort study (VEDOKIDS), children younger than 18 years with Crohn's disease, ulcerative colitis, or IBD unclassified (analysed with the ulcerative colitis group) who had initiated intravenous vedolizumab were enrolled from 17 centres in six countries (Israel, the USA, Italy, Ireland, Denmark, and Slovenia). Patients initiating vedolizumab to prevent postoperative recurrence were excluded. Vedolizumab dose or schedule were not standardised, and concomitant treatment with any other medication was permitted. Patients were prospectively followed up for 54 weeks, with repeated biosampling. The primary outcome was complete remission at week 54, defined as clinical remission (weighted Paediatric Crohn's Disease Activity Index [wPCDAI] of <12·5 points in Crohn's disease and Paediatric Ulcerative Colitis Activity Index [PUCAI] of <10 in ulcerative colitis) without the need for surgery, exclusive enteral nutrition for children with Crohn's disease, or steroids (steroid-free and exclusive enteral nutrition-free clinical remission) plus CRP concentration lower than 1·5 times the upper limit of normal (ULN) of 0·5 mg/dL. In cases of missing data on CRP, ESR was used instead (concentrations <1·5 times the ULN, which was 25 mm/h). Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT02862132.

FINDINGS

Between May 19, 2016, and April 1, 2022, we enrolled 142 patients. Five children who had received only one or two infusions of their three-infusion induction before switching drugs due to COVID-19 pandemic-related reasons were excluded, leaving 137 children (64 [47%] with Crohn's disease, 64 [47%] with ulcerative colitis, and nine [7%] with IBD unclassified; 63 [46%] male and 74 [54%] female; age range of 0·7-17·6 years) in the intention-to-treat population. The median wPCDAI score in children with Crohn's disease decreased from 35 (IQR 18 to 49) at baseline to 13 (0 to 25; median of differences -14 [95% CI -33 to 0]) at week 54, and the median PUCAI score in children with ulcerative colitis decreased from 25 (IQR 15 to 50) at baseline to 5 (0 to 25) at week 54 (median of difference -10 [-30 to 0]). Improvements in disease activity were significant by week 6, with no further significant changes between visits. At week 54, 16 (25%) of 64 children with Crohn's disease and 34 (47%) of 73 with ulcerative colitis or IBD unclassified were in complete remission. 38 vedolizumab-related adverse events were recorded in 29 (21%) of 137 children, the most common being headache (n=7), myalgia (n=4), and fever (n=4), and none were serious.

INTERPRETATION

Vedolizumab maintenance seems safe and efficacious in children, with a higher efficacy in those with ulcerative colitis than in those with Crohn's disease.

FUNDING

The European Crohn's and Colitis Organisation, the European Society for Paediatric Gastroenterology Hepatology and Nutrition, and Takeda.

A Complicated Matter: Predictors for Postoperative Infections After Bowel Resection in Pediatric Inflammatory Bowel Disease

INTRODUCTION

Children with inflammatory bowel disease (IBD) need surgery whenever medical therapy fails. The postoperative course is frequently accompanied by symptoms suggestive of infection, such as fever. The aim of our study was to analyze the postoperative course after bowel resection in pediatric IBD patients in relation to postoperative infections.

METHODS

All our pediatric IBD patients who underwent a bowel resection between 2012 and 2022 were retrospectively reviewed. Clinical data regarding surgery and the postoperative course were analyzed. The primary outcomes were signs and symptoms indicative of infection, such as fever, surgical site infection, and abscesses.

MAIN RESULTS

One hundred patients underwent an IBD-related resection, of whom 69 for Crohn's disease. A total of 42 postoperative infections occurred in 26 patients, most commonly a superficial surgical site infection (38 %). Out of 48 patients who experienced postoperative fever, 52 % had an actual infection, compared to 2 % of those without fever (p < 0.001). Preoperative use of immunomodulating therapy was not associated with higher complication rates. In 35 of 48 patients with fever (73 %) laboratory tests were done as a consequence of postoperative fever, with no differences in complication rates between patients with extremely high (>200 mg/L) and high (<200 mg/L) C-reactive protein levels.

CONCLUSIONS

Occurring in over a quarter of patients, postoperative infections are common in children after undergoing IBD-related bowel resection. Postoperative fever is indicative of an infection in half of the patients. Laboratory tests, such as serum C-reactive protein, do not seem to contribute to differentiating between complicated and non-complicated course after surgery in these patients.

Clinical effectiveness and safety of ustekinumab in youth with refractory inflammatory bowel disease: A retrospective cohort study

BACKGROUND

Inflammatory bowel disease (IBD) incidence and prevalence has been increasing worldwide. Limited data exists on the effectiveness of ustekinumab (UST) in children. We aimed to describe the effectiveness and safety of UST in pediatric patients with IBD.

METHODS

A single-center retrospective study was conducted between January 2017 and February 2022. The study included patients ≤16 years of age who were treated with UST and followed up for ≥1 year. Clinical remission was defined as a score of the Pediatric Crohn's Disease (CD) and Pediatric Ulcerative Colitis (UC) Activity Indices ≤10 at week 52.

RESULTS

Thirteen patients who had failed anti-tumor necrosis factor-α (anti-TNFα) therapy were included, eight (61.5%) with CD and five (38.5%) with UC. The median age was 13 years (interquartile range [IQR]: 11.5 to 14). UST treatment was initiated at a median age of 3 years (IQR: 2.3 to 7) after diagnosis. Ten patients (76.9%) achieved clinical remission. There were no statistically significant differences in characteristics between patients who achieved and did not achieve clinical remission. Biochemical remission (BioR) was achieved in six patients (46.2%). Body mass index (BMI) significantly improved, C-reactive protein (CRP) significantly decreased, and the need for corticosteroids significantly decreased in the remission group. Endoscopy conducted post-treatment in seven patients confirmed remission in six patients. Adverse events included two cases of infection and one of headache.

CONCLUSIONS

UST was effective as a secondary biologic therapy for the induction and maintenance of remission in patients with anti-TNFα refractory IBD. At one year, 84% of patients remained on UST with no severe adverse reactions reported.

Are Vitamin D Levels Related to Sarcopenia in Children with Inflammatory Bowel Disease?

Background: Data on the impacts of vitamin D deficiency on sarcopenia in pediatric patients with inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are lacking. We aimed to investigate the relationships between vitamin D levels and sarcopenia in patients with newly diagnosed IBD. Methods: A cross-sectional, retrospective study was conducted in a tertiary care children's hospital. Pediatric IBD patients who underwent magnetic resonance (MR) enteroclysis at the time of initial diagnosis were included. Total psoas muscle area (tPMA) at the L4/L5 intervertebral level was demonstrated on MR by scanning the right and left psoas muscle areas. Sarcopenia was defined as a measurement under the 10th percentile according to MR-derived reference values of tPMA percentile charts for healthy children aged 1-18 years. Vitamin D insufficiency was defined as a serum 25-OH-D level below 30 ng/mL and deficiency as that below 20 ng/mL. Collected data from demographic evaluation, clinic, and laboratory tests were statistically assessed. Results: According to the MR-derived reference values of tPMA, 85% (n = 33) of UC and 81% (n = 21) of CD patients had sarcopenia. The severe vitamin D deficiency ratio was 35.9% (n = 14) in UC and 38.5% (n = 10) in CD. We found that vitamin D levels were similar in patients with UC and CD, while they were significantly lower in the group below the 3rd percentile of tPMA (n = 41, median 9.8) than in the group between the 3rd and 10th percentiles (n = 13, median 16.9; p = 0.038). Conclusions: Formulating strategies to recognize and prevent sarcopenia, including the prevention and-if necessary-the treatment of vitamin D deficiency, could bring multi-faceted benefits.

Erythrocyte Methotrexate-Polyglutamate Concentrations in Pediatric Inflammatory Bowel Disease

BACKGROUND AND AIMS

Therapeutic drug monitoring (TDM) of methotrexate (MTX) is challenging due to its pharmacokinetics and short plasma half-life. Intracellular MTX-polyglutamates (PG1-5), which accumulate over time, have not been assessed in pediatric inflammatory bowel disease (IBD). This study aimed to evaluate erythrocyte MTX-PG as a potential TDM tool in pediatric IBD.

METHODS

In this cross-sectional study, MTX-PG concentrations were measured in erythrocytes of children with IBD on stable low-dose MTX for at least 12 weeks using stable-isotope dilution liquid chromatography-tandem mass spectrometry. The influence of administration route, MTX dosage, and anthropometrics on MTX-PG concentrations was examined.

RESULTS

Seventy-eight patients were included, showing MTX-PG3 as the predominant subspecies (median 27.0 nmol/L) with a median MTX-PGtotal of 74.8 nmol/L. A higher MTX dose correlated significantly with elevated levels of MTX-PG3, MTX-PG4, MTX-PG5, and MTX-PGtotal (P < .01). Adjusted for body surface area, MTX dose remained significantly associated with higher MTX-PG concentrations (P < .01). However, comparison by administration route was limited due to a few patients on subcutaneous MTX (n = 4).

CONCLUSIONS

We observed high interindividual variability in the reached erythrocyte MTX-PG concentrations. Body surface adjusted or unadjusted MTX dosage showed a positive linear correlation with erythrocyte MTX-PG concentrations in children with IBD. This is a prerequisite for TDM and provides a strong basis for further research into the relation between TDM of MTX, efficacy, and toxicity.

Metagenome-informed metaproteomics of the human gut microbiome, host, and dietary exposome uncovers signatures of health and inflammatory bowel disease

Host-microbiome-dietary interactions play crucial roles in regulating human health, yet their direct functional assessment remains challenging. We adopted metagenome-informed metaproteomics (MIM), in mice and humans, to non-invasively explore species-level microbiome-host interactions during commensal and pathogen colonization, nutritional modification, and antibiotic-induced perturbation. Simultaneously, fecal MIM accurately characterized the nutritional exposure landscape in multiple clinical and dietary contexts. Implementation of MIM in murine auto-inflammation and in human inflammatory bowel disease (IBD) characterized a "compositional dysbiosis" and a concomitant species-specific "functional dysbiosis" driven by suppressed commensal responses to inflammatory host signals. Microbiome transfers unraveled early-onset kinetics of these host-commensal cross-responsive patterns, while predictive analyses identified candidate fecal host-microbiome IBD biomarker protein pairs outperforming S100A8/S100A9 (calprotectin). Importantly, a simultaneous fecal nutritional MIM assessment enabled the determination of IBD-related consumption patterns, dietary treatment compliance, and small intestinal digestive aberrations. Collectively, a parallelized dietary-bacterial-host MIM assessment functionally uncovers trans-kingdom interactomes shaping gastrointestinal ecology while offering personalized diagnostic and therapeutic insights into microbiome-associated disease.

Dysplasia in Pediatric Patients with Inflammatory Bowel Disease Shows Distinct Clinicopathologic Features Compared to that in Adult Patients

Due to its rarity, there is limited information on the clinicopathologic features of dysplasia in pediatric patients with inflammatory bowel disease (IBD). The existing surveillance guidelines for these patients do not include dysplasia as a potential risk factor for colorectal cancer (CRC), and there is no clear guidance on the optimal strategy for detecting dysplasia. As such, we analyzed the clinicopathologic features of 20 IBD patients who developed at least one instance of dysplasia (n = 56) before the age of 21 years. The results were then compared with data from a previously published adult cohort, which included 315 dysplastic lesions from 167 consecutive adult IBD patients. The study group consisted of 11 males and 9 females, with a mean age of 11 years at the time of IBD diagnosis. The mean age at the time of the first dysplasia diagnosis was 18 years for the study group compared to 54 years for the adult group. The study group had a lower incidence of ulcerative colitis (65% vs. 92% in the adult group, p < 0.001), but the proportion of patients with concurrent primary sclerosing cholangitis (PSC) was nearly double that of the adult group (25% vs. 13%, p = 0.129). Dysplasia in the study group was more likely to be nonconventional (38%, p = 0.047) and invisible or flat (50%, p < 0.001) compared to the adult group (25% and 24%, respectively). High-risk nonconventional dysplastic subtypes, including crypt dysplasia (13%, p = 0.016), goblet cell-deficient dysplasia (11%, p = 0.010), and hypermucinous dysplasia (9%, p = 0.009), were more common in the study group compared to the adult group (4%, 3%, and 2%, respectively). The mean duration from IBD diagnosis to the first dysplasia diagnosis was significantly shorter in the study group (8 years) than in the adult group (16 years) (p = 0.005). While dysplastic lesions in the adult group were more likely to present as high-grade dysplasia (HGD) at initial diagnosis (17% vs. 4% in the study group, p = 0.008), the rate of advanced neoplasia (HGD or CRC) on follow-up was similar between the two groups (26% in the adult group vs. 22% in the study group, p = 1.000). In conclusion, dysplasia in pediatric IBD patients is often associated with nonconventional features (including the high-risk subtypes), an invisible/flat appearance, concurrent PSC, and early development (within 8 years of IBD diagnosis).

Pediatric to Adult Transition in Inflammatory Bowel Disease: Consensus Guidelines for Australia and New Zealand

BACKGROUND

The incidence of pediatric inflammatory bowel disease (IBD) is rising, and there is an increasing need to support adolescents when they transition to adult care. Evidence supports the use of a structured transition process but there is great variation across Australasia. The study aim was to develop evidence and expert opinion-based consensus statements to guide transitional care services in IBD.

METHODS

A modified UCLA-RAND methodology was employed to develop consensus statements. An IBD expert steering committee was formed and a systematic literature review was conducted to guide the drafting of consensus statements. A multidisciplinary group was formed comprising 16 participants (clinicians, nurses, surgeons, psychologists), who anonymously voted on the appropriateness and necessity of the consensus statements using Likert scales (1 = lowest, 9 = highest) with a median ≥7 required for inclusion. Patient support groups, including direct input from young people with IBD, informed the final recommendations.

RESULTS

Fourteen consensus statements were devised with key recommendations including use of a structured transition program and transition coordinator, mental health and transition readiness assessment, key adolescent discussion topics, allied health involvement, age for transition, and recommendations for clinical communication and handover, with individualized patient considerations. Each statement reached median ≥8 for appropriateness, and ≥7 for necessity, in the first voting round, and the results were discussed in an online meeting to refine statements.

CONCLUSIONS

A multidisciplinary group devised consensus statements to optimize pediatric to adult transitional care for adolescents with IBD. These guidelines should support improved and standardized delivery of IBD transitional care within Australasia.

Pharmacogenomic Assessment of Genes Implicated in Thiopurine Metabolism and Toxicity in a UK Cohort of Pediatric Patients With Inflammatory Bowel Disease

BACKGROUND

Thiopurine drugs are effective treatment options in inflammatory bowel disease and other conditions but discontinued in some patients due to toxicity.

METHODS

We investigated thiopurine-induced toxicity in a pediatric inflammatory bowel disease cohort by utilizing exome sequencing data across a panel of 46 genes, including TPMT and NUDT15.

RESULTS

The cohort included 487 patients with a median age of 13.1 years. Of the 396 patients exposed to thiopurines, myelosuppression was observed in 11%, gastroenterological intolerance in 11%, hepatotoxicity in 4.5%, pancreatitis in 1.8%, and "other" adverse effects in 2.8%. TPMT (thiopurine S-methyltransferase) enzyme activity was normal in 87.4%, intermediate 12.3%, and deficient in 0.2%; 26% of patients with intermediate activity developed toxicity to thiopurines. Routinely genotyped TPMT alleles associated with defective enzyme activity were identified in 28 (7%) patients: TPMT*3A in 4.5%, *3B in 1%, and *3C in 1.5%. Of these, only 6 (21%) patients developed toxic responses. Three rare TPMT alleles (*3D, *39, and *40) not assessed on routine genotyping were identified in 3 patients, who all developed toxic responses. The missense variant p.R139C (NUDT15*3 allele) was identified in 4 patients (azathioprine 1.6 mg/kg/d), but only 1 developed toxicity. One patient with an in-frame deletion variant p.G13del in NUDT15 developed myelosuppression at low doses. Per-gene deleteriousness score GenePy identified a significant association for toxicity in the AOX1 and DHFR genes.

CONCLUSIONS

A significant association for toxicity was observed in the AOX1 and DHFR genes in individuals negative for the TPMT and NUDT15 variants. Patients harboring the NUDT15*3 allele, which is associated with myelosuppression, did not show an increased risk of toxicity.

Inflammatory Bowel Disease in Children: Current Diagnosis and Treatment Strategies

Pediatric inflammatory bowel disease (PIBD), including Crohn's disease and ulcerative colitis, has emerged as a significant global health challenge with rising incidence rates. Unlike adult inflammatory bowel disease, PIBD presents complexities, including growth impairment, nutritional deficiencies, and psychosocial challenges that necessitate tailored management strategies. This article reviews current diagnostic and emerging treatment strategies to highlight the evolution from traditional therapies such as aminosalicylates, corticosteroids, and immunomodulators to advanced biologic agents like infliximab and adalimumab. Emerging biological therapies, including vedolizumab and ustekinumab, show promise, while novel small molecule therapies such as Janus kinase (JAK) inhibitors are under investigation for potential use in the pediatric population. Supportive treatments, including exclusive enteral nutrition, modified diets, and probiotics, play a critical role in comprehensive disease management. Stem cell therapy and fecal microbiota transplant represent innovative approaches still under clinical evaluation. The review underscores the significance of holistic care, incorporating mind-body interventions and psychosocial support to improve patient quality of life. Key challenges persist, such as infection risks associated with long-term biological therapy use, gaps in pediatric-specific guidelines, and the limited inclusion of children in clinical trials. Future recommendations emphasize the importance of structured transition programs bridging pediatric and adult care, regular updates to clinical guidelines, and the integration of precision medicine to personalize treatment plans. Continued research and collaboration are essential for advancing the understanding and management of PIBD, ensuring that pediatric patients benefit from the most effective, evidence-based care available.

Shaoyao decoction alleviates DSS-induced colitis by inhibiting IL-17a-mediated polarization of M1 macrophages

ETHNOPHARMACOLOGICAL RELEVANCE

The efficacy of Shaoyao decoction (SYD), a traditional Chinese medicine prescription, in alleviating colonic mucosal inflammation in ulcerative colitis (UC) has been established. However, the specific mechanism underlying the therapeutic effects of SYD on UC is not clear.

AIM OF STUDY

In this study, we demonstrated the therapeutic effect of SYD on the polarization of M1 macrophages and elucidated the underlying mechanism.

MATERIALS AND METHODS

UC mice were induced with 3% DSS for one week and subsequently treated with SYD for another week. The composition of SYD was determined by HPLC. To assess the therapeutic efficacy of SYD, key parameters, including body weight changes, DAI scores, colon length, and histological alterations in colonic tissues, were monitored. ELISA was performed to quantify inflammatory cytokines, while Western blotting and immunofluorescence analyses were performed to quantify tight junction protein expression and M1 macrophage infiltration, respectively. Functional assessments focused on lysosomal activity and glucose oxidation in primary macrophages and RAW 264.7 cells exposed to LPS, IL-17a, and SYD using dedicated kits. To elucidate the mechanisms underlying the action of SYD, the data derived from TMT-based proteomics were analyzed to screen and predict its potential targets and regulated pathways.

RESULTS

After treatment for seven days, SYD significantly mitigated colitis symptoms in mice, as determined by a decrease in body weight loss, an increase in colon length, and a decrease in disease activity index (DAI) score. The results of histopathological analysis showed substantial improvements in the integrity of colonic tissue. Additionally, SYD treatment significantly decreased the levels of proinflammatory cytokines, including IL-17a, IL-6, IL-1β, and TNF-α. This effect was accompanied by a reduction in the infiltration of CD86+ macrophages and restoration of occludin and ZO-1 levels, thus improving colonic mucosal permeability. SYD treatment also reversed the upregulation of cathepsin (CTS) E, CTSS, lysosomal-associated membrane protein (LAMP)-1, and LAMP-2 expression observed in CD86+ macrophages and RAW 264.7 cells treated with IL-17a. These changes were accompanied by an increase in lysosomal acidification and the enzymatic activities of CTSE and CTSS, suggesting that SYD can restore lysosomal function. SYD also corrected the metabolic alterations in M1 macrophages, characterized by an increase in the extracellular acidification rate (ECAR) and a decrease in oxygen consumption rate (OCR). This was confirmed by a decrease in the ADP/ATP ratio, downregulation of pyruvate dehydrogenase kinase 4 (PDK4) and lactate dehydrogenase (LDH) expression, and a decrease in the concentrations of intracellular pyruvate and lactate. These findings showed that SYD promotes glucose oxidation in macrophages. The data derived from TMT-based proteomics showed that the PPAR pathway was a key target in regulating the polarization of M1 macrophages. SYD was also found to regulate the expression of the PPAR-α, PPAR-γ, and PPAR-δ proteins.

CONCLUSION

SYD inhibited the polarization of M1 macrophages induced by IL-17a. This effect occurred due to the restoration of lysosomal activity and glucose oxidation via activation of the PPAR/NF-κB pathway. Our findings provided novel insights into the mechanisms underlying the therapeutic effects of SYD in UC.

Laparoscopic intracorporeal anastomosis vs open anastomosis for ileostomy reversal in Crohn's disease: A single center retrospective study

BACKGROUND

There is an increased maturation of laparoscopic intracorporeal anastomosis techniques. However, research on its application for small bowel stoma reversal in patients with Crohn's disease (CD) is limited. Therefore, in this study, we compared the perioperative outcomes between laparoscopic intracorporeal ileostomy reversal (LIIR) and open ileostomy reversal (OIR).

AIM

To compare the safety, feasibility, bowel function recovery, and short- and long-term LIIR and OIR outcomes in patients with CD.

METHODS

This study included patients who underwent ileal reversal for CD between January 2021 and January 2023 at our institution. The baseline data, postoperative recovery, and complication indicators were retrospectively analyzed. Logistic regression analysis was conducted to explore factors that significantly influenced the development of enteral nutrition intolerance-related symptoms.

RESULTS

Notably, 15 of the 45 patients in this study underwent OIR, and the remaining 30 received LIIR. Notably, no statistically significant differences were found between the two groups regarding clinical baseline characteristics, operation time, intraoperative hemorrhage, anastomotic site, enterolysis range, first postoperative flatus, postoperative complications, reoperation rate, or incidence of postoperative enteral nutrition intolerance. Compared with the OIR group, the LIIR group had a shorter postoperative hospital stay (P = 0.045), lower incidence of enteral nutrition intolerance symptoms (P = 0.019), and earlier postoperative total enteral nutrition initiation (P = 0.033); however, it incurred higher total hospital costs (P = 0.038). Furthermore, multivariate logistic regression analysis revealed that the duration of surgery and anastomotic technique were independent risk factors for postoperative symptoms of enteral nutrition intolerance (P < 0.05).

CONCLUSION

Laparoscopic intracorporeal anastomosis for ileostomy reversal is safe and feasible. Patients who underwent this technique demonstrated improved tolerance to postoperative enteral nutrition and quicker resumption of total enteral nutrition.

Precise and interpretable neural networks reveal epigenetic signatures of aging across youth in health and disease

Introduction

DNA methylation (DNAm) age clocks are powerful tools for measuring biological age, providing insights into aging risks and outcomes beyond chronological age. While traditional models are effective, their interpretability is limited by their dependence on small and potentially stochastic sets of CpG sites. Here, we propose that the reliability of DNAm age clocks should stem from their capacity to detect comprehensive and targeted aging signatures.

Methods

We compiled publicly available DNAm whole-blood samples (n = 17,726) comprising the entire human lifespan (0-112 years). We used a pre-trained network-coherent autoencoder (NCAE) to compress DNAm data into embeddings, with which we trained interpretable neural network epigenetic clocks. We then retrieved their age-specific epigenetic signatures of aging and examined their functional enrichments in age-associated biological processes.

Results

We introduce NCAE-CombClock, a novel highly precise (R2 = 0.978, mean absolute error = 1.96 years) deep neural network age clock integrating data-driven DNAm embeddings and established CpG age markers. Additionally, we developed a suite of interpretable NCAE-Age neural network classifiers tailored for adolescence and young adulthood. These clocks can accurately classify individuals at critical developmental ages in youth (AUROC = 0.953, 0.972, and 0.927, for 15, 18, and 21 years) and capture fine-grained, single-year DNAm signatures of aging that are enriched in biological processes associated with anatomic and neuronal development, immunoregulation, and metabolism. We showcased the practical applicability of this approach by identifying candidate mechanisms underlying the altered pace of aging observed in pediatric Crohn's disease.

Discussion

In this study, we present a deep neural network epigenetic clock, named NCAE-CombClock, that improves age prediction accuracy in large datasets, and a suite of explainable neural network clocks for robust age classification across youth. Our models offer broad applications in personalized medicine and aging research, providing a valuable resource for interpreting aging trajectories in health and disease.

Usefulness of Fecal Calprotectin Measurement in a Pediatric Patient with Crohn's Disease

Acute pancreatitis in children in Japan is often caused by an anatomical abnormality of the pancreatic and bile duct, resulting in fever, abdominal pain, vomiting, diarrhea, and other symptoms.　Crohn's disease, however, is a chronic granulomatous inflammatory bowel disease with ulcerative lesions of the intestinal tract of unknown cause that occurs mainly in young people, with symptoms similar to those of acute pancreatitis.　We report a case of acute pancreatitis diagnosed in a patient not only with incomplete fusion of the pancreatic duct but also with Crohn's disease.　A 14-year-old girl, healthy by nature, presented to our hospital with complaints of abdominal pain and diarrhea.　She was initially diagnosed as having acute pancreatitis due to incomplete pancreas divisum.　However, a high level of fecal calprotectin led to endoscopic examination, which resulted in the diagnosis of Crohn's disease.　Fecal calprotectin can be useful in the diagnosis of inflammatory bowel disease associated with acute pancreatitis in children.　Although the relationship between inflammatory bowel disease and acute pancreatitis has not yet been clarified, we suggest that in the present case, acute pancreatitis may have manifested as a complication of Crohn's disease and an underlying case of incomplete pancreas divisum.

Laparoscopic robotic-assisted ileo-caecal resection with intracorporeal anastomosis in children with Crohn disease: initial experience of a paediatric center and surgical feasibility

PURPOSE

Pediatric-onset Crohn's disease (CD) presents with a more aggressive course than adults. Surgical treatment is still necessary in many patients. The laparoscopic technique for treating terminal ileal CD is deemed safe and feasible, with the advantage to perform an intra-corporeal anastomosis (ICA). The robotic platform facilitates ICA creation thanks to 3D-visualization, tenfold magnification and better dexterity. The aim of this study was to report our initial experience of robotic ileocecal resection (RICR) with ICA in children with CD.

METHODS

Six patients underwent RICR for CD. Patient characteristics, intraoperative details, and postoperative outcomes were collected. The surgical technique consisted in an intra-corporeal ICR with a stapled side-to-side ileo-colic anastomosis.

RESULTS

The mean age at surgery was 14.8 years. The mean operative time was 210.8 min. No intraoperative complications or conversions were recorded. Bowel function returned on postoperative day 3 and the mean hospital stay was 8 days. Two minor complications were treated conservatively and 1 major (anastomotic dehiscence) required reoperation.

CONCLUSION

RICR is a safe and feasible technique in pediatric CD of terminal ileum. The robot offers advantages over other techniques for the precision of the suture, avoiding extracorporeal anastomosis. However, larger studies are needed to confirm these preliminary results.

Anti-Tumor Necrosis Factor-α Use in Pediatric Inflammatory Bowel Disease-Reports from a Romanian Center

Background/Objectives: The introduction of anti-tumor necrosis factor-α (anti-TNF-α) agents, particularly infliximab (IFX) and adalimumab (ADA), has significantly expanded the therapeutic arsenal for inflammatory bowel disease (IBD). While these biologics have demonstrated substantial efficacy, they are associated with a spectrum of potential adverse events (AEs). This study aims to evaluate and document these AEs to facilitate optimal patient selection and monitoring strategies of patients undergoing these therapies. Methods: This retrospective, single-center study examined pediatric IBD patients receiving anti-TNF-α therapy at the "Grigore Alexandrescu" Emergency Hospital for Children in Bucharest, Romania, from January 2015 to October 2024. AEs were categorized into non-infectious complications (acute infusion reactions, anti-drug antibody formation), dermatological effects (erythema nodosum, vasculitis), neurological effects (Guillain-Barré syndrome), and infections. AEs were analyzed in relation to the specific anti-TNF-α agent administered and comprehensively characterized. Results: Of 40 patients enrolled, 22 (55%) had Crohn's disease (CD). The median (IQR) age at diagnosis was 14.8 years [10.8-15.9]. IFX was used in 34 (85%) patients while 6 (15%) patients received either ADA or IFX/ADA sequential therapy. Twenty-seven AEs were documented in 19 (47.5%) patients, the most prevalent being antidrug antibody formation (44.4%), infections (22.2%), and acute infusion reactions (22.2%). All ADA-exposed patients experienced at least one AE, compared to 41.2% (n = 14) patients treated with IFX, p = 0.01. Conclusions: AEs were observed in approximately half of the study cohort, with anti-drug antibody formation emerging as the most frequent complication. ADA therapy was associated with a significantly higher rate of AEs compared to IFX. These findings underscore the critical importance of vigilant monitoring for patients undergoing anti-TNF-α therapy in pediatric IBD management.

Early Surgical Resection in Pediatric Patients with Localized Ileo-Cecal Crohn's Disease: Results of a Retrospective Multicenter Study

Background: Crohn's disease (CD) is an inflammatory bowel disease (IBD) that also affects pediatric patients. It frequently presents as a localized disease, affecting the ileocecal area, ileum, or colon. It requires targeted therapy to achieve a good quality of life and long-term control of disease activity. Despite multiple medical therapies available, several patients benefit from surgical treatment. The aim of our study is to demonstrate how an early surgical approach can bring an improvement in disease activity, evaluating the Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Pediatric Crohn's Disease Activity Index (PCDAI). Methods: A retrospective multicenter study was carried out from 2008 to 2023, including 29 patients, affected by localized CD. These data were analyzed: demographics, SES-CD, and PCDAI, before and after surgery. The differences between groups were analyzed using Student's t-test for continuous variables, and Pearson's Chi-squared test or Fisher's exact test for categorical variables. Results: The SES-CD significantly decreased from 12 (median, range 1-15) to 0 (median, range 0-6) (p < 0.0001) and the PCDAI decreased from 30 (median, range 10-50) to 0 (median, range 0-15) (p < 0.0001). The rate of patients receiving enteral nutrition decreased from 51.7% preoperatively to 0% postoperatively (p = 0.0001). The rate of antibiotic use decreased from 13.8% to 0% (p = 0.0001). The rate of patients receiving ≥2 drugs decreased from 10.3% to 0% (p = 0.0001). Conclusions: The early surgical approach can be considered an excellent therapeutic strategy in patients with localized CD. Both parameters examined, SES-CD and PCDAI, demonstrated a clear improvement in the endoscopic images and in disease activity.

Intestinal tissue levels of anti-TNF alpha, antibodies, and cytokines in paediatric Crohn disease

The aim was to explore factors associated with intestinal tissue levels of anti-TNF alpha (anti-TNF), anti-TNF antibodies, and cytokines in pediatric patients with Crohn Disease (CD). In a prospective exploratory study of CD patients undergoing ileocecal resection or colonoscopy between 6/2020 and 1/2023, we analysed tissue levels of anti-TNF, anti-TNF antibodies, and cytokines (TNF-α, IL-17, IL-1β, IFN-γ) from intestinal biopsies. Mixed-effects regression models, adjusted for potential confounders, were used. Data from 27 CD patients (18 females, 66.7%) were analysed. Fourteen (52%) received adalimumab (ADA) and thirteen received infliximab (IFX), with a median therapy duration of 17 (IQR 4.5-41.5) months. Higher levels of free anti-TNF were found in macroscopically inflamed tissue compared to non-inflamed tissue (β = 3.42, 95% CI 1.05-6.10). No significant association was found between serum and tissue anti-TNF levels (β= -0.06, 95% CI - 0.70-0.58). Patients treated longer with anti-TNF had increased IL-17 levels (β = 0.19, 95% CI 0.05-0.33), independent of disease duration and age. IFN-γ levels were linked with both follow-up duration and anti-TNF length. Our study shows significantly higher free drug levels in inflamed tissue. Long-term anti-TNF treatment has been linked to increased IL-17 levels, suggesting a possible impact on the cytokine response pathway. We did not observe a relationship between serum and tissue anti-TNF levels.

The Nancy Histopathological Index has limited value in predicting clinical outcomes in newly diagnosed pediatric patients with ulcerative colitis

The Nancy Histological Index (NHI) is used to score histologic disease activity in patients with ulcerative colitis (UC). Our goal was to assess the utility of NHI at diagnosis in predicting clinical outcomes in pediatric patients with UC, in comparison to clinical and endoscopic scores. We retrospectively reviewed data at diagnosis of 106 children with UC (59 [55.7%] females; median age 14.4 [11.2-15.9] years, median Pediatric Ulcerative Colitis Activity Index [PUCAI] 35 [25-55]). During a follow-up of 116 (55-171) weeks, 33 patients (31.1%) required azathioprine therapy, and 32 (30.2%) were escalated to anti-tumor necrosis factor alpha (anti-TNFa). The PUCAI and Mayo endoscopic scores at diagnosis were significantly associated with escalation to anti-TNFa (p = 0.036 and p = 0.02, respectively), but not with initiation of azathioprine or subsequent acute severe colitis (ASC) events. However, the NHI was not associated with subsequent immunomodulators or anti-TNFa therapy (p = 0.42 and p = 0.78, respectively), nor with future ASC events (p = 0.70). In conclusion, the NHI failed to predict clinical outcomes in newly diagnosed pediatric patients with UC.

Review on Advances in Pediatric Endoscopy in the Management of Inflammatory Bowel Disease

Over the past decades, an increased importance has been given to gastrointestinal (GI) endoscopy in the management of children with inflammatory bowel diseases (IBD), considering that mucosal healing has been recognized as the optimal endpoint in the treat-to-target paradigm. The recent advances in technology and anesthesia have facilitated the comprehensive evaluation of the GI tract. In this review, we will discuss the role of ileocolonoscopy, upper GI endoscopy, and device-assisted enteroscopy in the work-up and management of pediatric Crohn's disease (CD) and ulcerative colitis, with particular attention on non-invasive endoscopic techniques, such as wireless capsule endoscopy. We will also analyze the most commonly used endoscopic scoring systems, including small bowel scoring systems and endoscopic recurrence grading of neo-terminal ileum CD. Moreover, we will focus on the endoscopic management of complications, such as strictures, that commonly require surgery. Lastly, we will discuss cancer surveillance in children with IBD, with particular consideration of the role of high-definition endoscopic equipment and chromoendoscopy in dysplasia detection rates.

Long-term follow-up of children with Crohn's disease and small bowel mucosal lesions detected through video capsule endoscopy

OBJECTIVES

We report disease outcomes of pediatric Crohn's disease (CD) affecting the proximal small bowel (SB) and detected through video capsule endoscopy (VCE).

METHODS

We undertook a retrospective review of CD patients with VCE performed under age 18 between 2003 and 2017 and having received any biologics. We identified patients from our institutional registry.

RESULTS

Eligible patients (n = 118) had their first VCE performed after a median of 0.1 years after diagnostic endoscopies at a median age of 12.2 years. The proximal SB disease group (Paris classification L4b inclusive) comprised 70 patients with extensive SB lesions in 81% and deep ulcers in 79%. Patients with Paris L1-3 disease with no findings in VCE or disease restricted to the terminal ileum comprised the control group. At first VCE, levels of albumin (34 vs. 37 g/L) and hemoglobin (117 vs. 127 g/L) were lower in SB patients (p < 0.02). After the first VCE, 68% were introduced to biologics, while 10% already received them. Follow-up VCE was performed after a median of 2.4 years (SB group n = 42; controls n = 21). Proximal SB findings had disappeared in 40% of SB patients, and extensive lesions and deep ulcers had decreased to 26% and 29%, respectively (p = 0.001). In the control group, one had progressed to proximal disease. During the clinical follow-up of a median of 4.7 years, one patient with SB underwent surgery for a jejunal stricture.

CONCLUSIONS

Proximal SB disease detected through capsule endoscopy abated in most patients with biological medication.