Assessment of endoscopic activity index and biological inflammatory markers in clinically active Crohn's disease with normal C-reactive protein serum level

Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions

Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.

Therapeutic effects of biological treatments on AA amyloidosis associated with inflammatory bowel disease: a case report and literature review

AA amyloidosis is a rare and significant complication of long-term inflammation that can be caused by a variety of disorders, including inflammatory bowel disease, and is linked to an increased risk of morbidity and mortality. To date, there has been no effective direct treatment, and treatment aims at treating the underlying condition with potent immunosuppression to limit inflammatory activity and, as a result, switch off amyloidogenesis. Theoretically, biological treatment can control AA amyloidosis by inducing and maintaining inflammatory bowel disease remission and inhibiting the synthesis of Serum Amyloid A, which is an acute phase reactant and precursor protein of AA amyloidosis that accumulates in the organs. We report the first case of ustekinumab's therapeutic effect after infliximab's loss of response in AA amyloidosis associated with Crohn's disease. We also conducted a literature review of the therapeutic effect of biological treatment on AA amyloidosis.

Multicenter prospective registration study of efficacy and safety of capsule endoscopy in Crohn's disease in Japan (SPREAD-J study)

BACKGROUND

Evidence of small-bowel capsule endoscopy (SBCE) for evaluating lesions in Crohn's disease (CD) is lacking. We aimed to clarify the effectiveness and safety of SBCE in a large sample of patients with CD.

METHODS

This multicenter prospective registration study recorded the clinical information and SBCE results of patients with definitive CD (d-CD) or suspected CD (s-CD). The primary outcomes were the rates of successful assessment of disease activity using SBCE, definitive diagnosis of CD, and adverse events. Secondary outcomes were the assessment of SBCE findings in patients with d-CD and s-CD and factors affecting SBCE incompletion and retention; and tertiary outcomes included the association between clinical disease activity or blood examination, endoscopic disease activity, ileal CD, and the questionnaire assessment of patient acceptance of SBCE.

RESULTS

Of 544 patients analyzed, 541 underwent SBCE with 7 (1.3%) retention cases. Of 468 patients with d-CD, 97.6% could be evaluated for endoscopic activity. Of 76 patients with s-CD, 15.8% were diagnosed with 'confirmed CD'. CD lesions were more frequently observed in the ileum and were only seen in the jejunum in 3.4% of the patients. Male sex and stenosis were risk factors for incomplete SBCE, and high C-reactive protein levels and stenosis were risk factors for capsule retention. In L1 (Montreal classification) patients, clinical remission was associated with endoscopic remission but showed low specificity and accuracy. The answers to the acceptability questionnaire showed the minimal invasiveness and tolerability of SBCE.

CONCLUSION

SBCE is practical and safe in patients with CD.

Role of Biomarkers in the Diagnosis and Treatment of Inflammatory Bowel Disease

The number of patients with inflammatory bowel disease (IBD) is increasing worldwide. Endoscopy is the gold standard to assess the condition of IBD. The problem with this procedure is that the burden and cost on the patient are high. Therefore, the identification of a reliable biomarker to replace endoscopy is desired. Biomarkers are used in various situations such as diagnosis of IBD, evaluation of disease activity, prediction of therapeutic effect, and prediction of relapse. C-reactive protein and fecal calprotectin have a lot of evidence as objective biomarkers of disease activity in IBD. The usefulness of the fecal immunochemical test, serum leucine-rich glycoprotein, and urinary prostaglandin E major metabolite have also been reported. Herein, we comprehensively review the usefulness and limitations of biomarkers that can be used in daily clinical practice regarding IBD. To date, no biomarker is sufficiently accurate to replace endoscopy; however, it is important to understand the characteristics of each biomarker and use the appropriate biomarker at the right time in daily clinical practice.

Normalization of C-Reactive Protein Predicts Better Outcome in Patients With Crohn's Disease With Mucosal Healing and Deep Remission

Therapeutic targets for Crohn's disease (CD) have evolved from clinical and biological remission to mucosal healing (MH) and deep remission (DR). MH is defined as disappearance of ulceration, whereas DR is defined as a combination of clinical remission and MH. Limited data are available regarding differences in long-term outcomes of these patients reaching these targets. We thus aimed to evaluate patients' long-term clinical outcomes using different composite remission parameters.

Fibrotic Strictures in Crohn's Disease: Mechanisms and Predictive Factors

Fibrotic strictures are one of the most severe complications of Crohn's Disease (CD). They occur in about 50% of patients at five years and in 70% at ten years of the diagnosis. The only treatment available for symptomatic fibrotic strictures is surgical resection and endoscopic dilation. Both strategies are associated with a high rate of recurrence, and with multiple surgical resections, which pose the threat of surgical morbidity and short bowel syndrome. Therefore, it is crucial to identify, early, the patients more prone to develop intestinal fibrosis to intensify follow-ups, switch to more aggressive treatments, and suggest lifestyle modifications. Scarce data are available concerning biomarkers and genetic determinants to predict which patient will develop intestinal fibrosis. Biologic or clinical markers would be useful to determine this subgroup of CD patients and to predict the onset of intestinal fibrosis and, ideally, its severity. Furthermore, the identification of environmental risk factors may suggest lifestyle changes aimed at modifying the natural course, thus decreasing the risk of complicated CD. In this review, we will critically revise clinical, environmental, genetic, and serologic factors that have been associated with a complicated CD course with a particular focus on the fibrostenosing phenotype and their possible implications as predictive factors of intestinal fibrosis.

Evidence-based clinical practice guidelines for inflammatory bowel disease 2020

Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.

Assessment of disease activity in inflammatory bowel diseases: Non-invasive biomarkers and endoscopic scores

Inflammatory bowel diseases (IBD) comprise two major forms: Crohn's disease and ulcerative colitis. The diagnosis of IBD is based on clinical symptoms combined with results found in endoscopic and radiological examinations. In addition, the discovery of biomarkers has significantly improved the diagnosis and management of IBD. Several potential genetic, serological, fecal, microbial, histological and immunological biomarkers have been proposed for IBD, and they have been evaluated for clinical routine and clinical trials. Ileocolonoscopy, especially with biopsy collection, has been considered the standard method to diagnose IBD and to assess clinical activity of the disease, but it is limited to the colon and terminal ileum and is considered invasive. For this reason, non-invasive biomarkers are necessary for this type of chronic inflammatory disease, which affects mostly young individuals, as they are expected to have a long follow-up.

Treat-to-Target in Pediatric Inflammatory Bowel Disease: What Does the Evidence Say?

The traditional management of inflammatory bowel disease, based on treatment intensification guided by clinical activity alone, has been revised in the last 10 years and a treat-to-target approach has been proposed and is currently under evaluation as a disease-modifying strategy. Treat-to-target focuses on objective and scheduled measures to monitor intestinal damage, with consequent therapeutic adjustments in case of failure to achieve pre-defined targets. Identification of targets has been set out by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee in 2015. Mucosal healing is universally accepted as the main target both in Crohn's disease and ulcerative colitis, given its proven association with better long-term outcomes than clinical remission alone. Equally important is to ensure patients' clinical remission and improve patient-reported outcomes. Transmural healing (for Crohn's disease) and histological remission (for ulcerative colitis), listed as adjunctive targets, are likely to become primary targets in the near future. The ultimate goal of this approach is to modify the natural history of inflammatory bowel diseases by trying to block bowel damage progression, with interventions in the pre-clinical stage. In this review, we will discuss the current recommended therapeutic targets, as well as those that are considered adjunctive targets, with a focus on the limited pediatric literature available. Prospective long-term trials are warranted in order to identify the most appropriate target for the pediatric population and its specific issues. Identification of reliable predictors of disease course, outcome, and response to treatment will help to individually adapt each step of this monitoring algorithm and consequent therapeutic decision.

Is fecal calprotectin an accurate marker in the management of Crohn's disease?

Although lacking validated cutoff values, fecal calprotectin (FC), besides C-reactive protein, is considered the standard test for assessing disease activity in Crohn's disease (CD). The aim of the present review is to provide a general overview of the literature addressing the role of FC in the clinical and endoscopic assessment of disease activity in CD, seeking correlations with capsule endoscopy, response to therapy, prediction of relapse, and postoperative recurrence. A systematic search of the literature up to September 2019 was performed using Medline, Embase, and the Cochrane Library. Only papers written in English concerning FC in adult patients affected by CD were included. Pediatric studies, in vitro studies, animal studies, studies on blood/serum samples, and studies analyzing FC in ulcerative colitis or in both CD and ulcerative colitis were excluded. Out of 713 citations, 65 eligible studies were identified. FC showed high accuracy in the assessment of intestinal inflammation and response to therapy, in particular in colonic disease, thus proving a good surrogate marker for these aims. FC is useful in identifying patients at high risk for endoscopic relapse or postoperative recurrence, for optimizing or downstage therapy. Unfortunately, FC performs less well in small bowel CD. FC is an effective fecal marker in the management of CD patients, optimizing the use of endoscopic procedures. Owing to its diagnostic accuracy, FC may represent a cornerstone of the "treat-to-target" management strategy of CD patients.

Abdominal ultrasonography with color Doppler analysis in the assessment of ileal Crohn's disease: comparison with magnetic resonance enterography

Background/Aims

Consistently defining disease activity remains a critical challenge in the follow-up of patients with Crohn’s disease (CD). We investigated the potential applicability of abdominal ultrasonography with color Doppler (USCD) analysis for the detection of morphological alterations and inflammatory activity in CD.

Methods

Forty-three patients with CD ileitis/ileocolitis were evaluated using USCD analysis with measurements obtained on the terminal ileum and right colon. Sonographic parameters included wall thickening, stricture, hyperemia, presence of intra-abdominal mass, and fistulas. Patients were evaluated for the clinical activity (Harvey-Bradshaw Index [HBI]), fecal calprotectin (FC) and C-reactive protein (CRP). The USCD performance was assessed using magnetic resonance enterography (MRE) as a criterion standard.

Results

Most measurements obtained with USCD matched the data generated with MRE; however, the agreement improved in clinically active patients where sensitivity, positive predictive value, and accuracy were >80%, considering wall thickening and hyperemia. Complications such as intestinal wall thickening, stricture formation, and hyperemia, were detected in the USCD analysis with moderate agreement with MRE. The best agreement with the USCD analysis was obtained in regard to FC, where the sensitivity, positive predictive value, and accuracy were >70%. The overall performance of USCD was superior to that of HBI, FC and CRP levels, particularly when considering thickening, stricture, and hyperemia parameters.

Conclusions

USCD represents a practical noninvasive and low-cost tool for evaluating patients with ileal or ileocolonic disease, particularly in clinically active CD. Therefore, USCD might become a useful asset in the follow-up of patients with CD.

Update on C-reactive protein and fecal calprotectin: are they accurate measures of disease activity in Crohn's disease?

'Treat-to-target' paradigms in Crohn's disease (CD) directed at suppressing intestinal inflammation require accurate and reliable measures of disease activity. Although endoscopy has traditionally been considered a gold standard, cost, complexity, resource limitations, and invasiveness are important limitations. Hence, substantial interest exists for non-invasive serum and fecal biomarkers, namely C-reactive protein (CRP) and fecal calprotectin (FC), in the diagnosis, monitoring, and treatment of CD. Areas covered: We review the evidence for using serum CRP and FC in distinguishing patients with CD from those with irritable bowel syndrome, categorizing disease activity among patients with an established diagnosis of CD, predicting the likelihood of treatment response, identifying asymptomatic patients in medically or surgically induced remission who are at risk for disease relapse, and as treatment targets. Expert commentary: Accurate interpretation of CRP and FC is dependent on several factors including the clinical context, the performance characteristics of the assay, the specified test cut-offs, and the pre-test probability of disease. Emerging evidence indicates that CRP and FC are valuable adjuncts for the management of CD in specific circumstances described in this review.

What is the role of C-reactive protein and fecal calprotectin in evaluating Crohn's disease activity?

Historically, the evaluation of patients with Crohn's disease (CD) has centered on use of subjective symptom-based assessment. However, patients with CD experience a broad spectrum of non-specific symptoms that may not directly correlate with objective measures of inflammation. Endoscopy has been the gold standard for evaluating the burden and severity of mucosal disease. However, use of ileocolonoscopy for disease monitoring in long-term follow-up is limited by considerations of cost, resource utilization, and invasiveness. As treatment goals in CD have shifted towards 'treat-to-target' paradigms that emphasize tight control of inflammation, it has become increasingly evident that sensitive, accurate, and reliable measures of disease activity are required. The use of non-invasive serum and fecal biomarkers such as C-reactive protein (CRP) and fecal calprotectin (FC) has been evaluated in patients with CD for categorizing disease activity, predicting treatment response, identifying patients at risk for disease relapse, and as a potential therapeutic target. In this review, we summarize the interpretation of CRP and FC in patients with CD within specific clinical contexts and according to assay performance characteristics.

The usefulness of fecal calprotectin in assessing inflammatory bowel disease activity

BACKGROUND/AIMS

Fecal calprotectin (FC) is known to correlate with disease activity and can be used as a predictor for relapse or treatment response in inflammatory bowel disease (IBD). We evaluated the usefulness of FC as a biomarker for disease activity in patients with IBD using both enzyme-linked immunosorbent assay (ELISA) and a quantitative point-of-care test (QPOCT).

METHODS

Fecal samples and medical records were collected from consecutive patients with IBD. FC levels were measured by both ELISA and QPOCT and patient medical records were reviewed for clinical, laboratory, and endoscopic data.

RESULTS

Ninety-three patients with IBD were enrolled, 55 with ulcerative colitis (UC) and 38 with Crohn's disease (CD). The mean FC-ELISA levels were 906.3 ± 1,484.9 μg/g in UC and 1,054.1 ± 1,252.5 μg/g in CD. There was a strong correlation between FC-ELISA level and clinical activity indices (p < 0.05). FC-ELISA level was significantly lower in patients with mucosal healing (MH) compared to those without MH in UC (85.5 ± 55.6 μg/g vs. 1,503.7 ± 2,129.9 μg/g, p = 0.005). The results from the QPOCT corresponded well to those from ELISA. A cutoff value of 201.3 μg/g for FC-ELISA and 150.5 μg/g for FC-QPOCT predicted endoscopic inflammation (Mayo endoscopic subscore ≥ 1) in UC with a sensitivity of 81.8% and 85.8%, respectively, and a specificity of 100% for both.

CONCLUSION

FC was strongly associated with disease activity indices, serologic markers, and endoscopic activity in patients with IBD. QPOCT can be used more conveniently than ELISA to assess FC in clinical practice.

Fecal calprotectin is not a clinically useful marker for the prediction of the early nonresponse to exclusive enteral nutrition in pediatric patients with Crohn disease

Exclusive enteral nutrition (EEN) has been recommended as the first-line therapy in children with active Crohn disease (CD). The primary aim of our study was to determine whether it is possible to use the difference between basal fecal calprotectin (F-CPT) and the value at week 2 of EEN to predict clinical response at week 6. We prospectively collected stool samples for F-CPT analysis and clinical and laboratory parameters during EEN from 38 pediatric patients (28 boys, median age 12.8 years) with newly diagnosed active luminal CD. The difference between F-CPT concentrations before EEN and at week 2 did not predict clinical non-response at week 6 (OR 0.9996 95% CI 0.9989-1.0002, p = 0.18); however, it predicted patients who did not achieve clinical remission at week 6 (OR 0.9993, 95% CI 00.9985-0.9998, p = 0.006) with sensitivity of 58%, and specificity of 92% for cut-off of F-CPT increase by 486 μg/g.Conclusions: An early decrease in F-CPT levels in children with newly diagnosed active luminal CD did not predict clinical response at week 6 of EEN induction therapy, and clinical remission was predicted with low accuracy. Therefore, F-CPT cannot be used as a predictor to select the patients in whom EEN should be terminated. What is Known: • The fecal calprotectin (F-CPT) is an important marker of intestinal inflammation. • Approximately 25% of pediatric patients with Crohn disease (CD) do not achieve clinical remission, and there is still no sufficient predictor of response to exclusive enteral nutrition (EEN) treatment. What is New: • The difference between the F-CPT concentrations before EEN treatment and at week 2 did not predict clinical response to treatment at week 6, even if it predicted clinical remission, however, with low accuracy. F-CPT is not a suitable predictor to select the patients for discontinuing of EEN induction therapy.

Evidence-based clinical practice guidelines for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

Biomarker-Based Models Outperform Patient-Reported Scores in Predicting Endoscopic Inflammatory Disease Activity

BACKGROUND

The Crohn's Disease Activity Index (CDAI), a scoring index including patient-reported outcomes (PROs), has known limitations for measuring intestinal inflammatory disease burden. Noninvasive markers of inflammation could prove more accurate than PROs; thus, regulatory authorities are exploring the use of PROs and endoscopic data as coprimary end points in clinical trials. The aim of this study was to assess the predictive ability of individual components of the CDAI, along with biomarker concentrations, to create models for predicting endoscopic disease activity.

METHODS

Between 2004 and 2006, 164 patients with established Crohn's disease (CD) undergoing clinically indicated ileocolonoscopy were recruited. Individual CDAI variables and fecal calprotectin (FC) were selected to explore their predictive accuracy for endoscopic disease activity, with the Simple Endoscopic Score-Crohn's Disease (SES-CD) as the outcome variable. Simple Poisson regression was performed on each variable, and 2 multivariate models were created (PRO-exclusive and PRO+FC [PRO+]). Additional analyses explored the patient-level agreement between models.

RESULTS

Number of liquid stools, abdominal pain, hematocrit (Hct), FC, and high-sensitivity C-reactive protein (hsCRP) correlated significantly with the SES-CD. For the prediction of SES-CD (>7 vs ≤6), the area under the curve (AUC) was 0.81, with 63% and 88% sensitivity and specificity, for the PRO+ model, compared with a 0.56 AUC, with 61% and 55%, respectively, for the PRO model. Intra-individual comparison revealed the PRO+ model to be superior in the prediction of endoscopically active disease.

CONCLUSIONS

The inclusion of biomarkers significantly improved predictive accuracy for endoscopic disease activity compared with PRO-exclusive models.

Capsule Endoscopy Crohn's Disease Activity Index (CECDAIic or Niv Score) for the Small Bowel and Colon

BACKGROUND AND THE STUDY AIM

Crohn's disease (CD) is a chronic inflammatory disorder defined as a transmural inflammation of the bowel wall, affecting the small and large intestine. The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score) was devised to measure mucosal disease activity. We extended the Niv score to the colon and have a comprehensive view of the whole intestine.

METHODS

We evaluated 3 parameters of intestinal pathology: A, Inflammation; B, Extent of disease; C, Presence of strictures. The scoring formula is as follows: CEDCAIic=(A1×B1+C1)+(A2×B2+C2)+(A3×B3+C3)+(A4×B4+C4) (1=proximal small bowel, 2=distal small bowel, 3=right colon, 4=left colon).

RESULTS

The median CECDAIic score was 15.5 (range, 0 to 42), and the mean±SD score was 17.2±11.5. The CECDAIic scores per patient were similar among the 5 observers. Kendall's coefficient of concordance was high and significant for almost all the parameters examined except for strictures in the proximal small bowel and distal colon. Nevertheless, the coefficients for the small bowel and for the whole intestine were high, 0.85 and 0.77, P<0.0001, respectively.

CONCLUSIONS

We established a new score, the CECDAIic of the small-bowel and colonic CD. We offer this easy, user-friendly score for use in randomized controlled trials and in the clinical follow-up of CD patients.

Fecal calprotectin measurement is a marker of short-term clinical outcome and presence of mucosal healing in patients with inflammatory bowel disease

AIM

To evaluate the utility of fecal calprotectin (FC) in predicting relapse and endoscopic activity during follow-up in an inflammatory bowel disease (IBD) cohort.

METHODS

All FC measurements that were obtained during a 3-year period from patients with inflammatory bowel disease in clinical remission were identified. Data regarding the short-term (6 mo) course of the disease were extracted from the medical files. Exclusion criteria were defined as: (1) An established flare of the disease at the time of FC measurement, (2) Loss to follow up within 6 mo from baseline FC measurement, and, (3) Insufficient data on file. Statistical analysis was performed to evaluate whether baseline FC measurement could predict the short term clinical relapse and/or the presence of mucosal healing.

RESULTS

We included 149 [Crohn’s disease (CD) = 113, Ulcerative colitis (UC) = 36, male = 77] IBD patients in our study. Within the determined 6-month period post-FC measurement, 47 (31.5%) had a disease flare. Among 76 patients who underwent endoscopy, 39 (51.3%) had mucosal healing. Baseline FC concentrations were significantly higher in those who had clinical relapse compared to those who remained in remission during follow up (481.0 μg/g, 286.0-600.0 vs 89.0, 36.0-180.8, P < 0.001). The significant predictive value of baseline median with IQR FC for clinical relapse was confirmed by multivariate Cox analysis [HR for 100μg/g: 1.75 (95%CI: 1.28-2.39), P = 0.001]. Furthermore, lower FC baseline values significantly correlated to the presence of mucosal healing in endoscopy (69.0 μg/g, 30.0-128.0 vs 481.0, 278.0-600.0, in those with mucosal inflammation, median with IQR, P < 0.001). We were able to extract cut-off values for FC concentration with a high sensitivity and specificity for predicting clinical relapse (261 μg/g with AUC = 0.901, sensitivity 87.2%, specificity 85.3%, P < 0.001) or mucosal healing (174 μg/g with AUC = 0.956, sensitivity 91.9%, specificity 87.2%, P < 0.001). FC was better than CRP in predicting either outcome; nevertheless, having a pathological CRP (> 5 mg/L) in addition to the cut-offs for FC, significantly enhanced the specificity for predicting clinical relapse (95.1% from 85.3%) or endoscopic activity (100% from 87.2%).

CONCLUSION

Serial FC measurements may be useful in monitoring IBD patients in remission, as FC appears to be a reliable predictor of short-term relapse and endoscopic activity.

Comparative Acceptability and Perceived Clinical Utility of Monitoring Tools: A Nationwide Survey of Patients with Inflammatory Bowel Disease

BACKGROUND

Objective control of intestinal inflammation during inflammatory bowel disease (IBD) is becoming the main driver for medical treatment. However, the monitoring tools-related burden remains poorly investigated. We aimed to evaluate their comparative acceptability and utility according to patients with IBD.

METHODS

After a preliminary phase, the final questionnaire encompassing self-administered and physician questionnaires was prospectively and consecutively submitted to 916 patients with IBD from 20 public and private centers. Acceptability and utility visual analog scales (VAS) were expressed as median with interquartile range.

RESULTS

Regarding the group of patients with Crohn's disease (n = 618), venipuncture (VAS = 9.3 [8.8-9.7]) and ultrasonography (VAS = 9.3 [8.7-9.7]) were the most acceptable tools (P < 0.0001, for each comparison), whereas rectosigmoidoscopy was the least acceptable tool (VAS = 4.4 [1.2-7.3]) (P < 0.0001, for each comparison). Wireless capsule endoscopy (VAS = 8.5 [5.2-9.3]), magnetic resonance enterocolonography (VAS = 8.0 [5.0-9.2]), and stools collection (VAS = 7.7 [4.6-9.3]) were more acceptable than colonoscopy (VAS = 6.7 [4.3-8.9]) (P < 0.0001, for each comparison). The acceptability was assessed in 298 patients with ulcerative colitis for venipuncture (VAS = 9.4 [8.8-9.7]), stools collection (VAS = 8.1 [5.7-9.4]), colonoscopy (VAS = 7.5 [4.7-9.2]), and rectosigmoidoscopy (VAS = 6.7 [2.8-9.1]); (P < 0.001 for each comparison). All monitoring tools were considered as highly useful by patients with IBD. Decreased acceptability was related to embarrassment for the collection/transport of stools (60.7%), bowel cleansing (76.3%) for colonoscopy, abdominal discomfort (51.3%) and rectal enema (36.6%) for rectosigmoidoscopy, bowel distension (48.3%) for magnetic resonance enterocolonography, and potential capsule retention (21.4%) for wireless capsule endoscopy.

CONCLUSIONS

Among the IBD monitoring tools, endoscopy demonstrated the lowest acceptability supporting the development of alternative modalities. Patients' information and examination conditions should be improved to ensure proper monitoring adherence.

[Fecal Calprotectin in Inflammatory Bowel Disease]

Inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis comprise conditions characterized by chronic, relapsing immune activation and inflammation within the gastrointestinal tract. Objective estimation of intestinal inflammation is the mainstay in the diagnosis and observation of IBD, but is primarily dependent on expensive and invasive procedures such as endoscopy. Therefore, a simple, noninvasive, inexpensive, and accurate test would be extremely important in clinical practice. Fecal calprotectin is a calcium-containing protein released into the lumen that is excreted in feces during acute and chronic inflammation. It is well-researched, noninvasive, and has high sensitivity and specificity for identification of inflammation in IBD. This review will focus on the use of fecal calprotectin to help diagnose, monitor, and determine treatment in IBD.

Serum platelet factor 4 is a reliable activity parameter in adult patients with inflammatory bowel disease: A pilot study

To investigate the diagnostic utility of serum platelet factor 4 (PF4) levels and to assess its accuracy in detecting inflammatory bowel disease activity.This study included 45 patients with ulcerative colitis (UC), 45 patients with Crohn disease (CD), and 30 control subjects at Jinling Hospital between May 2014 and July 2015. Laboratory tests measured white blood count, C-reactive protein, erythrocyte sedimentation rate, and platelet count. PF4 was examined by enzyme-linked immunosorbent assays. Patients were divided into 2 groups according to disease activity: active and inactive.Median PF4 values dramatically increased in UC and CD patients compared with the healthy group (UC: 26.64 [20.00-36.22] mg/mL vs 20.02 [14.63-26.83] mg/mL, P = 0.002; CD: 25.56 [18.57-36.36] mg/mL vs 20.02 [14.63-26.83] mg/mL, P = 0.014); however, the serum PF4 levels between UC and CD failed to show a significant difference (26.64 [20.00-36.22] mg/mL vs 25.56 [18.57-36.36] mg/mL, P = 0.521). Furthermore, serum PF4 levels were elevated in both UC and CD patients with active disease (UC: 20.19 [14.89-23.53] mg/mL vs 28.86 [22.57-37.29] mg/mL, P < 0.001; CD: 18.33 [16.72-25.77] mg/mL vs 34.38 [22.58-39.92] mg/mL, P < 0.001). Multivariate analysis revealed higher PF4 level as an independent predictor of disease activity in UC and CD patients (UC: odds ratio 30.375, P = 0.002; CD: odds ratio 54.167, P < 0.001). The cut-off level of PF4 for distinguishing active from inactive UC patients was 24.1 mg/mL. While in CD patients, the cut-off level of PF4 was 19.24 mg/mL.Serum PF4 levels could be a potential biomarker for monitoring the disease activity of inflammatory bowel disease.

Treat to Target in Inflammatory Bowel Disease: An Updated Review of Literature

OPINION STATEMENT

Therapeutic management of patients with inflammatory bowel diseases (IBDs) has, for years, been tailored towards monitoring patient clinical presentation as a way to gauge therapeutic management. With the advent of newer biological agents, treatment and management have begun to focus on more objective rather than subjective parameters. These objective parameters include endoscopic targets and focus on the impact of mucosal healing, radiologic and histologic targets, patient reported outcomes, and use of non-invasive biomarkers. However, a recent consensus statement has identified clinical/patient-reported outcome (PRO) remission and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1) as the target for UC with histological remission being an adjunctive goal. For CD, clinical/PRO remission defined as resolution of abdominal pain and diarrhea/altered bowel habit and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, and resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy were the primary targets. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. This approach requires continuous monitoring and therapeutic adjustments with an aim to achieve the target. This article attempts to review the most updated literature regarding the treat to target approach and thus provides current recommendations and supported evidence.

New Biomarkers for Diagnosing Inflammatory Bowel Disease and Assessing Treatment Outcomes

Despite advances in our understanding of the pathophysiology underlying inflammatory bowel disease, there remains a significant need for biomarkers that can differentiate between Crohn's disease and ulcerative colitis with high sensitivity and specificity, in a cost-efficient manner. As the focus on personalized approaches to the delivery of medical treatment increases, new biomarkers are being developed to predict an individual's response to therapy and their overall disease course. In this review, we will outline many of the existing and recently developed biomarkers, detailing their role in the assessment of patients with inflammatory bowel disease. We will identify opportunities for improvement in our biomarkers, including better differentiation between the subtypes of inflammatory bowel disease. We will also discuss new targets and strategies in biomarker development, including combining modalities to create biomarker signatures to improve the ability to predict disease courses and response to therapy among individual patients.

Evolving roles of cross-sectional imaging in Crohn's disease

The implementation of cross-sectional imaging techniques for the clinical management of Crohn's disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohn's disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohn's disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohn's disease post-surgical recurrence.

Endoscopic scoring indices for evaluation of disease activity in Crohn's disease

BACKGROUND

Endoscopic assessment of mucosal disease activity is widely used to determine eligibility and response to therapy in clinical trials of treatment for Crohn's disease. However, the operating properties of the currently available endoscopic indices remain unclear.

OBJECTIVES

A systematic review was undertaken to evaluate the development and operating characteristics of the Crohn's Disease Endoscopic Index of Severity (CDEIS) and Simple Endoscopic Scale for Crohn's Disease (SES-CD).

SEARCH METHODS

Electronic searches of the MEDLINE (1966 to December 2015), EMBASE (1980 to December 2015), and Cochrane CENTRAL Register of Controlled Trials (Issue 12, 2015) databases were supplemented by manual reviews of reference listings and conference proceedings (Digestive Disease Week, United European Gastroenterology Week, European Crohn's and Colitis Organization).

SELECTION CRITERIA

Any study design (e.g. randomized controlled trials, cohort studies, case series) that evaluated either or both the CDEIS or SES-CD in patients with Crohn's disease was considered for inclusion. Eligible participants were adult patients (> 16 years), diagnosed with Crohn's disease using conventional clinical, radiographic, and endoscopic criteria.

DATA COLLECTION AND ANALYSIS

Two authors (RK, JKM) independently reviewed the titles and abstracts of the studies identified from the literature search. The full texts of potentially relevant citations were reviewed for inclusion and the study investigators were contacted to clarify any unclear data. Any disagreements were resolved by discussion and consensus with a third author. A standardized form was used to assess eligibility of trials for inclusion in the study and for data extraction.Two authors independently extracted and recorded data (RK, SAN). The number of patients enrolled; number of patients per treatment arm; patient characteristics including age and gender distribution; endoscopic index; and outcomes such as intra-rater reliability, inter-rater reliability responsiveness, validity, feasibility, construct validity, and criterion validity were recorded for each trial.

MAIN RESULTS

Forty-three reports of 30 studies fulfilled the inclusion criteria.For the SES-CD, inter-rater reliability was assessed in four studies. In the development study for the SES-CD (Daperno 2004), the overall ICC (0.9815, 95% CI 0.9705 to 0.9884) and the kappa for the regions is high; however the paired raters were in the same room which introduces the potential for bias.For the CDEIS, inter-rater reliability was assessed in six studies. Daperno 2014 reported that the ICC for the CDEIS was 0.985 (95% CI 0.939-1.000) for average measures of video score and was 0.835 (95% CI 0.540-0.995) for single measures of video score.With respect to validity, correlation between the CDEIS and clinical measures, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), was also reported. The estimates of correlation with CRP were r = 0.521 (Sipponen 2010b), r = 0.553 (Sipponen 2008a) and r = 0.608 (Sipponen 2008c). For the SES-CD, the corresponding values for correlation with CRP ranged from r = 0.46 (Jones 2008) to r = 0.68 (Green 2011).Responsiveness data for the CDEIS were available in nine studies. Seven studies demonstrated statistically significant decreases in the CDEIS score after administration of a treatment of known efficacy. Minimal responsiveness data were available for the SES-CD. Sipponen 2010a and Sipponen 2010b demonstrated statistically significant changes in the SES-CD score after subjects were administered a treatment of known efficacy.No studies were identified that explicitly evaluated the feasibility for either the SES-CD or the CDEIS. The SES-CD requires fewer calculations and may therefore be easier to use than the CDEIS.

AUTHORS' CONCLUSIONS

Although they are used in clinical trials, the CDEIS and SES-CD remain incompletely validated. Future research is required to determine the operating properties and to define the optimal index.

Fecal calprotectin: its scope and utility in the management of inflammatory bowel disease

Gastrointestinal symptoms such as abdominal pain, dyspepsia, and diarrhea are relatively nonspecific and a common cause for seeking medical attention. To date, it is challenging for physicians to differentiate between functional and organic gastrointestinal conditions and it involves the use of serological and endoscopic techniques. Therefore, a simple, noninvasive, inexpensive, and effective test would be of utmost importance in clinical practice. Fecal calprotectin (FC) is considered to be a reliable biomarker that fulfills these criteria. FC can detect intestinal inflammation, and its level correlates well with macroscopic and histological inflammation as detected by colonoscopy and biopsies, respectively. FC has a decent diagnostic accuracy for differentiating organic diseases and functional disorders because of its excellent negative predictive value in ruling out inflammatory bowel disease (IBD) in symptomatic undiagnosed patients. There is accumulating evidence that FC has been effectively used to monitor the natural course of IBD, to predict relapse, and to see the response to treatment. This novel biomarker has the ability to assess mucosal healing (MH), which is a therapeutic goal in IBD management. A literature search was carried out using PubMed with the keywords FC, IBD, intestinal inflammation, and MH. In our review, we provide an overview of the utility and scope of FC as a biomarker in patients with IBD as well as undiagnosed patients with lower gastrointestinal symptoms.

Correlation between serological biomarkers and endoscopic activity in patients with inflammatory bowel disease

BACKGROUND/AIMS

Endoscopy is the gold standard for assessing disease severity in inflammatory bowel disease (IBD), although it is an invasive procedure. Biological markers have been routinely used as a non-invasive means of determining disease activity. The aim of this study was to determine the correlation between common biological markers and endoscopic activity in IBD.

METHODS

Consecutive patients with IBD were included. Serum concentrations of different biomarkers (C-reactive protein [CRP], orosomucoid [ORM], erythrocyte sedimentation rate [ESR], fibrinogen, platelets, leukocytes, neutrophils and hemoglobin [Hb]) were measured, and their accuracy in detecting endoscopic activity was determined.

RESULTS

Eighty patients were included (mean age 46 years, 53% Crohn's disease), 70% with endoscopic activity. Among Crohn's disease patients, 24% had mild endoscopic activity, 12% moderate activity and 39% severe activity. Among ulcerative colitis patients, 35% had an endoscopic Mayo score of 0-1 points, 30% 2 points and 35% 3 points. None of the biomarkers included had a good correlation with endoscopic activity (Area Under the ROC curve [AUC]<0.70) in ulcerative colitis. ORM, fibrinogen and platelets had the best accuracy to detect endoscopic activity in Crohn's disease (AUC: 0.80-0.085). A sub-analysis in postoperative Crohn's disease patients found no correlation between endoscopic recurrence and biomarkers (AUC<0.70).

CONCLUSION

Serological biomarkers, including CRP, have low accuracy to detect endoscopic activity in ulcerative colitis and postoperative Crohn's disease. ORM, fibrinogen and platelets have the best accuracy to detect endoscopic activity in Crohn's disease.

Diffusion-weighted magnetic resonance enterocolonography in predicting remission after anti-TNF induction therapy in Crohn's disease

BACKGROUND

Diffusion-weighted magnetic resonance entero-colonography (DW-MREC) with no rectal distension and with no bowel cleansing is accurate to assess inflammatory activity in ileocolonic Crohn's disease (CD).

AIM

To study DW-MREC parameters as predictors of remission (CDAI < 150 and CRP < 5mg/L) after anti-TNF induction therapy.

METHODS

Forty consecutive CD patients were prospectively and consecutively included. All the patients underwent DW-MREC with apparent diffusion coefficient (ADC) and MaRIA calculation before starting anti-TNF. Mean ADC was defined as the mean of the segmental ADC.

RESULTS

Twenty patients (50.0%) experienced remission at W12. Low mean ADC (2.05 ± 0.22 vs 1.89 ± 0.25, p = 0.03) and high total MaRIA (39.2 ± 16.6 vs 51.7 ± 18.2, p = 0.03) were predictive of remission at W12. Using a ROC curve, we determined a mean ADC of 1.96 as predictive cut-off of remission at W12 (AUC = 0.703 [0.535-0.872]) with sensitivity, specificity, positive predictive value and negative predictive value of 70.0%, 65.0%, 66.7% and 68.4%, respectively. In multivariate analysis, mean ADC < 1.96 (OR = 4.87, 95% CI [1.04-22.64]) and total MaRIA > 42.5 (OR = 5.11, 95% CI [1.03-25.37]), reflecting high inflammatory activity, were predictive of remission at week 12.

CONCLUSIONS

DW-MREC using quantitative parameters i.e. ADC, is useful in detecting and assessing inflammatory activity but also to predict efficacy of anti-TNF induction therapy in CD.

Defining Disease Severity in Inflammatory Bowel Diseases: Current and Future Directions

Although most treatment algorithms in inflammatory bowel disease (IBD) begin with classifying patients according to disease severity, no formal validated or consensus definitions of mild, moderate, or severe IBD currently exist. There are 3 main domains relevant to the evaluation of disease severity in IBD: impact of the disease on the patient, disease burden, and disease course. These measures are not mutually exclusive and the correlations and interactions between them are not necessarily proportionate. A comprehensive literature search was performed regarding current definitions of disease severity in both Crohn's disease and ulcerative colitis, and the ability to categorize disease severity in a particular patient. Although numerous assessment tools for symptoms, quality of life, patient-reported outcomes, fatigue, endoscopy, cross-sectional imaging, and histology (in ulcerative colitis) were identified, few have validated thresholds for categorizing disease activity or severity. Moving forward, we propose a preliminary set of criteria that could be used to classify IBD disease severity. These are grouped by the 3 domains of disease severity: impact of the disease on the patient (clinical symptoms, quality of life, fatigue, and disability); measurable inflammatory burden (C-reactive protein, mucosal lesions, upper gastrointestinal involvement, and disease extent), and disease course (including structural damage, history/extension of intestinal resection, perianal disease, number of flares, and extraintestinal manifestations). We further suggest that a disease severity classification should be developed and validated by an international group to develop a pragmatic means of identifying patients with severe disease. This is increasingly important to guide current therapeutic strategies for IBD and to develop treatment algorithms for clinical practice.

Diagnosis and management of functional symptoms in inflammatory bowel disease in remission

Inflammatory bowel disease (IBD) patients in remission may suffer from gastrointestinal symptoms that resemble irritable bowel syndrome (IBS). Knowledge on this issue has increased considerably in the last decade, and it is our intention to review and summarize it in the present work. We describe a problematic that comprises physiopathological uncertainties, diagnostic difficulties, as IBS-like symptoms are very similar to those produced by an inflammatory flare, and the necessity of appropriate management of these patients, who, although in remission, have impaired quality of life. Ultimately, from almost a philosophical point of view, the presence of IBS-like symptoms in IBD patients in remission supposes a challenge to the traditional functional-organic dichotomy, suggesting the need for a change of paradigm.

Illness perceptions and stress: mediators between disease severity and psychological well-being and quality of life among patients with Crohn's disease

BACKGROUND

Disease severity, illness perceptions, coping strategies, stress, psychological well-being, and quality of life were reported to have close relationships. According to the Common Sense Model, illness perceptions and coping strategies could mediate the relationship between illness stimuli and illness outcomes such as psychological health and quality of life. Stress was also associated with the individual's disease severity, anxiety, depression, and quality of life.

OBJECTIVES

The study aimed to explore the influencing factors of illness outcomes, and to what extent illness perceptions, coping strategies, and stress mediate the relationship between disease severity and anxiety, and depression and quality of life.

METHODS

Our study included 159 patients with Crohn's disease who were attending a tertiary hospital outpatient clinic or who were hospitalized. Disease severity was measured with the Crohn's Disease Activity Index. Illness perceptions were measured with the Brief Illness Perceptions Questionnaire. Coping strategies were measured with the Carver Brief Coping Questionnaire. Stress was measured with the Perceived Stress Questionnaire. Anxiety and depression were measured with the Hospital Anxiety and Depression Scale. Quality of life was measured with the Inflammatory Bowel Disease Questionnaire.

RESULTS

Disease severity, illness perceptions, maladaptive coping, stress, anxiety, depression and quality of life were significantly correlated with each other among patients with Crohn's disease. Using structural equation modeling to describe the inner relationship of the aforementioned variables, an excellent-fitted model was drawn. (χ²[10]=13.83, P=0.18, χ²/N=1.38, standardized root mean square residual [SRMR] <0.05, root mean square error of approximation [RMSEA] <0.05, goodness of fit index [GFI] >0.97, comparative fit index [CFI] >0.99). Disease severity had a direct influence on illness perceptions. Illness perceptions had a direct influence on stress. Both illness perceptions and stress had direct influences on anxiety, depression, and quality of life, while maladaptive coping did not directly influence anxiety, depression, or quality of life. Stress had a direct influence on maladaptive coping. Quality of life was also directly influenced by disease severity and anxiety.

CONCLUSION

Interrelationships between disease stimuli, disease perceptions and management and disease outcomes could be found in patients with Crohn's disease. Illness perceptions and stress mediated an individual's disease severity and anxiety, depression and quality of life, while coping strategy was not an applicable mediator.

Capsule Endoscopy for Crohn's Disease: Current Status of Diagnosis and Management

Crohn's disease (CD) is an idiopathic inflammatory bowel disease involving the small and/or large intestine. More than 50% of Western CD patients and up to 88% of Asian CD patients may have small intestinal involvement. Video capsule endoscopy (VCE) has a higher diagnostic yield than small bowel barium radiography and computed tomography enterography for the detection of small intestinal involvement of CD. VCE also provides diagnostic yields comparable to magnetic resonance- (MR-) based enterography or enteroclysis and may have several advantages over MR-based tests for the detection of early small intestinal lesions. Several studies have suggested the use of VCE-based disease activity scoring systems to evaluate small intestinal mucosal disease activity, although their clinical relevance needs to be further studied. A possible indication for VCE is recurrence monitoring after complete surgical excision of CD-involved segments but its usefulness and efficacy compared with conventional endoscopy should be evaluated. The capsule retention rate ranges from 0 to 5.4% in suspected CD patients and from 0 to 13.2% in established CD patients. If VCE is necessary, significant small bowel stricture should be ruled out before VCE by performing a patency capsule study and/or small bowel radiological study in suspected or established CD patients.

Use of blood based biomarkers in the evaluation of Crohn’s disease and ulcerative colitis

Despite significant improvements in our understanding of Crohn’s disease (CD) and ulcerative colitis (UC) in recent years, questions remain regarding the best approaches to assessment and management of these chronic diseases during periods of both relapse and remission. Various serologic biomarkers have been used in the evaluation of patients with both suspected and documented inflammatory bowel disease (IBD), and while each has potential utility in the assessment of patients with IBD, potential limitation remain with each method of assessment. Given these potential shortcomings, there has been increased interest in other means of evaluation of patients with IBD, including an expanding interest in the role of gene expression profiling. Among patients with IBD, gene expression profiles obtained from whole blood have been used to differentiate active from inactive CD, as well as to differentiate between CD, UC, and non-inflammatory diarrheal conditions. There are many opportunities for a non-invasive, blood based test to aid in the assessment of patients with IBD, particularly when considering more invasive means of evaluation including endoscopy with biopsy. Furthermore, as the emphasis on personalized medicine continues to increase, the potential ability of gene expression analysis to predict patient response to individual therapies offers great promise. While whole blood gene expression analysis may not completely replace more traditional means of evaluating patients with suspected or known IBD, it does offer significant potential to expand our knowledge of the underlying genes involved in the development of these diseases.

Fecal calprotectin and its correlation with inflammatory markers and endoscopy in patients from India with inflammatory bowel disease

INTRODUCTION

In clinical practice, endoscopic findings are often used for assessing disease activity in inflammatory bowel disease (IBD). In recent years, blood and stool markers are being increasingly used for this purpose. Among them, the fecal calprotectin (FC) level is probably the most favored. Data on the reliability of FC are lacking from countries like India, where gut infections are common.

OBJECTIVE

The aims of this study were to compare the FC level with the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) as non-invasive markers of IBD and, in patients with ulcerative colitis (UC), and to study its correlation with disease extent, clinical activity, and endoscopic severity.

METHODS

Records of patients with IBD who had tests for FC, ESR and CRP and colonoscopy done within a 2-week period, between 2012 and 2014, were retrieved. Sixty-three patients (UC 32, Crohn's disease [CD] 31) were included for analysis. ESR, CRP and FC were compared to endoscopy to assess inflammation.

RESULTS

Patients with UC had higher levels of FC than those with ileocolonic CD (median FC 800 mcg/g vs. 619 mcg/g, respectively; p = 0.04). FC levels correlated with CRP (r = 0.4, p < 0.001) but not with ESR (r = 0.21, p = 0.09). In patients with UC with endoscopic evidence of inflammation, more (86.9 %) had FC > 200 mcg/g (cut-off for disease activity in our laboratory) than had ESR >20 mm in the first hour (60.6 %) or positive CRP (65.6 %) (< 0.01); FC levels increased with increasing endoscopic Mayo score (p = 0.001) and Truelove-Witt's clinical severity score (p = 0.006), but did not correlate with disease extent (p = 0.7). The best FC cut-off level to identify 'active UC' (Mayo grade 2 or more) was 800 mcg/g.

CONCLUSION

Fecal calprotectin level correlates with CRP but not with ESR. In patients with UC with inflammation, FC > 200 mcg/g is more often positive than raised ESR or CRP; it also correlates with clinical and endoscopic activity but not with disease extent. FC level > 800 mcg/g can be used to differentiate active from inactive UC.

Platelet Activation Markers Are Associated with Crohn's Disease Activity in Patients with Low C-Reactive Protein

BACKGROUND

In assessing Crohn's disease (CD) activity, C-reactive protein (CRP) is an important indicator of inflammation; however, it is not necessarily associated with the Crohn's Disease Activity Index (CDAI), particularly in patients with low CRP. Recently, platelet activation factors have been recognized due to their importance in the inflammatory response. In this study, we examined associations between the CDAI and platelet factor 4 (PF-4), β-thromboglobulin (β-TG), and other coagulation and fibrinolysis factors.

AIMS

We aimed to find a new marker for evaluating disease activity in patients with CD and low CRP.

METHODS

Nine markers, including CRP, platelet count, white blood cell count, fibrin and fibrinogen degradation product, fibrinogen, thrombin-antithrombin complex, prothrombin fragments 1 + 2, PF-4, and β-TG were evaluated in 47 patients with CD and low CRP (<1.0 mg/dl). Patients were assigned to high or low disease activity groups, CDAI-H (CDAI ≥ 150) and CDAI-L (CDAI < 150), respectively.

RESULTS

CDAI-H exhibited significantly higher PF-4 and β-TG levels than CDAI-L (P < 0.01). Other markers were not significantly different between groups. CDAI was positively correlated with the levels of PF-4 and β-TG (P = 0.0033 and 0.0024; r = 0.4202 and 0.4321, respectively). Receiver operating characteristic curve analyses of PF-4 and β-TG showed high sensitivity (61.9 and 81%, respectively) and specificity (84.7 and 69.2%, respectively) for diagnosing active CD.

CONCLUSION

Among eight potential markers, PF-4 and β-TG were the most highly correlated with CDAI in patients with CD and low CRP. PF-4 and β-TG levels showed promise as new markers for assessing CD in patients with low CRP.

Are faecal markers good indicators of mucosal healing in inflammatory bowel disease?

AIM: To review the published literature concerning the accuracy of faecal inflammatory markers for identifying mucosal healing.

METHODS: Bibliographical searches were performed in MEDLINE electronic database up to February 2015, using the following terms: “inflammatory bowel disease”, “Crohn´s disease”, “ulcerative colitis”, “faecal markers”, “calprotectin”, “lactoferrin”, “S100A12”, “endoscop*”, “mucosal healing”, “remission”. In addition, relevant references from these studies were also included. Data were extracted from the published papers including odds ratios with 95%CI, P values and correlation coefficients. Data were grouped together according to each faecal marker, Crohn’s disease or ulcerative colitis, and paediatric compared with adult study populations. Studies included in this review assessed mucosal inflammation by endoscopic and/or histological means and compared these findings to faecal marker concentrations in inflammatory bowel diseases (IBD) patient cohorts. Articles had to be published between 1990 and February 2015 and written in English. Papers excluded from the review were those where the faecal biomarker concentration was compared between patients with IBD and controls or other disease groups, those where serum biomarkers were used, those with a heterogeneous study population and those only assessing post-operative disease.

RESULTS: The available studies show that faecal markers, such as calprotectin and lactoferrin, are promising non-invasive indicators of mucosal healing. However, due to wide variability in study design, especially with regard to the definition of mucosal healing and evaluation of marker cut offs, the available data do not yet indicate the optimal roles of these markers. Thirty-six studies published between 1990 and 2014 were included. Studies comprised variable numbers of study participants, considered CD (15-164 participants) or UC (12-152 participants) separately or as a combined group (11-252 participants). Eight reports included paediatric patients. Several indices were used to document mucosal inflammation, encompassing eleven endoscopic and eight histologic grading systems. The majority of the available reports focused on faecal calprotectin (33 studies), whilst others assessed faecal lactoferrin (13 studies) and one study assessed S100A12. Across all of the biomarkers, there is a wide range of correlation describing the association between faecal markers and endoscopic disease activity (r values ranging from 0.32 to 0.87, P values ranging from < 0.0001 to 0.7815). Correlation coefficients are described in almost all studies and are used more commonly than outcome measures such as sensitivity, specificity, PPV and/or NPV. Overall, the studies that have evaluated faecal calprotectin and/or faecal lactoferrin and their relationship with endoscopic disease activity show inconsistent results.

CONCLUSION: Future studies should report the results of faecal inflammatory markers in the context of mucosal healing with clear validated cut offs.

Clinic-based Point of Care Transabdominal Ultrasound for Monitoring Crohn's Disease: Impact on Clinical Decision Making

BACKGROUND AND AIMS

The use of cross-sectional imaging is important to characterise inflammatory bowel disease [IBD] activity, extent, and location and to exclude complications, regardless of symptoms. The aim of this study was to evaluate the impact of routine use of sonography in the management of inflammatory bowel disease.

METHODS

A total of 49 patients with Crohn's disease were prospectively evaluated. Clinical symptoms (Harvey-Bradshaw Index [HBI]), disease character, serological markers of inflammation [C-reactive protein], and endoscopic evaluation were collected and reviewed by two independent IBD-specialty physicians. Clinical decisions regarding management were recorded. A separate, blinded physician then performed bowel ultrasound [US] and graded disease activity:] as inactive, mild, or active. A second blinded physician read and graded a sub-set of the US images. Clinical decisions of both IBD-physicians after US were independently recorded. Changes in clinical management following US information and inter-rater agreement on US disease activity parameters were evaluated. The concordance between US, CRP and clinical symptoms [HBI] were analysed. Follow-up data after US evaluation were collected.

RESULTS

Clinical decisions were changed after ultrasound assessment in 30/49 [60%] and 28/48 [58%] of cases, for each physician respectively [p < 0.0001 for each]. Many [59%] of the patients seen in clinic were asymptomatic with an HBI of 3 or less [n = 29]; however, 52% [n = 15] of these had active disease found on US, resulting in alterations in clinical management. The agreement in overall score between the US reviewers was good, ĸ = 0.749 [0.5814, 0.9180], p < 0.001.

CONCLUSIONS

Clinic-based point of care US can play a significant role in guiding therapeutic management and is an important adjunct to routine clinical and laboratory assessment.

No association between serum adenosine deaminase activity and disease activity in Crohn's disease

BACKGROUND

Adenosine deaminase activity is proposed as a marker of inflammation in some inflammatory conditions.

AIMS

To investigate the association of serum adenosine deaminase activity and disease activity in Crohn's disease patients.

METHODS

In a cross-sectional study, 30 consecutive known cases of Crohn's disease (15 with active disease and 15 in remission) referring to a university hospital in Tehran (Iran) and 15 age- and gender-matched healthy controls were studied. Disease activity was assessed using the Crohn's disease activity index (cutoff >150). Total serum adenosine deaminase activity, C-reactive protein, erythrocyte sedimentation rate, and fecal calprotectin were evaluated in patients. Serum adenosine deaminase activity was measured in controls.

RESULTS

Mean age of the patients was 36.8 ± 12.6 years, and 56.7 % were male. Serum adenosine deaminase activity in patients with active disease, patients in remission, and controls was 12.3 ± 5.9, 14.6 ± 6.2, and 11.9 ± 6.4 U/L, respectively (P = 0.458). Compared with patients in remission, those with active disease had higher erythrocyte sedimentation rate (40.4 ± 30.6 vs. 16.9 ± 16.0 mm/h, P = 0.014) and higher frequency of positive C-reactive protein (66.6 vs. 13.3 %, P = 0.004) and positive fecal calprotectin tests (86.6 vs. 33.3 %, P = 0.004). Serum adenosine deaminase activity was not correlated with erythrocyte sedimentation rate (r = 0.05, P = 0.761) and was not different between patients with positive and negative C-reactive protein (12.2 ± 5.4 vs. 14.2 ± 6.5 U/L, P = 0.393) and fecal calprotectin tests (11.7 ± 5.3 vs. 16.0 ± 6.5 U/L, P = 0.063).

CONCLUSIONS

In patients with Crohn's disease, serum adenosine deaminase activity is not associated with clinical disease activity or with other inflammation markers and cannot be suggested as an inflammation marker.

Treat to target: a proposed new paradigm for the management of Crohn's disease

The traditional management of Crohn's disease, which is based on progressive, step-wise treatment intensification with re-evaluation of response according to symptoms, does not improve long-term outcomes of Crohn's disease and places patients at risk for bowel damage. The introduction of novel therapies and the development of new approaches to treatment in rheumatoid arthritis led to better outcomes for patients. Prominent among these is a "treat to target" strategy that is based on regular assessment of disease activity by using objective clinical and biological outcome measures and the subsequent adjustment of treatments. This approach is complementary to the concept of early intervention in high-risk patients. This review evaluates current literature on this topic and proposes a definition for the concept of treating to targets for Crohn's disease.

New Trends in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory disease of the gastrointestinal (GI) tract. In the past decade a shift in the treatment paradigm of IBD has ensued. The availability of drugs capable of inducing mucosal healing, combined with the recognition that IBD is not an intermittent disease, but rather a progressive one causing bowel damage and disability, led us to a more stringent strategy. Tailored therapy with more aggressive treatment in high-risk patients, treating beyond symptoms, intervening early before damage occurs, optimizing therapeutic regimens, and actively pursuing sustained remission and sustained control of inflammation are strategies that are slowly being incorporated in our clinical practice. Furthermore, new drugs targeting different immunological pathways, such as vedolizumab, have recently been approved and therefore more therapeutic resources for patients failing anti-tumour necrosis factor alpha (anti-TNFα) agents will be available. The future years look promising for IBD. Hopefully the new trends in IBD management, combined with new drugs, will make possible to change the course of disease and provide better therapy and quality of life for patients suffering from this disabling disease.

Disease activity assessment in IBD: clinical indices and biomarkers fail to predict endoscopic remission

BACKGROUND

In the current management paradigm, mucosal healing is preferred over clinical remission as a therapeutic end point in inflammatory bowel disease (IBD) because of the benefits engendered with respect to durability of remission. Colonoscopy, however, is not suitable for regular disease monitoring, and routine clinical assessment is often inaccurate with respect to endoscopic disease activity. The current investigation set out to characterize the relationship that exists between endoscopically determined IBD activity and clinical and biochemical measures of disease severity and to determine clinically useful thresholds for use in clinical practice.

METHODS

Patients attending for colonoscopy with known or suspected IBD were recruited. Clinical disease activity was recorded as per the Harvey-Bradshaw Index for Crohn's disease or the simple clinical colitis activity index for ulcerative colitis. Endoscopic activity was recorded using the simple endoscopic score for Crohn's disease or the modified Baron score for ulcerative colitis. Receiver operating characteristic analysis determined the predictive value and optimal predictive thresholds for clinical and biomarker data.

RESULTS

The Harvey-Bradshaw Index was not able to distinguish active from inactive Crohn's disease. The sensitivity, specificity, and positive and negative predictive values of simple clinical colitis activity index to detect endoscopic active disease were 43%, 96%, 94%, and 51%, respectively. Any elevation of C-reactive protein or fecal calprotectin was predictive of active mucosal disease, however, no lower threshold could be identified that predicted disease in remission.

CONCLUSIONS

C-reactive protein and fecal calprotectin are useful for the identification of endoscopically active IBD, but normal results do not confirm endoscopic remission.

The impact of bacterial DNA translocation on early postoperative outcomes in Crohn's patients undergoing abdominal surgery

BACKGROUND AND AIMS

Bacterial DNA (bactDNA) translocation occurs frequently in patients with Crohn's disease and can be present in patients with a negative blood microbiological culture. We aimed to determine the effects of bactDNA translocation on postoperative outcomes in Crohn's disease patients undergoing abdominal surgery.

METHODS

Patients with Crohn's disease who underwent abdominal surgery between January 2012 and March 2014 were identified. General and postoperative outcome-related information was retrieved from a database, and the data were compared between patients with and without bactDNA translocation. Multivariate analysis was used to determine the independent effect of bactDNA translocation on postoperative morbidity.

RESULTS

One hundred and seven patients who underwent abdominal surgery were included in our study. The presence of bactDNA in blood samples was identified in 29 patients (27.1%). There was a total of 55 complications in 28 patients (26.2%). Patients with bactDNA in their blood had a mean postoperative hospital stay of 12.7±4.2 days and patients without DNA translocation had a mean postoperative hospital stay of 10.1±4.8 days (p = 0.009). The readmission rate was increased in patients with bactDNA translocation (p = 0.032). A low preoperative level of serum albumin (p = 0.024), preoperative immunosuppressive agent use (p = 0.046), and the presence of bactDNA in blood (p = 0.005) were independently associated with increased postoperative adverse outcomes.

CONCLUSIONS

Preoperative bactDNA translocation into the blood increases the incidence of postoperative adverse outcomes in patients with Crohn's disease who undergo abdominal surgery.

[Evaluation of the concordance between biological markers and clinical activity in inflammatory bowel disease]

BACKGROUND AND OBJECTIVES

Endoscopy is the gold standard to assess disease severity in inflammatory bowel disease, although it is an invasive procedure. Clinical activity and biological markers have been routinely used to determine disease activity in a non-invasive manner. The aim of this study was to determine concordance between common biological markers (C reactive protein, orosomucoid, erythrocyte sedimentation rate, fibrinogen, platelets, leukocytes, neutrophils and haemoglobin) and clinical activity in inflammatory bowel disease.

PATIENTS AND METHOD

Consecutive patients with inflammatory bowel disease were included. Clinical activity was evaluated according to the Harvey-Bradshaw index in Crohn's disease and to the partial Mayo score in ulcerative colitis. Serum concentrations of the different biomarkers were analysed. Concordance between clinical activity and elevation of the serological biomarkers was determined using the kappa statistic.

RESULTS

In total, 350 patients were included (median age 46 years, Crohn's disease 59%). Eleven percent of patients had clinical activity. Crohn's disease patients had mild clinical activity in 44% of cases, moderate disease in 44% and only 12% of patients had severe clinical activity. In ulcerative colitis, patients had mild, moderate and severe clinical activity in 50, 42 and 8% of cases, respectively. None of the biomarkers included had an acceptable concordance with clinical activity (kappa statistic ≤ 0.30).

CONCLUSIONS

Concordance between serological biomarkers and clinical activity in inflammatory bowel disease is remarkably low.

Sequential capsule endoscopy of the small bowel for follow-up of patients with known Crohn's disease

BACKGROUND AND AIMS

The aim of this study was to perform sequential small bowel (SB) capsule endoscopy (CE) studies in patients with known active Crohn's disease (CD) during different treatments, to characterize the changes in the SB mucosa over time, and to correlate the CE findings with clinical and laboratory parameters of inflammation.

METHODS

Consecutive patients with known moderately active CD were prospectively recruited. After proven patency with Agile capsule, CE studies were performed at baseline and after 4, 12 and 24 weeks. CE parameters and a Lewis score were calculated. Clinical and laboratory parameters were correlated. A control group of 178 non-CD patients was used for comparisons.

RESULTS

Thirty-one CD patients were recruited and 19 met the inclusion criteria. A total of 43 CE studies were performed over the time. There was no capsule retention despite a high rate of previous SB surgery. The mean baseline CDAI, IBDQ and Lewis scores were 306±56, 135±26.6 and 1730±1780, respectively. There was no correlation at the baseline between clinical and laboratory parameters (CDAI, CRP, IBDQ) and mucosal disease (Lewis scores). CDAI and IBDQ changes over a period of 4 and 12 weeks did not correlate with the Lewis score. The cecum arrival rate of the CD patients was significantly lower (p=0.0047) and the SB transit time was significantly longer (p=0.005) compared to those of the controls.

CONCLUSIONS

Sequential CE studies are feasible and safe in CD patients. In patients with complete CE studies, they provide reliable information on mucosal changes in CD and should be considered as an independent and objective follow-up tool in known CD patients.

Cytomegalovirus infection in inflammatory bowel disease is not associated with worsening of intestinal inflammatory activity

Background

Cytomegalovirus is highly prevalent virus and usually occurs in immunocompromised patients. The pathophysiology and treatment of inflammatory bowel disease often induce a state of immunosuppression. Because this, there are still doubts and controversies about the relationship between inflammatory bowel disease and cytomegalovirus.

Aim

Evaluate the frequency of cytomegalovirus in patients with inflammatory bowel disease and identify correlations.

Methods

Patients with inflammatory bowel disease underwent an interview, review of records and collection of blood and fecal samples. The search for cytomegalovirus was performed by IgG and IgM blood serology, by real-time PCR in the blood and by qualitative PCR in feces. Results were correlated with red blood cell levels, C-reactive protein levels, erythrocyte sedimentation rates and fecal calprotectin levels for each patient.

Results

Among the 400 eligible patients, 249 had Crohn's disease, and 151 had ulcerative colitis. In the group of Crohn's disease, 67 of the patients had moderate or severe disease, but 126 patients presented with active disease, based on the evaluation of the fecal calprotectin. In patients with ulcerative colitis, only 21 patients had moderate disease, but 76 patients presented with active disease, based on the evaluation of the fecal calprotectin. A large majority of patients had positive CMV IgG. Overall, 10 patients had positive CMV IgM, and 9 patients had a positive qualitative detection of CMV DNA by PCR in the feces. All 400 patients returned negative results after the quantitative detection of CMV DNA in blood by real-time PCR. Analyzing the 19 patients with active infections, we only found that such an association occurred with the use of combined therapy (anti-TNF-alpha + azathioprine)

Conclusion

The findings show that latent cytomegalovirus infections are frequent and active cytomegalovirus infection is rare. We did not find any association between an active infection of CMV and inflammatory bowel disease activity.

Clinical trials in luminal Crohn's disease: a historical perspective

It goes back to 1932 when Dr. Burrill Bernard Crohn and co-workers published their landmark paper, describing regional ileitis as a disease entity. However, clinical trial research has been developing rather slowly in luminal Crohn's disease. It took until the early seventies before the first randomized clinical trial was set up by the National Co-operative Crohn's Disease Study (NCCDS) group. Although the efforts of this group triggered a first wave of clinical trials in Crohn's disease, the lack of guidelines for conducting a clinical trial in this research area resulted in a variety of study designs and much criticism. Besides having a rather small sample size and a short follow-up time, they were often characterized by vague and subjective assessment of disease activity and treatment response. Following the advent of a new and very potent drug class in the late nineties, the anti-TNF agents, investigators started to re-think their study protocols and the first guidelines were set up by the regulatory authorities. Over the last 15years, clinical trials in luminal Crohn's disease have been evolving significantly. Inclusion criteria have been shifting from clinical scores such as Crohn's Disease Activity Index (CDAI) to more objective disease activity parameters such as biomarkers (C-reactive protein and faecal calprotectin) and endoscopic lesions. Primary endpoints have been developing from clinical response to corticosteroid-free remission and more ambitious end-points such as mucosal healing. In this paper, we will give a historical overview on clinical trials in luminal Crohn's disease, before and within the biologic era, and provide insight into how they have shaped our current understanding of trial designs in Crohn's disease.

Endogenous regulation of inflammatory pain by T-cell-derived opioids: when friend turns to foe

Painful sensation is a hallmark of microbe-induced inflammation. This inflammatory pain is downregulated a few days after infection by opioids locally released by effector T lymphocytes generated in response to microbe-derived antigens. This review focuses on the endogenous regulation of inflammatory pain associated with adaptive T-cell response and puts in perspective the clinical consequences of the opioid-mediated analgesic activity of colitogenic T lymphocytes in inflammatory bowel disease.

Measuring disease activity in Crohn's disease: what is currently available to the clinician

Crohn’s disease (CD) is a chronic inflammatory bowel disease characterized by a relapsing-remitting clinical behavior and dominated by intestinal inflammation. Being a chronic disorder that with time develops into a disabling disease, it is important to monitor the severity of inflammation to assess the efficacy of medication, rule out complications, and prevent progression. This is particularly true now that the goals of treatment are mucosal healing and deep remission. Endoscopy has always been the gold standard for assessing mucosal activity in CD, but its use is limited by its invasiveness and its inability to examine the small intestine, proximal to the terminal ileum. Enteroscopy and the less invasive small bowel capsule endoscopy enable the small bowel to be thoroughly explored and scores are emerging for classifying small bowel disease activity. Cross-sectional imaging techniques (ultrasound, magnetic resonance, computed tomography) are emerging as valid tools for monitoring CD patients, assessing inflammatory activity in the mucosa and the transmucosal extent of the disease, and for excluding extra-intestinal complications. Neither endoscopy nor imaging are suitable for assessing patients frequently, however. Noninvasive markers such as C-reactive protein, and fecal biomarkers such as calprotectin and lactoferrin, are therefore useful to confirm the inflammatory burden of the disease and to identify patients requiring further investigations.