Development of the Crohn's disease digestive damage score, the Lémann score

Cross-sectional imaging modalities in Crohn's disease

The standard tools assessing the activity of Crohn's disease (CD) measure the severity of symptoms (the Crohn's Disease Activity Index) or the degree of endoscopic lesions (the Crohn's Disease Endoscopic Index of Severity, the Simplified Endoscopy Score), not the global bowel damage. It is necessary to find new instruments able to assess the structural and functional damage to the intestine and the progression over time. We reviewed recent publications on the accuracy of abdominal ultrasound (US), computed tomography enterography (CTE), and magnetic resonance imaging enterography (MRE) for the assessment of CD. US, CTE and MRE have been shown to have a high and comparable diagnostic accuracy for both the diagnosis and complications of CD, but US and MRE have the major advantage of not imparting ionizing radiation. In summary, findings from these imaging modalities with endoscopic lesions and surgical history incorporating into the Lémann score will allow measuring the global bowel damage at specific time and the progression of disease over time and assessing the impact of different strategies.

Optimising monitoring in the management of Crohn's disease: a physician's perspective

Management of Crohn's disease has traditionally placed high value on subjective symptom assessment; however, it is increasingly appreciated that patient symptoms and objective parameters of inflammation can be disconnected. Therefore, strategies that objectively monitor inflammatory activity should be utilised throughout the disease course to optimise patient management. Initially, a thorough assessment of the severity, location and extent of disease is needed to ensure a correct diagnosis, identify any complications, help assess prognosis and select appropriate therapy. During follow-up, clinical decision-making should be driven by disease activity monitoring, with the aim of optimising treatment for tight disease control. However, few data exist to guide the choice of monitoring tools and the frequency of their use. Furthermore, adaption of monitoring strategies for symptomatic, asymptomatic and post-operative patients has not been well defined. The Annual excHangE on the ADvances in Inflammatory Bowel Disease (IBD Ahead) 2011 educational programme, which included approximately 600 gastroenterologists from 36 countries, has developed practice recommendations for the optimal monitoring of Crohn's disease based on evidence and/or expert opinion. These recommendations address the need to incorporate different modalities of disease assessment (symptom and endoscopic assessment, measurement of biomarkers of inflammatory activity and cross-sectional imaging) into robust monitoring. Furthermore, the importance of measuring and recording parameters in a standardised fashion to enable longitudinal evaluation of disease activity is highlighted.

Magnetic resonance enterography in Crohn's disease: a guide to common imaging manifestations for the IBD physician

Patients with Crohn's disease (CD) frequently require cross-sectional imaging. Magnetic resonance enterography (MRE) is an accurate tool for assessment of bowel disease and of various complications of CD. The lack of non-ionizing radiation exposure is an important advantage of this imaging modality. Familiarity with common and pathognomonic imaging features of CD is essential for every clinician that is involved in inflammatory bowel disease (IBD) patients' care. This review is aimed to describe the indications for performing MRE in CD, essentials of MRE techniques and typical radiological findings in patients with CD to aid the IBD doctor in daily practice.

Drug advances in inflammatory bowel disease

The pathogenesis of inflammatory bowel disease (IBD) remains incompletely understood, but is thought to be a consequence of immune dysregulation, impaired mucosal integrity, enteric bacterial dysbiosis and genetic susceptibility factors. Recent drug advances in the treatment of IBD have clarified the role of existing medication, including 5-amino-salicylic acids (5-ASAs) and has seen a burgeoning use of treatment with biologicals. With recent advances in our understanding of these debilitating diseases, it is hoped that novel therapeutic targets can be identified.

Serial magnetic resonance imaging for monitoring medical therapy effects in Crohn's disease

BACKGROUND

Tumor necrosis factor (TNF) antagonists can induce mucosal healing in patients with Crohn's disease (CD), but the effects on transmural inflammation and stenotic lesions are largely unknown.

METHODS

We performed a retrospective study in 50 patients (54% female, median age 37 yr) with CD who had undergone serial magnetic resonance imaging (MRI) examinations while receiving infliximab or adalimumab. Patients were grouped as clinical responders or nonresponders based on physician's assessment, laboratory, and endoscopic appearance. MRI scoring was performed by 2 radiologists in consensus blinded to clinical data using a validated MRI scoring system. In total, 64 lesions on MRI were identified for analysis. Analyses were performed using paired t test and Wilcoxon rank test.

RESULTS

During anti-TNF treatment, MRI inflammation scores improved in 29 of 64 lesions (45.3%), remained unchanged in 18 of 64 lesions (28.1%), or deteriorated in 17 of 64 lesions (26.6%) over time. In the anti-TNF responder group, the mean intestinal inflammation score of all lesions improved from 5.19 to 3.12 (P < 0.0001). The mean inflammation scores in stenotic lesions in anti-TNF responders also improved significantly, from 6.33 to 4.58 (P = 0.01). In contrast, the mean inflammation scores did not change significantly (5.55-5.92, P = 0.49) in nonresponders. Diagnostic accuracy of anti-TNF response on MRI was 68%.

CONCLUSIONS

Improved inflammatory activity on serial MRI scans was observed in patients with clinical response to medical therapy with anti-TNF agents in luminal CD. MRI can be used as a complementary approach to measure transmural inflammation in patients with CD and guide the optimal use of TNF antagonists in daily clinical practice.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Predictive factors for an uncomplicated long-term course of Crohn's disease: a retrospective analysis

BACKGROUND

Predictive factors for a mild course of Crohn's disease (CD) may have therapeutic consequences, but as yet have not been identified.

AIMS

To identify baseline factors that predict mild CD and design a predictive scoring system.

METHODS

A retrospective, multicenter study of newly diagnosed CD patients allocated to mild CD (no therapy, mesalazine only, or mesalazine with a single initial short course of low-dose prednisone) or moderate CD (all other patients including resected patients).

RESULTS

162 patients (median follow-up 43 months) were analyzed: 47 mild CD and 115 moderate CD. For mild CD versus moderate CD, mean age at first diagnosis was higher (41.1 versus 33.9 years, p=0.02), mean C-reactive protein (CRP) concentration was lower (1.6 versus 3.6 mg/L, p<0.01), and perianal lesions were less frequent (0% versus 10.4%, p=0.02). The combined incidence of complications (stenosis, any type of fistula, extraintestinal complications or fever) was 21.3% in mild CD versus 35.7% in moderate CD (p=0.07). A scoring system based on age, CRP, endoscopic severity (adapted Rutgeert's score), perianal lesions and combined incidence of complications was developed which can predict a mild prognosis at the initial diagnosis, giving patients the chance of simplified therapy and accelerated step-up in the event of treatment failure.

CONCLUSIONS

Approximately a third of CD patients experience a mild disease course and require only basic therapy. A possible scoring system to predict mild CD which may avoid overtreatment and unnecessary risks for the patient and costs is suggested.

Deep remission in inflammatory bowel disease: looking beyond symptoms

Inflammatory bowel diseases (IBD) are chronic and disabling conditions. Accumulating evidence indicates that we need to look beyond clinical symptoms as current therapeutic strategies have not modified the course of IBD. Therapeutic goals for IBD have evolved from a mere control of symptoms to mucosal healing (MH). Achieving deep remission (clinical remission, biomarker remission and MH) might be the only way to alter disease course in IBD patients. In Crohn's disease (CD), deep remission has been recently defined as Crohn's Disease Activity Index <150 and complete MH. In ulcerative colitis (UC), there is no proposed definition of deep remission. It could be defined as clinical and endoscopic remission in UC. These definitions remain to be validated in large prospective studies. In the near future, the concept of deep remission might include transmural healing in CD and histologic healing in UC. Advances in drug development have provided highly effective treatments for IBD, making deep remission a realistic goal. Whether IBD patients may benefit by experiencing a 'deep' remission beyond the control of clinical symptoms, which might ultimately impact on important outcomes such as the need for surgery and the development of disability, needs to be evaluated in future disease modification trials.

Crohn's disease complicated by strictures: a systematic review

The occurrence of strictures as a complication of Crohn's disease is a significant clinical problem. No specific antifibrotic therapies are available. This systematic review comprehensively addresses the pathogenesis, epidemiology, prediction, diagnosis and therapy of this disease complication. We also provide specific recommendations for clinical practice and summarise areas that require future investigation.

Moving towards disease modification in inflammatory bowel disease therapy

PURPOSE OF REVIEW

The inflammatory bowel diseases (IBDs) are chronic disabling conditions. Despite the benefits of anti-tumor necrosis factor (TNF)-α agents in improving quality of life and reducing the need for surgeries, overall only one-third of patients are in clinical remission at 1 year and loss of response is frequent. It seems clear that treatment must go beyond alleviation of symptoms in IBD. It is important that treatment targets in IBD will ensure mucosal healing and deep remission.

RECENT FINDINGS

The induction of deep remission might be the best way to alter the natural course of these diseases by preventing disability and bowel damage. New disability indices and the new Crohn's disease damage score have recently been developed and they can be used to evaluate the long-term effect on patients and as new endpoints in trials. Early intervention with disease-modifying anti-IBD drugs (DMAIDs) should be considered in patients with poor prognostic factors.

SUMMARY

New therapeutic targets in IBD patients who failed anti-TNF-α therapy are urgently required, and tofacitinib, vedolizumab and ustekinumab appear to be the most promising drugs. Herein, we review the new and current trends in IBD therapy, with the final aim of changing disease course and patients' lives by both improving quality of life and avoiding disability.

Top-down or step-up treatment in Crohn's disease?

In recent years, a change in the treatment goals for patients with Crohn's disease (CD) has come under intense discussion. Whereas 10 years ago treatment was initiated mainly in reaction to acute flares of the disease aimed to improve clinical symptoms, the focus now has changed to the prevention of damage to the intestinal wall. The prevention of structural damage by achievement of 'mucosal healing', however, is associated with the more 'aggressive' treatment and an earlier use of immunosuppressants and biologicals. The use of immunosuppressants and biologicals especially in patients with CD has decreased the rates of surgery and hospitalizations, indicating that there is a group of patients definitely profiting from such an early use of immunosuppressive treatment. In this group of patients, the benefits outweigh the disadvantages of immunosuppression: the increased risk of severe infections. However, it remains questionable whether this improvement can only be achieved by completely reversing established treatment strategies. The dispute has been condensed to the questions whether 'top-down' (e.g. start with a combination of biological and immunosuppressant and 'de-escalate' if possible) or 'step-up' treatment (e.g. start with topical steroids, step up to systemic steroid, go to immunosuppression and biologicals if necessary) may be better. In general, in an upcoming era of individualized and personalized medicine, a 'one-size-fits-all' approach does not appear to be desirable. CD patients definitely should not be undertreated (which is still frequently the case) or remain on steroid treatment (which is inappropriate); however, overtreatment (putting patients at risk of side effects without benefit) is against a fundamental principle of medicine: nihil nocere (do no harm).

Adalimumab prevents barrier dysfunction and antagonizes distinct effects of TNF-α on tight junction proteins and signaling pathways in intestinal epithelial cells

Intestinal barrier dysfunction is pivotal in the etiology of inflammatory bowel diseases. Combined clinical and endoscopic remission ("mucosal healing") in patients who received anti-TNF-α therapies suggests restitution of the intestinal barrier, but the mechanisms involved are largely unknown. We therefore investigated the impact of the anti-TNF-α antibody adalimumab on barrier function in two in vitro models. Combined stimulation of Caco-2 and T-84 cells with interferon-γ and TNF-α resulted in a significant decrease of transepithelial electrical resistance (TEER) within 6 h that was prevented by adalimumab in concentrations down to 100 ng/ml. Adalimumab furthermore antagonized the appearance of irregular membrane undulations and prevented internalization of tight junction proteins upon cytokine exposure. In addition, TNF-α induced a downregulation of claudin-1, claudin-2, claudin-4, and occludin as well as activation of phosphatidylinositol 3-kinase signaling in T-84 but not Caco-2 cells, which was reversed by adalimumab. At the signaling level, adalimumab prevented increased phosphorylation of myosin light chain as well as activation of p38 MAPK and NF-κB accompanying the decline in TEER in both model systems. Pharmacological inhibition of NF-κB signaling partially prevented the TNF-α-induced TEER loss, whereas inhibition of p38 worsened barrier dysfunction in Caco-2 but not T-84 cells. Taken together, these data demonstrate that adalimumab prevents barrier dysfunction induced by TNF-α both functionally and structurally as well as at the level of signal transduction. Barrier protection might therefore constitute a novel mechanism how anti-TNF-α therapy contributes to epithelial restitution and tissue repair in inflammatory bowel diseases.

First-line therapy in adult Crohn's disease: who should receive anti-TNF agents?

Therapy for Crohn's disease has long been based on a step-up approach, with monoclonal antibodies against TNF as a final option before surgery. Despite the introduction of these monoclonal antibodies, no major changes have occurred in the natural history of Crohn's disease, with half of all patients still requiring intestinal resection at 10 years. Labelling for anti-TNF agents does not take into account prognostic factors. In this Review, we propose that treatment of Crohn's disease be based on the following three disease stages: mild, moderate and severe. In patients with Crohn's disease who have complicated disease or bowel damage, and with poor prognostic factors and/or severe disease, anti-TNF treatment should be considered as first-line therapy. For patients living in areas of high risk of developing tuberculosis, as well as for patients with mild-to-moderate Crohn's disease without poor prognostic factors and with uncomplicated disease, steroids and thiopurine should be the first-line therapy. By treating patients with Crohn's disease in accordance with these disease stages, we might be able to alter disease course and reduce overtreatment. Upcoming disease-modification trials are expected to provide information to guide decision-making, ultimately changing the course of disease and improving patient quality of life.

Imaging indexes of activity and severity for Crohn's disease: current status and future trends

BACKGROUND

Cross-sectional imaging techniques, including ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) are increasingly used for evaluation of Crohn's disease (CD).

AIM

To review the accuracy of cross-sectional imaging indexes for measurement of disease activity and severity in patients with CD, and to evaluate its applicability on daily clinical practice and research.

METHODS

Relevant publications were identified by literature search, and selected based on predefined quality parameters, including a sample size and reference standard. Nineteen publications were chosen.

RESULTS

The US-based indexes of activity showed high correlation with reference standard indexes. There is a good or very good agreement between the MR-based indexes and the reference standard when the comparison is limited to small segments of intestine. Significant discrepancies have been found between indexes that evaluate the colon. Only one CT-based index was included. The main strengths and weaknesses of the indexes, according to its design, are discussed.

CONCLUSION

Standardization of image acquisition protocols and patient preparation should be procured, especially for MRI. In daily practice, a simple, semi-quantitative index providing relevant information on disease activity and severity is preferable. For research purposes, a precise and reproducible index should be mandatory.

Subgroup analysis of the placebo-controlled CHARM trial: increased remission rates through 3 years for adalimumab-treated patients with early Crohn's disease

BACKGROUND AND AIMS

We examined the impact of disease duration on clinical outcomes and safety in a post hoc analysis of a remission maintenance trial with adalimumab in patients with moderate to severe CD.

METHODS

Patients in the CHARM trial were divided into 3 disease duration categories: <2 (n=93), 2 to <5 (n=148), and ≥5 years (n=536). Clinical remission and response rates at weeks 26 and 56 were compared between adalimumab and placebo subgroups, and assessed through 3 years of adalimumab treatment in the ADHERE follow-on trial. Logistic regression assessed the effect of disease duration and other factors on remission and safety.

RESULTS

At week 56, clinical remission rates were significantly greater for adalimumab-treated versus placebo-treated patients in all 3 duration subgroups (19% versus 43% for <2 years; P=0.024; 13% versus 30% for 2 to <5 years; P=0.028; 8% versus 28% for ≥5 years, P<0.001). Logistic regression identified shorter duration as a significant predictor for higher remission rate in adalimumab-treated patients. Patients with disease duration <2 years maintained higher remission rates than patients with longer disease duration through 3 years of treatment. The incidence of serious adverse events in adalimumab-treated patients was lowest with disease duration <2 years.

CONCLUSIONS

Adalimumab was superior to placebo for maintaining clinical remission in patients with moderately to severely active CD after 1 year of treatment regardless of disease duration. Clinical remission rates through 3 years of treatment were highest in the shortest disease duration subgroup in adalimumab-treated patients, with a trend to fewer side effects.

Taking Crohn's disease personally

Crohn's disease (CD) is a heterogeneous disorder that can involve any segment of the gastrointestinal tract. The pathogenesis of CD is unknown but is thought to involve an uncontrolled immune response triggered by an environmental factor in a genetically susceptible host. The heterogeneity of disease pathogenesis and clinical course, combined with the variable response to treatment and its associated side effects, creates an environment of complex therapeutic decisions. Despite this complexity, significant progress has been made which allows physicians to start and predict disease behavior and natural course, response to therapy, and factors associated with significant side effects. In this manuscript the data pertaining to these variables including clinical, endoscopic and the various biological and genetic markers are reviewed, and the possibility of tailoring personal treatment is discussed.

The Crohn's disease activity index (CDAI) is similarly elevated in patients with Crohn's disease and in patients with irritable bowel syndrome

BACKGROUND

While the Crohn's disease activity index (CDAI) is the gold standard for defining clinical endpoints in Crohn's disease (Crohn's) clinical trials, its ability to distinguish symptoms due to inflammation from those that are non-inflammatory has been questioned.

AIM

To compare CDAI scores in patients with Crohn's and those with Irritable Bowel Syndrome (IBS).

METHODS

This was a prospective, cross-sectional cohort study of 91 patients with either Crohn's (n = 44) or IBS (n = 47). Total CDAI and individual component scores were recorded and comparisons were made between Crohn's and IBS patients.

RESULTS

Mean CDAI scores were higher in the IBS patients (183 vs. 157, P = 0.1). Sixty-two per cent (n = 29) of IBS patients had CDAI scores greater than 150. Mean CDAI haematocrit score (35.9 vs. 23.0, P = 0.02) and CRP level (6.8 vs. 2.0, P = 0.002) were higher in the Crohn's group. Analysis of CDAI sub-scores demonstrated that IBS patients had significantly higher pain (mean 1.7 vs. 0.8, P = 0.0007) and well-being scores (mean 1.2 vs. 0.8, P = 0.04) relative to patients with Crohn's. Specifically evaluating patients with CDAI greater than 150 (n = 51), IBS patients had higher pain sub-scores (mean 2.4 vs. 1.4, P = 0.002), whereas patients with Crohn's had higher CRP (mean 8.4 vs. 1.8, P = 0.001).

CONCLUSIONS

Our study demonstrates that the CDAI does not discriminate patients with symptoms due to active Crohn's from patients with IBS. Patients with IBS can have CDAI scores in the clinically meaningful range. Objective measures, such as CDAI haematocrit score and CRP, are more specific markers of inflammation.

Diffusion-weighted magnetic resonance imaging for detecting and assessing ileal inflammation in Crohn's disease

BACKGROUND

Whether diffusion-weighted imaging (DWI)-MRI is of value in detecting and assessing inflammation of ileal Crohn's disease (CD) remains poorly investigated.

AIM

To compare DWI-MR enterography (MRE) with conventional MRE in estimating inflammation in small bowel CD, to determine an apparent diffusion coefficient (ADC) threshold to differentiate active from non-active lesions and to assess inter-observer agreement.

METHODS

Thirty-one CD patients from the Clermont-Ferrand IBD unit with ileal involvement were consecutively and prospectively included between April and June 2011. All patients underwent DWI-MRI to detect the digestive segment with the most severe lesions, which was then used to calculate the ADC. Qualitative and quantitative results were compared with conventional MRE including MaRIA (Magnetic Resonance Index of Activity) score calculation and independent activity predictors (wall thickening, oedema, ulcers). Each examination was interpreted independently by two radiologists blinded for clinical assessment.

RESULTS

Seventeen patients (54.8%) had active CD as defined by the MaRIA score ≥7. DWI hyperintensity was highly correlated with disease activity evaluated using conventional MRE (P = 0.001). Qualitative analysis of DW sequences determined sensitivity, specificity, positive predictive value and negative predictive value as 100%, 92.9%, 94.4% and 100% respectively. Quantitative analysis using a cut-off of 1.6 × 10(-3) mm(2)/s for ADC yielded sensitivity and specificity values of, respectively, 82.4% and 100%. Inter-observer agreement was high with regard to DWI hyperintensity (κ = 0.69, accuracy rate = 85.7%) and ADC (correlation = 0.74, P < 0.001, and concordance = 0.71, P < 0.001).

CONCLUSION

DWI-MR enterography is a well-tolerated, non-time-consuming and accurate tool for detecting and assessing inflammation in small bowel Crohn's disease.

Mucosal healing in inflammatory bowel disease

It is becoming increasingly recognized that purely clinical endpoints may not be sufficient in the treatment of patients with inflammatory bowel disease. As such, mucosal disease assessment has become a prominent component of the majority of recent clinical trials in Crohn's disease and ulcerative colitis. There is mounting evidence that the attainment of mucosal healing leads to improved clinical outcomes in both Crohn's disease and ulcerative colitis. However, the use of mucosal healing as a therapeutic endpoint in inflammatory bowel disease is in its early stages, as a number of issues limit its application to routine clinical practice.

The future of inflammatory bowel disease therapy: where do we go from here?

There are six important trends that will impact the future of inflammatory bowel disease therapy. (1) Increased use of the biomarkers C-reactive protein (CRP) and fecal calprotectin, and increased imaging with colonoscopy and MRI enterography. (2) Increased use of pharmacokinetics to customize drug dosing for individual patients. Multiple factors impact the pharmacokinetics of monoclonal antibodies including the presence of antidrug antibodies, concomitant immunosuppression and low serum albumin and high CRP concentrations. (3) Evolution of treatment end points from symptoms to deep remission (a combination of both clinical remission and mucosal healing) to the prevention of bowel damage (in Crohn's disease) and surgery in the short-to-intermediate term and prevention of disability in the longer term. (4) Evolving data demonstrate that azathioprine monotherapy is minimally effective as a disease modification agent in Crohn's disease. Use of azathioprine as a monotherapy will decline. (5) Combination therapy with azathioprine and infliximab is superior to monotherapy with either agent. Use of combination therapy will increase. (6) There is a rich pipeline of novel therapeutic agents. Treatment strategies that appear particularly appealing include selective anti-integrin therapy with vedolizumab (anti-α4β7), etrolizumab (anti-β7 antibody) and PF-00547,659 (anti-MAdCAM-1 antibody), anti-interleukin 12/23p40 therapy with ustekinumab and Janus kinase 1, 2 and 3 inhibition with toafacitinib.

Protocol for a prospective multicentre cohort study to develop and validate two new outcome measures for patients with inflammatory bowel disease

INTRODUCTION

Most of the health-related quality of life (HRQoL) measures for patients with inflammatory bowel disease (IBD) were designed to be used in outpatient settings and are therefore not suitable for use in acute inpatient settings. None of the currently used clinical severity indices for patients with IBD have been properly validated. The aim of this study was to describe the development of a new HRQoL questionnaire and a clinical severity index for patients with ulcerative colitis or Crohn's disease that were short, valid and suitable at any stage of their disease. The new HRQoL and disease severity index will be easily used at the point of care, and invaluable monitoring tools for clinical care, audit and research.

METHODS AND ANALYSIS

This is a prospective multisite validation study of two new outcome measures, the Crohn's and Colitis quality of life (CCQ) questionnaire and the Clinical IBD severity score (CISS). We plan to recruit patients with ulcerative colitis or Crohn's disease. The questionnaire items will be selected through extensive literature review and a focus group involving patients, methodologists, statisticians and IBD specialists. The CCQ questionnaire will be completed by patients attending IBD clinics, having endoscopy procedures or when admitted to hospital. CISS will be completed by clinicians while assessing patients with IBD. Psychometric analysis will be carried out to test the validity and reliability of the questionnaires and to determine the potential to produce shorter versions of CISS and CCQ. The construct validity of CCQ will be tested against short form-12 and the European Quality of Life Five Dimensions. The construct validity of CISS will be tested against biochemical markers, clinical and endoscopic indices to assess severity.

ETHICS

This study was approved by the South East Wales Research Ethics Committee (Ref 11/WA/0239).

Development of the Paris definition of early Crohn's disease for disease-modification trials: results of an international expert opinion process

We report the findings and outputs of an international expert opinion process to develop a definition of early Crohn's disease (CD) that could be used in future disease-modification trials. Nineteen experts on inflammatory bowel diseases held an international expert opinion meeting to discuss and agree on a definition for early CD to be used in disease-modification trials. The process included literature searches for the relevant basic-science and clinical evidence. A published preliminary definition of early CD was used as the basis for development of a proposed definition that was discussed at the expert opinion meeting. The participants then derived a final definition, based on best current knowledge, that it is hoped will be of practical use in disease-modification trials in CD.

Challenges to the design, execution, and analysis of randomized controlled trials for inflammatory bowel disease

Treatment of inflammatory bowel disease has greatly improved with the development of targeted, monoclonal antibody-based therapies. Tumor necrosis factor antagonists are frequently used to treat patients with Crohn's disease or ulcerative colitis, but they have side effects and their efficacy often decreases with use. New, more effective drugs are therefore needed and in development. However, many agents that appeared to be promising in preclinical studies have failed to show efficacy in clinical trials. We discuss possible reasons for the failures of these reagents in trials, which include the high rate of response to placebo, an inadequate range of doses, inappropriate timing of end point measurements, the changing therapeutic environment, and the competitive trial system. We also review regulatory guidelines for end points and trial design and recommend ways to improve trials.

Crohn's disease

Crohn's disease is a relapsing systemic inflammatory disease, mainly affecting the gastrointestinal tract with extraintestinal manifestations and associated immune disorders. Genome wide association studies identified susceptibility loci that--triggered by environmental factors--result in a disturbed innate (ie, disturbed intestinal barrier, Paneth cell dysfunction, endoplasmic reticulum stress, defective unfolded protein response and autophagy, impaired recognition of microbes by pattern recognition receptors, such as nucleotide binding domain and Toll like receptors on dendritic cells and macrophages) and adaptive (ie, imbalance of effector and regulatory T cells and cytokines, migration and retention of leukocytes) immune response towards a diminished diversity of commensal microbiota. We discuss the epidemiology, immunobiology, amd natural history of Crohn's disease; describe new treatment goals and risk stratification of patients; and provide an evidence based rational approach to diagnosis (ie, work-up algorithm, new imaging methods [ie, enhanced endoscopy, ultrasound, MRI and CT] and biomarkers), management, evolving therapeutic targets (ie, integrins, chemokine receptors, cell-based and stem-cell-based therapies), prevention, and surveillance.

Clinical predictors at diagnosis of disabling pediatric Crohn's disease

BACKGROUND

Identification of children with Crohn's disease (CD) at high risk of disabling disease would be invaluable in guiding initial therapy. Our study aimed to identify predictors at diagnosis of a subsequent disabling course in a population-based cohort of patients with pediatric-onset CD.

METHODS

Among 537 patients with pediatric CD diagnosed at <17 years of age, 309 (57%) with 5-year follow-up were included. Clinical and demographic factors associated with subsequent disabling CD were studied. Three definitions of disabling CD were used: Saint-Antoine and Liège Hospitals' definitions and a new pediatric definition based on the presence at maximal follow-up of: 1) growth delay defined by body mass index (BMI), weight or height lower than -2 SD Z score; and 2) at least one intestinal resection or two anal interventions. Predictors were determined using multivariate analyses and their accuracy using the kappa method considering a relevant value ≥ 0.6.

RESULTS

According to the Saint-Antoine definition, the rate of disabling CD was 77% and predictors were complicated behavior and L1 location. According to the Liège definition, the rate was 37% and predictors included behavior, upper gastrointestinal disease, and extraintestinal manifestations. According to the pediatric definition, the rate of disabling CD was 15%, and predictors included complicated behavior, age <14, and growth delay at diagnosis. Kappa values for each combination of predictors were, respectively, 0.2, 0.3, and 0.2 and were nonrelevant.

CONCLUSIONS

Clinical parameters at diagnosis are insufficient to predict a disabling course of pediatric CD. More complex models including serological and genetic biomarkers should be tested.

Development of a numerical index quantitating small bowel damage as detected by ultrasonography in Crohn's disease

Small intestine contrast ultrasonography (SICUS) has emerged as a valuable tool in the detection of intestinal damage in Crohn's disease (CD). Our aim was to develop a numerical index quantitating small bowel damage as detected by SICUS in patients with an established diagnosis of CD. One hundred and ten patients with ileal or ileocolonic CD were prospectively enrolled and followed up for one year. Disease activity was assessed by CDAI and CRP levels. Study variables included bowel wall thickness, lumen diameter, lesion length and number of lesion site. Fistula, mesenteric adipose tissue alteration, abscess and lymphnodes were also considered. Bowel segments were considered as a hollow cylinder. Standardized variations of variables were combined into a statistical and mathematical model to create an algorithm scoring an index value ranging from 0 to 200. Index was subdivided into a severity scale with 5 classes from the lower (A) to the higher score (E). Median lesion index value was significantly higher (p<0.005) in patients with a CDAI>150 and in patients with CRP>5 mg/l (p=0.003). Patients classified in class E and D at SICUS underwent surgery within one year follow up more frequently than those in class C, B and A (p<0.0001). We propose a new index for assessment of small bowel lesions in CD (SLIC: sonographic lesion index for CD) developed by using SICUS. This index may turn ultrasonography in CD from a descriptive qualitative assessment to a quantitative numerical index suitable for comparison studies.

Investigation of small bowel in pediatric Crohn's disease

Investigation of the small bowel has been traditionally a challenge for pediatric gastroenterologists due to its location, anatomical tortuosity, and invasiveness of the available techniques. Recently, there has been a remarkable improvement in imaging and endoscopic tools aimed at exploring successfully the small intestine in inflammatory bowel disease. The former are represented by ultrasonography (either alone or with administration of oral contrast agents) and by magnetic resonance: both have provided accurate methods to detect structural bowel changes, diminishing patient discomfort and precluding radiation hazard. The use of traditional radiologic techniques such as fluoroscopy have been markedly reduced due to radiation exposure and inability to depict transmural inflammation or extraluminal complications. Among the novel endoscopic tools, capsule endoscopy and balloon-assisted enteroscopy have tremendously opened new diagnostic and therapeutic perspectives, by allowing the direct visualization of small intestinal mucosa and, through enteroscopy, histological diagnosis as well as therapeutic interventions such as stricture dilation and bleeding treatment. These endoscopic techniques should always be preceded by imaging of the intestine in order to identify strictures. This review describes the most recent progress with the employment of novel imaging and endoscopic methodologies for investigating the small bowel in children with suspected or established Crohn's disease.

Impact of medical therapies on inflammatory bowel disease complication rate

Crohn’s disease and ulcerative colitis are progressive diseases associated with a high risk of complications over time including strictures, fistulae, perianal complications, surgery, and colorectal cancer. Changing the natural history and avoiding evolution to a disabling disease should be the main goal of treatment. In recent studies, mucosal healing has been associated with longer-term remission and fewer complications. Conventional therapies with immunosuppressive drugs are able to induce mucosal healing in a minority of cases but their impact on disease progression appears modest. Higher rates of mucosal healing can be achieved with anti-tumor necrosis factor therapies that reduce the risk of relapse, surgery and hospitalization, and are associated with perianal fistulae closure. These drugs might be able to change the natural history of the disease mainly when introduced early in the course of the disease. Treatment strategy in inflammatory bowel diseases should thus be tailored according to the risk that each patient could develop disabling disease.

Epidemiology of the transition from early to late Crohn's disease

Phenotypically, the transition from early to late Crohn's disease is characterized by the occurrence of complications including strictures, intra-abdominal fistulas and perianal fistulas, all of them leading to various types of surgeries and currently non-reversible tissue damage. It must, however, be kept in mind that this transition is not at all a uniform and linear process. According to these simple phenotypic criteria, Crohn's disease can already be a late disease at diagnosis while in other patients, it can still be an early disease after 20 years of evolution. This simply highlights the relativity of time in this field, actually reflecting the nature, location and severity of the inflammatory process. The risk over time of the development of these complications has been described, first in cohort studies and then in population-based studies. Globally, at diagnosis, between 19 and 38% only of Crohn's disease patients have complicated Crohn's disease. After 10 years, between 56 and 65% of patients have developed either stricturing or penetrating complications. After 20 years, these numbers are between 61 and 88%. In parallel to these structural changes, changes in the immunobiology of the disease also seem to occur; the latter seem to happen quicker with major modification already within 2 years of the diagnosis. Beside these general figures, important questions remain pending. First, the real timing of these changes is still unclear. Second, the precise role of genetics and environment in the development of these changes remains to be clarified. Third, the correlation between changes in immunobiology and intestinal structural damages has not been specifically studied.

The future developments in gastrointestinal radiology

The last decade has witnessed great advances in abdominal imaging with technological developments and diagnostic improvements in CT, MRI and positron emission tomography-CT. Over the next decade, gastrointestinal imaging is set to rapidly evolve. Fluoroscopic techniques will be left behind and we will develop beyond simply anatomical imaging, embracing increasingly functional and quantitative techniques. Dose reduction and radiation-free modalities will take centre stage as imaging goes mobile, allowing clinicians at the bedside and remote subspecialty radiologists to review radiology from electronic devices. The authors discuss some of the key trends set to define the next decade in gastrointestinal radiology.

Cost-effectiveness of imaging strategies to reduce radiation-induced cancer risk in Crohn's disease

BACKGROUND

The aim was to examine the cost-effectiveness of magnetic resonance enterography (MRE) compared with computed tomography enterography (CTE) for routine imaging of small bowel Crohn's disease (CD) patients to reduce patients' life-time radiation-induced cancer risk.

METHODS

We developed a Markov model to compare the lifetime costs, benefits (measured in quality-adjusted life-years [QALYs] of survival and cancers averted) and cost-effectiveness of using MRE rather than CTE for routine disease monitoring in hypothetical cohorts of 100,000 20-year-old patients with CD. We assumed each CT radiation exposure conferred an incremental annual risk of developing cancer using the linear, no-threshold model.

RESULTS

In the base case of 16 mSv per CTE, we estimated that radiation from CTE resulted in 1,206 to 20,146 additional cancers depending on the frequency of patient monitoring. Compared to using CTE only, using MRE until age 30 and CTE thereafter resulted in incremental cost-effectiveness ratios (ICERs) between $37,538 and $41,031 per life-year (LY) gained and between $52,969 and $57,772 per quality-adjusted life-year (QALY) gained. Using MRE until age 50 resulted in ICERs between $58,022 and $62,648 per LY gained and between $84,250 and $90,982 per QALY gained. In a threshold analysis, any use of MRE had an ICER of greater than $100,000 per QALY gained when CT radiation doses are less than 6.0 mSv per CTE exam.

CONCLUSIONS

MRE is likely cost-effective compared to CTE in patients younger than age 50. Low-dose CTE may be an alternative cost-effective choice in the future.

A new look at Crohn's disease: novel imaging techniques

PURPOSE OF REVIEW

Imaging the gut provides information on Crohn's disease activity, identifies complications and provides insight into patient symptoms. Imaging can help direct therapy and can predict important patient outcomes. In a rapidly changing, technology-driven field, new imaging applications add novel insights that we are only beginning to appreciate. The purpose of this review is to highlight recent advances in imaging as they are applied to the assessment of patients with Crohn's disease.

RECENT FINDINGS

In the past year, key literature describing cross-sectional imaging techniques, including computed tomography (CT) based imaging, specifically CT enterography (CTE) and magnetic resonance enterography (MRE), transcutaneous ultrasound, and PET-based imaging, has emerged in the field of inflammatory bowel disease. MRI sequences that have been recently applied to Crohn's disease assessment, including diffusion-weighted imaging (DWI) and magnetization transfer imaging (MTI), add important new insights. These new data highlight the current status of available imaging modalities and provide a glimpse into the future of our practice.

SUMMARY

CTE and MRE are our new standard imaging modalities for small bowel Crohn's disease. PET scanning is promising but currently only used routinely in centers with a strong research presence in this area. Ultrasound is emerging as a useful, potentially less costly, radiation-free technique. New MRI sequences offer future promise for effectively monitoring the natural history of Crohn's disease.

Ulcerative colitis as a progressive disease: the forgotten evidence

In the management of Crohn's disease, earlier aggressive treatment is becoming accepted as a strategy to prevent or retard progression to irreversible bowel damage. It is not yet clear, however, if this same concept should be applied to ulcerative colitis. Hence, we review herein the long-term structural and functional consequences of this latter disease. Disease progression in ulcerative colitis takes six principal forms: proximal extension, stricturing, pseudopolyposis, dysmotility, anorectal dysfunction, and impaired permeability. The precise incidence of these complications and the ability of earlier, more aggressive treatment to prevent them have yet to be determined.

Results of the 2nd scientific workshop of the ECCO (IV): therapeutic strategies to enhance intestinal healing in inflammatory bowel disease

Evidence supporting the importance of assessment of mucosal healing in inflammatory bowel disease has increased in the last years. Mucosal healing has been integrated in the assessment of treatment efficacy in ulcerative colitis, but in Crohn's disease this thought has arised after biological agents have been evaluated in clinical trials. Although a validated definition of mucosal healing still does not exist, its use is also assuming an increasingly important role in the follow-up of individual patients in clinical practice. Corticosteroids induce mucosal healing in a small proportion of patients with Crohn's disease and are of no benefit to maintain it. By contrast, mucosal healing in Crohn's disease can be achieved and maintained, with varying degrees of evidence and success, with thiopurines and biological agents. In ulcerative colitis, the ability of corticosteroids to induce mucosal healing is well recognized. 5-aminosalicylates, thiopurines and biological agents are also able to induce mucosal healing and, additionally, to maintain it. Mucosal healing assessment should be considered in clinical practice when symptoms persist despite therapy or when treatment discontinuation is being considered. Conversely, in patients whose clinical remission is not associated with mucosal healing, intensification of treatment is not currently recommended because of lack of evidence.

Implementing changes in clinical practice to improve the management of Crohn's disease

The introduction of anti-tumour necrosis factor therapies has provided highly effective treatments for Crohn's disease, making it possible to significantly improve the prognosis of patients. However, neither conventional non-biological therapies nor anti-tumour necrosis factor therapies are routinely used to optimum effect. There are several reasons for this, including a lack of specific evidence to guide common clinical questions and a lack of clearly defined treatment targets. This paper suggests some simple changes to the management of Crohn's disease that have the potential to significantly improve patient outcomes. A new treatment target, 'deep remission', which includes mucosal healing as well as clinical remission, may be the first step in defining the successful treatment of Crohn's disease; early clinical studies have demonstrated that this is a readily achievable target. Initiating appropriate treatment early can increase clinical remission rates, improve steroid sparing, induce mucosal healing and prevent structural bowel damage, whereby reducing the need for hospitalization and surgery. There are also clear indications that modifying treatment based on regular objective assessments of disease activity to provide tight disease control can improve patient outcomes in a similar way to that observed in rheumatoid arthritis. These simple changes to management strategy appear to allow the full potential of available treatments to be realized. Clinical studies to further define optimized treatment strategies for Crohn's disease are underway and will provide future direction.

Changing Crohn's disease management: need for new goals and indices to prevent disability and improve quality of life

Crohn's disease is a destructive, inflammatory condition. The recent IMPACT survey showed that it has a major impact on quality of life including fatigue, relationships and employment. Although patients are generally satisfied with healthcare services, improvements are needed in the timeliness of diagnosis and in communication between patients and healthcare professionals. Evidence is lacking about what constitutes quality of care and value to patients. Moving forward, value should become the primary goal of healthcare delivery, which is likely to require new treatment goals. Indeed, goals are already evolving beyond symptom control towards deep remission, which encompasses clinical remission together with mucosal healing. The ultimate goals are to prevent bowel damage, reduce long-term disability and maintain normal quality of life. A new treat-to-target approach, with increased monitoring and tighter control of symptoms and inflammation, will be needed. This approach will be enabled by use of biomarkers and new indices such as the Lémann score, which assesses the extent and severity of bowel damage at a specific time-point and over time, and a new disability index for patients with inflammatory bowel disease. These principles have been adopted for managing rheumatoid arthritis where there is now a focus on treat-to-target to achieve early remission. Lessons from rheumatoid arthritis can be translated to Crohn's disease.

Development of the first disability index for inflammatory bowel disease based on the international classification of functioning, disability and health

OBJECTIVE

The impact of inflammatory bowel disease (IBD) on disability remains poorly understood. The World Health Organization's integrative model of human functioning and disability in the International Classification of Functioning, Disability and Health (ICF) makes disability assessment possible. The ICF is a hierarchical coding system with four levels of details that includes over 1400 categories. The aim of this study was to develop the first disability index for IBD by selecting most relevant ICF categories that are affected by IBD.

METHODS

Relevant ICF categories were identified through four preparatory studies (systematic literature review, qualitative study, expert survey and cross-sectional study), which were presented at a consensus conference. Based on the identified ICF categories, a questionnaire to be filled in by clinicians, called the 'IBD disability index', was developed.

RESULTS

The four preparatory studies identified 138 second-level categories: 75 for systematic literature review (153 studies), 38 for qualitative studies (six focus groups; 27 patients), 108 for expert survey (125 experts; 37 countries; seven occupations) and 98 for cross-sectional study (192 patients; three centres). The consensus conference (20 experts; 17 countries) led to the selection of 19 ICF core set categories that were used to develop the IBD disability index: seven on body functions, two on body structures, five on activities and participation and five on environmental factors.

CONCLUSIONS

The IBD disability index is now available. It will be used in studies to evaluate the long-term effect of IBD on patient functional status and will serve as a new endpoint in disease-modification trials.

MRI in Crohn's disease--current and future clinical applications

Crohn's disease is a chronic, disabling disease that, over time, can lead to irreversible bowel damage. MRI can be used to diagnose and assess the activity, severity and complications of Crohn's disease; however, the role of MRI in therapeutic monitoring of changes in disease-related intestinal damage is still to be defined. Objective, validated MRI-based scores have been developed to assess the activity of Crohn's disease; these indices are based on the extent and severity of intestinal inflammation, postoperative recurrence and perianal disease. MRI is accurate, safe, reproducible and can allow repeated evaluations of patients without radiation exposure. Evidence that MRI might be valuable in the therapeutic monitoring of patients with Crohn's disease is increasing and, in combination with endoscopy and surgical history, this imaging technique could enable clinicians to assess Crohn's-disease-related intestinal damage. MRI could, therefore, have a crucial role in a future 'damage-driven' treatment paradigm--in which imaging is used to monitor intestinal damage and medication use is targeted to prevent the accumulation of further damage. This damage-driven therapeutic approach could potentially change the course of Crohn's disease.

MRI in Crohn's disease--current and future clinical applications

Crohn's disease is a chronic, disabling disease that, over time, can lead to irreversible bowel damage. MRI can be used to diagnose and assess the activity, severity and complications of Crohn's disease; however, the role of MRI in therapeutic monitoring of changes in disease-related intestinal damage is still to be defined. Objective, validated MRI-based scores have been developed to assess the activity of Crohn's disease; these indices are based on the extent and severity of intestinal inflammation, postoperative recurrence and perianal disease. MRI is accurate, safe, reproducible and can allow repeated evaluations of patients without radiation exposure. Evidence that MRI might be valuable in the therapeutic monitoring of patients with Crohn's disease is increasing and, in combination with endoscopy and surgical history, this imaging technique could enable clinicians to assess Crohn's-disease-related intestinal damage. MRI could, therefore, have a crucial role in a future 'damage-driven' treatment paradigm--in which imaging is used to monitor intestinal damage and medication use is targeted to prevent the accumulation of further damage. This damage-driven therapeutic approach could potentially change the course of Crohn's disease.