Toward transmural healing: Sonographic healing is associated with improved long-term outcomes in patients with Crohn's disease

Role of Intestinal Ultrasound for IBD Care: A Practical Approach

Intestinal ultrasound (IUS) has recently become the imaging technique of choice for patients with different types of intestinal inflammation. IUS has a high sensitivity, specificity, positive predictive value, and negative predictive value when diagnosing Crohn's disease or ulcerative colitis. Further, it is now the preferred imaging modality for routine IBD reevaluations because of its non-invasiveness, cost-effectiveness, availability (at least in Europe), and reproducibility in all age groups. However, the clinical success of IUS requires IUS training for doctors and technicians who perform IUS with a standardised description of ultrasound findings of the terminal ileum and entire colon. Complications such as abscess formation, fistulae, and stenosis can be detected by either conventional IUS or contrast-enhanced ultrasound (CEUS). Lately, several disease activity scores have been proposed for Crohn's disease, postoperative Crohn's disease, and ulcerative colitis both in adults (including elderly) and in children. IUS was successfully used in randomised clinical trials in order to measure the treatment response. Therefore, IUS now plays a central role in clinical decision making.

People with Inflammatory Bowel Disease Prefer Cognitive Behavioral Therapy for Fatigue Management: A Conjoint Analysis

BACKGROUND

Psychological interventions are a promising area for fatigue management in patients with inflammatory bowel disease (IBD). However, most interventions trialled to date have been pilots with limited direct input from patients about the type of intervention they want. Thus, this study aimed to explore patient preferences for a psychological IBD fatigue intervention.

METHODS

An international online cross-sectional survey was conducted with adults with self-reported IBD. A conjoint analysis was employed to elicit, through a series of forced-choice scenarios, patient preferences for a fatigue intervention. For this study, the attributes manipulated across these forced-choice scenarios were type of intervention, modality of delivery, and duration of intervention.

RESULTS

Overall, 834 people with IBD were included in analysis. Respondents ranked the type of psychological intervention as most important for overall preference (with cognitive-behavioral therapy (CBT) preferred over the other approaches), followed by modality of delivery, but placed very little importance on how long the intervention runs for. Patients with IBD appear to most strongly preference a short online CBT intervention for managing their IBD-related fatigue.

CONCLUSION

This study helps provide therapists and program developers clear direction on patient preferences when it comes to developing new psychological programs that address fatigue in IBD.

Factors correlated with transmural healing in patients with Crohn's disease in long-term clinical remission on anti-TNF medication

BACKGROUND & AIMS

Transmural healing is a long-term target for patients with Crohn's disease. Factors contributing to its promotion are poorly understood. This study assessed factors correlating with transmural healing based on intestinal ultrasound, in patients in long-term clinical remission on anti-TNF.

METHODS

68 consecutive Crohn's patients on adalimumab (50) or infliximab (18) therapy with clinical remission ≥1 year were recruited and assessed for clinical features, trough serum levels of anti-TNF and intestinal ultrasound findings. Univariate analysis and multivariate binary logistic regression analysis identified variables independently associated with bowel wall thickening behavior.

RESULTS

Sixty eight patients were in remission for a mean of 4.1 years. Thirty-six patients (52.9 %) showed anti-TNF trough levels below the normal threshold. Twenty-two patients (38.4 %) showed transmural healing, 32 (47.1 %) transmural response, and 26 (38.2 %) no treatment response. Transmural healing correlated with higher BMI and lower baseline bowel wall thickening; transmural response correlated with short Crohn's disease duration, high drug levels, and with non-stricturing phenotype. Treatment non-response correlated with lower BMI, lower drug levels, higher baseline bowel wall thickening, and stricturing phenotype.

CONCLUSIONS

Lack of transmural healing in stable remission Crohn's patients on anti-TNF therapy is multifactorial, mainly due to low anti-TNFs trough levels, development of strictures, and higher baseline bowel wall thickening at treatment initiation.

Advancements in Targeted Therapies for the Management of Crohn's Disease: A Comprehensive Review

Crohn's disease (CD) is a complex clinical condition characterized by persistent gastrointestinal inflammation that leads to episodes of flare-ups and subsequent healing. The treatment options for this disease are heterogeneous as its impact on different patients is also different. This study aims to evaluate the effectiveness of recently approved drugs that specifically target certain pathways within cells that are involved in CD pathogenesis. These medicines include biologics like anti-TNF agents, interleukin inhibitors, and small molecule inhibitors; they work by altering the modulation of immune responses and reducing inflammation. These drugs seem promising in terms of inducing remission in moderate to severe CD among various patient populations. Conversely, it is possible to examine how well these drugs perform using gene expression and molecular markers. By understanding these results along with other ongoing trials, personalized medicine can be used more frequently by doctors who will adopt a strategy for an individual patient, maximizing benefits while minimizing adverse effects. There are still some issues that need to be worked out like the high cost associated with these drugs or immunogenicity risk and infectious complications too. In conclusion, there has been a remarkable improvement in CD management over the past decade with customized drugs leading toward a precision medical era. Further understanding of molecular mechanisms implicated in CD pathogenesis and new therapeutic approaches could potentially improve treatment outcomes among affected individuals. This research is crucial in understanding how CD therapeutics are changing, thus facilitating selection by doctors on the most appropriate methods for individualized patient care.

Novelties and Perspectives of Intestinal Ultrasound in the Personalised Management of Patients with Inflammatory Bowel Diseases-A Systematic Review

Inflammatory bowel diseases (IBDs) affect over 4.9 million individuals worldwide. Colonoscopy (CS) is the gold-standard technique for diagnosis. The remissive-recurrent pattern of evolution raises the need for non-invasive techniques to monitor disease activity. This review aims to present the advantages of intestinal ultrasound (IUS) in managing IBDs. Our search was conducted on the PubMed, Embase, and Cochrane (CENTRAL) databases, selecting original studies comparing IUS with other imaging and invasive monitoring methods. Our search yielded 8654 results, of which 107 met the inclusion criteria. Increased bowel wall thickness (BWT) and colour Doppler signal (CDS) are discriminative for disease activity. IUS can predict disease outcomes and detect response to treatment or postoperative recurrence. Contrast-enhanced ultrasound (CEUS) and elastography help differentiate fibrotic from inflammatory stenoses. The difficult rectal assessment limits the use of IUS in ulcerative colitis (UC). Transmural healing may develop as a therapeutic target as it is associated with better outcomes. Patients are compliant with this technique, and its results correlate well with CS and other imaging methods. In conclusion, IUS proves to be essential in assessing IBD activity and treatment response, predicting outcomes and detecting complications. CEUS and elastography are researched to improve the diagnostic values of IUS.

Crohn's disease

Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract that might lead to progressive bowel damage and disability. The exact cause of Crohn's disease is unknown, but evidence points towards multifactorial events causing dysregulation of the innate immune system in genetically susceptible people. Commonly affecting the terminal ileum and proximal colon, Crohn's disease inflammation is often discontinuous and patchy, segmental, and transmural. Identification of characteristic findings on ileocolonoscopy and histology remains the diagnostic gold standard, but complete assessment involves laboratory abnormalities, including micronutrient deficiencies, cross-sectional imaging to identify transmural disease extent, severity and complications, and a psychosocial assessment. Treatment strategies for patients with Crohn's disease now go beyond achieving clinical remission to include deeper targets of endoscopic healing and consideration of adjunctive histological and transmural targets to alter disease progression potentially further. The use of early effective advanced therapies and development of therapies targeting alternative novel pathways with improved safety profiles have resulted in a new era of healing in Crohn's disease management. Future combination of advanced therapies with diet or other biological drugs and small molecules, together with improvements in tight control monitoring tools and predictive biomarkers might continue to improve outcomes for patients with Crohn's disease.

The value of whole-body dual-energy x-ray absorptiometry in assessing body composition in patients with inflammatory bowel disease: a prospective study

OBJECTIVES

Low skeletal muscle index (SMI) is common in inflammatory bowel disease (IBD) but has an uncertain relationship with active intestinal inflammation. This study evaluated body composition by whole-body dual-energy X-ray absorptiometry (DXA) in patients with IBD and healthy controls to enable the value of formal body composition analysis to be judged.

METHODS

Patients with IBD and sex/age-matched controls prospectively underwent full body composition assessment by DXA, assessment by BMI, eating questionnaires and handgrip strength. Disease activity was assessed by faecal calprotectin (active ≥150 µg/g). A cohort undergoing biologic induction therapy were assessed at baseline and after ≥13 weeks.

RESULTS

Total fat mass was higher in 54 patients with IBD (56% Crohn's disease, 61% male) than in 30 controls (median 25.1 vs. 18.7 kg, P  = 0.042). DXA offered little more than BMI. Low SMI was more common than in controls (15% vs. 0%, P  = 0.027). A normal BMI was seen in many patients with low SMI and handgrip strength was a poor marker of change in SMI. Body composition was similar in 28 patients with active vs. 22 with inactive disease. However, SMI increased specifically by 9.7% ( P  = 0.004) and BMI by 6.4% ( P  = 0.012) in 9 responders to therapy.

CONCLUSION

DXA identifies many patients with reduced SMI who are not detected by standard methodologies. While disease activity is not associated with low SMI, resolution of inflammation leads to improved SMI. The potential for recognition of such patients to influence therapeutic decisions underlines the need for DXA assessment in clinical practice.

Effectiveness of transabdominal ultrasonography in predicting clinical relapse of Crohn's disease

BACKGROUND/AIMS

Transabdominal ultrasonography (US) helps evaluate Crohn's disease (CD) activity. We investigated whether the US could predict subsequent adverse outcomes for patients with CD in clinical remission.

METHODS

This single-center retrospective study included patients with CD in clinical remission who underwent US between April 2011 and April 2021, focusing on the predictability of subsequent adverse outcomes within 5 years. We used the US-CD, which was calculated using multiple US findings. Predictive variables were assessed using Cox proportional hazards regression analysis, and the predictive value was evaluated using receiver operating characteristic curves.

RESULTS

Seventy-three patients were included. During a median follow-up of 1,441 days (range, 41-1,825 days), 16.4% (12/73) experienced clinical relapse, 9.6% (7/73) required endoscopic balloon dilation (EBD), 58.9% (43/73) required enhanced treatment, and 20.5% (15/73) underwent surgery. In the multivariate analysis, US-CD was significantly associated with clinical relapse (P= 0.038) and the need for enhanced treatment (P= 0.005). The area under the receiver operating characteristic curve for predicting clinical relapse and the need for EBD was 0.77 and 0.81, respectively, with US-CD (cutoff value = 11), and that for requiring enhanced treatment was 0.74 with US-CD (cutoff value = 6). Patients with US-CD ≥ 11 demonstrated a significantly higher occurrence of clinical relapse (P= 0.001) and EBD (P= 0.002) within 5 years. Patients with US-CD ≥ 6 experienced a significantly higher likelihood of requiring enhanced treatment (P< 0.001) within 5 years.

CONCLUSIONS

High US-CD is associated with subsequent adverse outcomes in patients with CD.

Automatized Detection of Crohn's Disease in Intestinal Ultrasound Using Convolutional Neural Network

INTRODUCTION

The use of intestinal ultrasound (IUS) for the diagnosis and follow-up of inflammatory bowel disease is steadily growing. Although access to educational platforms of IUS is feasible, novice ultrasound operators lack experience in performing and interpreting IUS. An artificial intelligence (AI)-based operator supporting system that automatically detects bowel wall inflammation may simplify the use of IUS by less experienced operators. Our aim was to develop and validate an artificial intelligence module that can distinguish bowel wall thickening (a surrogate of bowel inflammation) from normal bowel images of IUS.

METHODS

We used a self-collected image data set to develop and validate a convolutional neural network module that can distinguish bowel wall thickening >3 mm (a surrogate of bowel inflammation) from normal bowel images of IUS.

RESULTS

The data set consisted of 1008 images, distributed uniformly (50% normal images, 50% abnormal images). Execution of the training phase and the classification phase was performed using 805 and 203 images, respectively. The overall accuracy, sensitivity, and specificity for detection of bowel wall thickening were 90.1%, 86.4%, and 94%, respectively. The network exhibited an average area under the ROC curve of 0.9777 for this task.

CONCLUSIONS

We developed a machine-learning module based on a pretrained convolutional neural network that is highly accurate in the recognition of bowel wall thickening on intestinal ultrasound images in Crohn's disease. Incorporation of convolutional neural network to IUS may facilitate the use of IUS by inexperienced operators and allow automatized detection of bowel inflammation and standardization of IUS imaging interpretation.

Different levels of healing in inflammatory bowel diseases: mucosal, histological, transmural, barrier and complete healing

Mucosal healing on endoscopy has emerged as a key prognostic parameter in the management of patients with IBD (Crohn's disease, ulcerative colitis/UC) and can predict sustained clinical remission and resection-free survival. The structural basis for this type of mucosal healing is a progressive resolution of intestinal inflammation with associated healing of ulcers and improved epithelial barrier function. However, in some cases with mucosal healing on endoscopy, evidence of histological activity in mucosal biopsies has been observed. Subsequently, in UC, a second, deeper type of mucosal healing, denoted histological healing, was defined which requires the absence of active inflammation in mucosal biopsies. Both levels of mucosal healing should be considered as initial events in the resolution of gut inflammation in IBD rather than as indicators of complete transmural healing. In this review, the effects of anti-inflammatory, biological or immunosuppressive agents as well as small molecules on mucosal healing in clinical studies are highlighted. In addition, we focus on the implications of mucosal healing for clinical management of patients with IBD. Moreover, emerging techniques for the analysis of mucosal healing as well as potentially deeper levels of mucosal healing such as transmural healing and functional barrier healing of the mucosa are discussed. Although none of these new levels of healing indicate a definitive cure of the diseases, they make an important contribution to the assessment of patients' prognosis. The ultimate level of healing in IBD would be a resolution of all aspects of intestinal and extraintestinal inflammation (complete healing).

Current and Novel Uses of Intestinal Ultrasound in Inflammatory Bowel Disease

Intestinal ultrasound (IUS) is a patient-centric, noninvasive, real-time, point-of-care tool with the capability to aid in diagnosis and monitoring of disease activity in both Crohn's disease and ulcerative colitis without the need for bowel preparation. IUS can be used as a tool for precision monitoring of inflammatory bowel disease (IBD) treatment response. IUS as a cross-sectional imaging tool is as accurate as magnetic resonance enterography (MRE) for assessing the ileum and is more accurate than MRE for colonic assessment proximal to the rectum. Multiple simple ultrasound-based scoring systems have been internally validated with endoscopy in both Crohn's disease and ulcerative colitis, and changes in IUS parameters can be seen as early as 2 weeks after treatment initiation. IUS also plays a unique role in IBD activity monitoring of patients in whom avoidance of invasive testing is paramount, such as children and pregnant patients. Novel uses go beyond monitoring activity, with potential use of elastography to measure bowel wall stiffness to detect fibrosis and bowel damage for enhanced decision-making. Ultimately, IUS is likely to expand in the United States, facilitated by accessible expert training, access to equipment, and the development of a reimbursement model. This article provides a comprehensive review of the current and novel uses of IUS in IBD.

Prognostic role of intestinal ultrasound in Crohn’s disease

The majority of patients affected by Crohn’s disease (CD) develop a chronic condition with persistent inflammation and relapses that may cause progressive and irreversible damage to the bowel, resulting in stricturing or penetrating complications in around 50% of patients during the natural history of the disease. Surgery is frequently needed to treat complicated disease when pharmacological therapy failes, with a high risk of repeated operations in time. Intestinal ultrasound (IUS), a non-invasive, cost-effective, radiation free and reproducible method for the diagnosis and follow-up of CD, in expert hands, allow a precise assessment of all the disease manifestations: Bowel characteristics, retrodilation, wrapping fat, fistulas and abscesses. Moreover, IUS is able to assess bowel wall thickness, bowel wall stratification (echo-pattern), vascularization and elasticity, as well as mesenteric hypertrophy, lymph-nodes and mesenteric blood flow. Its role in the disease evaluation and behaviour description is well assessed in literature, but less is known about the potential space of IUS as predictor of prognostic factors suggesting response to a medical treatment or postoperative recurrence. The availability of a low cost exam as IUS, able to recognize which patients are more likely to respond to a specific therapy and which patients are at high risk of surgery or complications, could be a very useful instrument in the hands of IBD physician. The aim of this review is to present current evidence about the prognostic role that IUS can show in predicting response to treatment, disease progression, risk of surgery and risk of post-surgical recurrence in CD.

Intestinal ultrasound as a non-invasive tool to monitor inflammatory bowel disease activity and guide clinical decision making

Intestinal ultrasound (IUS) is a non-invasive, real-time, cross-sectional imaging tool that can be used at the point-of-care to assess disease activity in patients with Crohn’s disease or ulcerative colitis. IUS promotes quick and impactful treatment decisions that can modify disease progression and enhance patient compliance. This review will summarize the technical aspects of IUS, the evidence to support the use of IUS in disease activity monitoring, the comparison of IUS to current standard of care monitoring modalities such as colonoscopy and calprotectin, and the optimal positioning of IUS in a tight-control monitoring strategy.

Mucosal healing assessment in Crohn's disease with normalized iodine concentration from dual-energy CT enterography: comparison with endoscopy

OBJECTIVES

Mucosal healing (MH) is an important goal in the treatment of patients with Crohn's disease (CD). Noninvasive assessment of MH with normalized iodine concentration (NIC) is unknown.

METHODS

In this retrospective study, 94 patients with diagnosed CD underwent endoscopy and dual-energy CT enterography (DECTE) at the post-infliximab treatment review. Two radiologists reviewed DECTE images by consensus for assessing diseased bowel segments of the colon or terminal ileum, and the NIC was measured. Patients were divided into transmural healing (TH), MH and non-MH groups. The diagnostic performance of the MH and non-MH groups with clinical factors and NIC was assessed utilizing receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 94 patients included in our study, 8 patients achieved TH, 34 patients achieved MH, and 52 patients did not achieve MH at the post-IFX treatment review. The area under the ROC curve (AUC), sensitivity, specificity, and accuracy values were 0.929 (95% confidence interval [CI] 0.883-0.967), 0.853, 0.827, and 0.837, respectively, for differentiating MHs from non-MHs, and the optimal NIC threshold was 0.448. The AUC of the combined model for distinguishing MHs from non-MHs in CD patients, which was based on the NIC and calprotectin, was 0.964 (95% CI 0.935-0.987).

CONCLUSIONS

The normalized iodine concentration measurement in DECTE has good performance in assessment MH in patients with CD. Iodine concentration from DECTE can be used as a radiologic marker for MH.

The Arrival of Intestinal Ultrasound for Inflammatory Bowel Disease Care in the United States

Intestinal ultrasound (IUS) is a noninvasive and highly reliable point-of-care tool to evaluate inflammation of the bowel. It offers comparable accuracy to endoscopy and magnetic resonance enterography. Although IUS has been incorporated into the management of inflammatory bowel disease (IBD) in other parts of the world, it has only recently arrived in the United States. However, barriers to integration of IUS into IBD care in the United States have included a lack of adoption by leading centers, lack of educational opportunities, and an unclear path for remuneration. This article provides information about the use of IUS in IBD, reviews the data comparing existing modalities of assessment of IBD with IUS, and summarizes strategies to overcome existing barriers to IUS implementation, including the newly available US-based training pathway and appropriate billing practice.

Transmural remission characterized by high biologic concentrations demonstrates better prognosis in Crohn's disease

BACKGROUND

The importance and pathophysiology of transmural healing in patients with Crohn's disease (CD) remains to be verified. We aimed to examine the association between serum concentrations of biologics and transmural remission evaluated via magnetic resonance enterography (MRE).

METHODS

We enrolled patients with CD who received maintenance biologics 1 year after induction and prospectively followed up for at least 1 year after baseline laboratory, endoscopic and MRE examination. We evaluated the relationship between baseline factors including the presence of transmural remission and patient prognosis, as well as between serum concentrations and transmural remission.

RESULTS

We included 134 patients. Of them, 65, 31, 27, and 11 patients received infliximab, adalimumab, ustekinumab, and vedolizumab, respectively. Those who achieved transmural remission showed a lower risk of hospitalization and surgery than those who did not achieve remission (P < 0.01). Adjusted hazard ratios of transmural remission for predicting hospitalization and surgery was 0.11 and 0.02, respectively, which was lower than that of clinical remission, biochemical remission, and endoscopic remission. Regarding serum concentrations, the median concentration was higher in patients with transmural remission than in patients with transmural activity for all agents (P < 0.01 for infliximab, P = 0.04 for adalimumab, P < 0.01 for ustekinumab, P = 0.08 for vedolizumab).

CONCLUSIONS

Transmural remission was the best predictor for prognosis in CD patients who received maintenance biologic therapy. High drug concentration levels were associated with transmural remission confirmed via MRE.

Inflammatory bowel disease cross-sectional imaging: What's new?

Cross-sectional imaging-ultrasonography, computed tomography enterography, and magnetic resonance enterography-is a routine and indispensable tool for patients with Crohn's disease (CD) that helps to detect or monitor disease characteristics before, during, and after CD treatment. New emerging radiological technologies may have further clinical applications in the management of CD. In this review article, we focus on the latest developments in cross-sectional imaging in CD research, including its role in intra- and extra-luminal lesion detection, intestinal inflammation and fibrosis grading, therapeutic response assessment and outcome prediction, postoperative recurrence detection and prediction, and the gut-brain axis.

Outcomes of Escalating Immunosuppressive Treatments for Recalcitrant Noninfectious Posterior Scleritis

INTRODUCTION

This article aimed to summarize the outcomes of escalating immunosuppressive treatments for patients with recalcitrant noninfectious posterior scleritis (PS).

METHODS

Clinical records of 16 patients diagnosed with recalcitrant noninfectious PS in the Ocular Immunity and Uveitis Department of Zhongshan Ophthalmic Center from September 2016 to December 2021 were reviewed. Patients were treated with escalating immunosuppressive regimen including corticosteroid, immunosuppressants (IMTs), and adalimumab (ADA). Demographic characteristics and clinical findings at each visit were recorded. The doses of prednisone were analyzed. Main outcomes were corticosteroid-sparing effects, control of inflammation, visual acuity, and safety profile.

RESULTS

Ocular pain was the most common finding (100%), followed by the T sign on the B scan (93.8%) and associated anterior scleritis (75.0%). The average initial dose of prednisone was 25.0 mg/day, and tapered to 11.3 and 5.0 mg/day at month 1 and 3, respectively, with statistical significance (p < 0.05). The median overall periods of prednisone tapering to 10, 5, and 0 mg/day were 1.0, 3.0, and 3.0 months, respectively. There were 93.8% of patients receiving prednisone ≤ 10 mg/day and 68.8% of patients off prednisone at last visit. There were 80% of patients treated with IMT and ADA off prednisone at last visit, reaching the highest percentage compared with others. A best-corrected visual acuity of 1.0 or better at last visit was achieved in 10 eyes (62.5%). The escalating treatments showed good safety profile.

CONCLUSION

Patients of recalcitrant noninfectious PS benefited from escalating immunosuppressive treatments with favorable visual outcome, in which methotrexate, ciclosporin, and ADA were preferred with good safety.

Intestinal Ultrasound in the Assessment of Luminal Crohn’s Disease

Crohn’s disease is a chronic inflammatory disease affecting the gastrointestinal tract. Expert guidelines now recommend regular objective assessments as part of a treat-to-target approach. Intestinal ultrasound provides a noninvasive, patient-friendly modality for assessing Crohn’s disease without the risk of radiation exposure and does not require fasting or bowel preparation. Enhancement techniques, including oral and intravenous contrast, can improve disease-activity and complication detection. Due to its acceptability, intestinal ultrasound can be performed frequently, allowing for closer disease-activity monitoring and treatment adjustments. There have been significant advances in the utility of intestinal ultrasound; particularly for assessing disease activity during pregnancy and fibrosis detection utilising elastography. This review provides a comprehensive overview of performing intestinal ultrasound, the diagnostic accuracy, role in disease-activity monitoring, and recent advances in utilising ultrasound for the assessment of luminal Crohn’s disease.