Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Understanding the Presentation of Terminal Ileitis

Our patient is a 47-year-old African American female with a past medical history of recurrent episodes of small bowel obstruction. She presented to the emergency department with symptoms of nausea, vomiting, and abdominal pain. Upon further evaluation, imaging showed obstruction at the terminal ileum. Based on the holistic clinical presentation, we initially thought that this patient was experiencing symptoms of early onset Crohn's disease. Gastroenterology evaluated the patient and was uncertain of the formal diagnosis. Colonoscopy and biopsy were not pathognomonic for Crohn's disease, suggesting that there may be a component of terminal ileitis or another inflammatory bowel disease process. This case exemplifies the degree to which these inflammatory bowel disease processes frequently overlap.

Advancement in Therapeutic Intervention of Prebiotic-Based Nanoparticles for Colonic Diseases

Intestinal flora has become a therapeutic target for the intervention of colonic diseases (CDs) with better understanding of the interplay between microbiota and CDs. Depending on unique properties and prominent ability of regulating the intestinal flora, prebiotics can not only achieve a colon-specific drug delivery but also maintain the intestinal homeostasis, thus playing a positive role in the intervention of CDs. Currently, different studies on prebiotic-based nanoparticles have been contrived for colonic drug delivery and have shown great potential in curing various CDs, such as colitis and colorectal cancer. Nevertheless, there is a lack of systematic survey on the use of prebiotic nanoparticles for the treatment of CDs. This review aims to generalize the state-of-the-art of prebiotic nanomedicines specific for CDs. The species and function of intestinal flora and various kinds of prebiotics available as well as their regulating effects on intestinal flora were expounded. A variety of prebiotic nanoparticles pertinent to colon-targeted drug delivery systems were illustrated with particular emphasis on their curative activities on CDs. The efficacy and safety of prebiotic-based colonic drug delivery systems (p-CDDs) were also analyzed. In conclusion, the synergy between prebiotic nanoparticles and their cargos may hold promise for the treatment and intervention of CDs.

Development and Validation of a Deep Neural Network for Accurate Identification of Endoscopic Images From Patients With Ulcerative Colitis and Crohn's Disease

Background and Aim

The identification of ulcerative colitis (UC) and Crohn's disease (CD) is a key element interfering with therapeutic response, but it is often difficult for less experienced endoscopists to identify UC and CD. Therefore, we aimed to develop and validate a deep learning diagnostic system trained on a large number of colonoscopy images to distinguish UC and CD.

Methods

This multicenter, diagnostic study was performed in 5 hospitals in China. Normal individuals and active patients with inflammatory bowel disease (IBD) were enrolled. A dataset of 1,772 participants with 49,154 colonoscopy images was obtained between January 2018 and November 2020. We developed a deep learning model based on a deep convolutional neural network (CNN) in the examination. To generalize the applicability of the deep learning model in clinical practice, we compared the deep model with 10 endoscopists and applied it in 3 hospitals across China.

Results

The identification accuracy obtained by the deep model was superior to that of experienced endoscopists per patient (deep model vs. trainee endoscopist, 99.1% vs. 78.0%; deep model vs. competent endoscopist, 99.1% vs. 92.2%, P < 0.001) and per lesion (deep model vs. trainee endoscopist, 90.4% vs. 59.7%; deep model vs. competent endoscopist 90.4% vs. 69.9%, P < 0.001). In addition, the mean reading time was reduced by the deep model (deep model vs. endoscopists, 6.20 s vs. 2,425.00 s, P < 0.001).

Conclusion

We developed a deep model to assist with the clinical diagnosis of IBD. This provides a diagnostic device for medical education and clinicians to improve the efficiency of diagnosis and treatment.

Assessment of Murine Colon Inflammation Using Intraluminal Fluorescence Lifetime Imaging

Inflammatory bowel disease (IBD) is typically diagnosed by exclusion years after its onset. Current diagnostic methods are indirect, destructive, or target overt disease. Screening strategies that can detect low-grade inflammation in the colon would improve patient prognosis and alleviate associated healthcare costs. Here, we test the feasibility of fluorescence lifetime imaging (FLIm) to detect inflammation from thick tissue in a non-destructive and label-free approach based on tissue autofluorescence. A pulse sampling FLIm instrument with 355 nm excitation was coupled to a rotating side-viewing endoscopic probe for high speed (10 mm/s) intraluminal imaging of the entire mucosal surface (50-80 mm) of freshly excised mice colons. Current results demonstrate that tissue autofluorescence lifetime was sensitive to the colon anatomy and the colonocyte layer. Moreover, mice under DSS-induced colitis and 5-ASA treatments showed changes in lifetime values that were qualitatively related to inflammatory markers consistent with alterations in epithelial bioenergetics (switch between β-oxidation and aerobic glycolysis) and physical structure (colon length). This study demonstrates the ability of intraluminal FLIm to image mucosal lifetime changes in response to inflammatory treatments and supports the development of FLIm as an in vivo imaging technique for monitoring the onset, progression, and treatment of inflammatory diseases.

Knowledge and attitudes of primary healthcare physicians toward the diagnosis and management of inflammatory bowel disease following an educational intervention: A comparative analysis

BACKGROUND/AIMS

Inflammatory bowel disease (IBD) is a chronic inflammatory condition that requires early diagnosis and proper management. Patients with early symptoms of IBD are typically evaluated first by primary healthcare (PHC) physicians, who in turn refer patients with suspected IBD to specialists. Therefore, we aimed to assess the knowledge and attitude of PHC physicians toward IBD.

MATERIALS AND METHODS

We conducted a comparative cross-sectional survey of PHC physicians practicing at the Ministry of Health PHC centers in Jeddah, KSA. Demographics and data on the knowledge and practices of physicians were collected through a predefined and tested questionnaire that included three domains (Eaden, Leong, and Sign/Symptom Awareness). A subgroup of the cohort was educated about IBD referral criteria (group A, n = 65) prior to study initiation and their responses were compared with those from the remaining group (group B, n = 135). Regression analysis was used to test associations with the significance threshold set at 5%.

RESULTS

A total of 211 PHC physicians were surveyed with a response rate of 95%. Female physicians comprised 66.5% of the cohort and the mean age was 32.26 ± 6.6 years. About 91% of physicians were Saudi nationals, and 75.5% were MBBS degree holders. The majority of the respondents (93%) reported seeing zero to five patients with IBD per month, and almost half of the physicians preferred to always refer patients to specialists (49.5%). Most of the respondents were uncomfortable (3.27 ± 1.4 to 4.35 ± 1.2) with initiating or managing specific medical therapies (maintenance therapy, therapy for acute flare, corticosteroids, immunomodulators, and biologics) for patients with IBD. With regard to knowledge, group A had higher scores in all three domains especially in the Sign/Symptom Awareness domain (mean score 6.17 ± 1.1 vs. 3.5 ± 1.01, P < 0.001). According to multivariate analyses, both groups' knowledge showed no significant relationship with any of the medical therapies, except for the Sign/Symptom Awareness domain which was shown to be significantly affecting the comfort of doctors in managing maintenance therapy among patients with IBD [odds ratio (OR) =1.61, P = 0.008]. Gender, nationality, and qualifications were found to have a significant influence on the comfort in initiating specific medical therapies. Group A was identified as a significant factor in predicting comfort with managing corticosteroids (OR = 8.25, P = 0.006) and immunomodulators (OR = 6.03, P = 0.02) on patients with IBD.

CONCLUSION

The knowledge and comfort of PHC physicians with IBD medication prescription appears to be higher when education is provided. This observation is important, since PHC physicians are responsible for early identification and referral of patients suspected of having IBD, to specialists.

Effect of the Sphingosine Kinase 1 Selective Inhibitor, PF543 on Dextran Sodium Sulfate-Induced Colitis in Mice

Ulcerative colitis (UC) is a chronic relapsing inflammatory bowel disease, which often affects colon or rectum or both. It is now well recognized that sphingosine kinases-1/sphingosine-1-phosphate (S1P) signaling may have a very significant potential as targets for therapeutic intervention in UC. Compared with the pure dextran sodium sulfate group, administration of PF543 significantly reduced clinical symptoms with less weight loss, diarrhea, and shortening of the colon. The severity of colitis was improved with reduced disease activity index and degree of histological damage in colon. Moreover, treatment with PF543 not only decreased S1P but also inhibited mRNA expression of proinflammatory factors such as interleukin (IL)-1β and IL-6. This suggests that PF543 might exhibit an anti-inflammatory function against colitis through inhibition of expression of proinflammatory factors.

Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes

Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.

Body image dissatisfaction in patients with inflammatory bowel disease: a systematic review protocol

BACKGROUND

Inflammatory bowel disease (IBD) is a debilitating chronic disease characterised by inflammation and ulceration of the gastrointestinal tract. It is associated with a range of debilitating symptoms and reduced quality of life. People living with IBD may also be at risk of body image dissatisfaction (BID). BID is a distorted and negative view of the physical self, which in turn can adversely affect mental health and quality of life. To date, there have been no systematic reviews of the evidence on BID in IBD patients. Therefore, the aim of this systematic review is to clarify the evidence base on BID in *IBD patients including (i) the tools used to measure BID, (ii) the prevalence and severity of BID, (iii) the risk factors associated with BID and (iv) the relationship between BID and quality of life.

METHODS

Bibliographic databases (EMBASE, MEDLINE, PsycINFO, Cochrane CENTRAL) will be searched using a sensitive search strategy aiming to identify any quantitative study reporting on body image in the context of IBD. This will be supplemented by searches of ongoing trials registers and checking of reference lists. Studies will be assessed for eligibility using predetermined selection criteria for each question. Data will be extracted using a predefined data extraction form, and risk of bias (quality) of included studies will be assessed based on checklists appropriate to the study designs identified. Key methodological steps will be undertaken in duplicate to minimise bias and error. Synthesis will be undertaken separately for the different systematic review sub-questions. Given the anticipated heterogeneity of evidence on each question, it is likely that synthesis will be mostly narrative.

DISCUSSION

To the best of our knowledge, this will be the first systematic review to collate the existing evidence on BID in IBD patients. Understanding the impact of BID, its relationship with quality of life, and which patients may be at greater risk, may ultimately lead to the development of interventions to prevent or treat BID and to better patient care. Any gaps in the identified evidence will help to inform the research agenda in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: (CRD42018060999).

Epidemiology, disease burden, and treatment challenges of ulcerative colitis in Africa and the Middle East

Ulcerative colitis is an idiopathic, chronic, inflammatory bowel disorder characterized by an unpredictable course of alternating cycles of relapse and remission. Traditionally viewed as a disease of Western countries, the prevalence of ulcerative colitis is reported to be increasing in the developing world. In these regions, there is the potential to further explore the etiology of the disease, mainly through genetic studies. With this in mind, we consider available data relating to the epidemiology, clinical manifestations, and disease course of ulcerative colitis in Africa and the Middle East. Current treatment approaches in these countries are also reviewed and discussed in the context of new, small molecule, orally administered therapies. Areas covered: Available data on the epidemiology, clinical manifestations, and risk factors of ulcerative colitis in Africa and the Middle East are reviewed using a PubMed database search. Expert commentary: Epidemiologic studies from African and Middle Eastern countries suggest disease trends similar to the West, and an important health and economic burden. The management of ulcerative colitis within these developing countries is challenging, with the need to improve early diagnosis, access to healthcare, and patient education, along with facilitation of access to treatment options and improvement of medication adherence.

Modulation of sphingosine-1-phosphate in inflammatory bowel disease

Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease, involve an inappropriate immune reaction in the digestive tract, causing a variety of disabling symptoms. The advent of monoclonal antibodies (anti-tumor necrosis factor, anti-integrin, anti-interleukin -23) has revolutionized IBD management. Nevertheless, these agents, with potential for immunogenicity, are associated with high rates of response loss and disease relapse over time. They are also associated with high production costs. Sphingosine-1-phosphate (S1P), a membrane-derived lysophospholipid signaling molecule, is implicated in a vast array of physiological and pathophysiological processes, primarily via extracellular activation of S1P1-S1P5 receptors. S1P1, S1P4 and S1P5 are involved in regulation of the immune system, while S1P2 and S1P3 may be associated with cardiovascular, pulmonary, and theoretical cancer-related risks. Targeting S1P receptors for inflammatory conditions has been successful in clinical trials leading to approval of the non-selective S1P modulator, fingolimod, for relapsing forms of multiple sclerosis. However, the association of this non-selective S1P modulator with serious adverse events provides the rationale for developing more selective S1P receptor modulators. Until recently, three S1P modulators with differing selectivity for S1P receptors were in clinical development for IBD: ozanimod (RPC1063), etrasimod (APD334) and amiselimod (MT-1303). The development of amiselimod has been stopped as Biogen are currently focusing on other drugs in its portfolio. Following encouraging results from the Phase 2 TOUCHSTONE trial, a Phase 3 trial of the S1P modulator ozanimod in patients with moderate-to-severe ulcerative colitis is ongoing. Etrasimod is also being tested in a phase 2 trial in ulcerative colitis. These pipeline medications can be administered orally and may avoid the formation of anti-drug antibodies that can lead to treatment failure with injectable biologic therapies for IBD. Data from ongoing clinical trials will establish the relationship between the selectivity of S1P modulators and their safety and efficacy in IBD, as well as their potential place in the clinical armamentarium for IBD.

Small intestine contrast ultrasonography for the detection and assessment of Crohn disease: A meta-analysis

BACKGROUND

Crohn disease (CD) is a chronic relapsing disease. Imaging modalities are essential for the diagnosis and assessment of CD. Small intestine contrast ultrasonography (SICUS) is a well-tolerated, noninvasive and radiation-free modality and has shown potential in CD assessment. We aimed at evaluating the diagnostic accuracy of SICUS in the detection and assessment of small-bowel lesions and complications in CD.

METHODS

We searched PubMed database for relevant studies published before April 24, 2016. We integrated the true positive, false positive, false negative, and true negative into the pooled estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. Forest plots were to represent the pooled results of all studies.

RESULTS

Thirteen articles were finally considered eligible. The pooled sensitivity and specificity of SICUS in detecting small-bowel lesions were 0.883 (95% confidence interval (CI) 0.847-0.913) and 0.861 (95% CI 0.828-0.890), respectively. The pooled diagnostic odds ratio was 39.123 (95% CI 20.014-76.476) and the area under the curve of summary receiver operating characteristic was 0.9273 (standard error: 0.0152). In subgroup analyses, SICUS represented fine sensitivity and specificity in proximal and distal small intestine lesion, as well as in CD-related complications such as stricture, dilation, abscess, and fistula.

CONCLUSION

SICUS is accurate enough to make a complete assessment about the location, extent, number, and almost all kinds of complications in CD small-bowel lesions.

Faecal lactoferrin is a useful biomarker for mucosal healing in patients with ulcerative colitis during granulocyte and monocyte adsorptive apheresis therapy

AIM

The study investigated the value of faecal lactoferrin as a follow-up biomarker for mucosal healing of ulcerative colitis during granulocyte and monocyte adsorptive apheresis (GMA) therapy.

METHOD

Patients with ulcerative colitis exhibiting a moderate or severe disease activity with a partial Mayo Score (pMS) of over 4 were enrolled in this study. The patients received 10 courses of GMA therapy. The pMS value and faecal lactoferrin level were monitored and compared with the findings of endoscopy until 12 months after the last dose of GMA therapy.

RESULTS

Twenty patients (male:female 11:9) were enrolled in this study. Twelve had total colitis, while six had left-sided involvement and two had distal proctitis. Thirteen (65.0%) responded to GMA therapy. The faecal lactoferrin levels were significantly decreased in patients who responded to GMA therapy (P < 0.05), whereas the levels did not change in non-responders. Moreover, the faecal lactoferrin levels correlated with the endoscopic findings (r = 0.792, P < 0.01) and pMS scores (r = 0.529, P < 0.01). The correlation coefficients between the faecal lactoferrin levels and mucosal findings were higher than those observed between the pMS score and mucosal findings.

CONCLUSION

The faecal lactoferrin level is a useful biomarker of the mucosal findings in ulcerative colitis. Although endoscopy is the gold standard, the faecal lactoferrin level can be used as a biomarker during GMA therapy in patients with ulcerative colitis.

Neutrophil anti-neutrophil cytoplasmic autoantibody proteins: bactericidal increasing protein, lactoferrin, cathepsin, and elastase as serological markers of inflammatory bowel and other diseases

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract comprising Crohn's disease and ulcerative colitis. Although the pathogenesis of the disease is not clearly defined yet, environmental, genetic and other factors contribute to the onset of the disease. Apart from the clinical and histopathological findings, several serological biomarkers are also employed to detect IBD. One of the most thoroughly studied biomarker is anti-neutrophil cytoplasmic autoantibody (ANCA). We herein provide an overview of the current knowledge on the use of ANCA and certain ANCA proteins, such as bactericidal increasing protein, lactoferrin, cathepsin G and elastase, as serological markers for IBD and other diseases.

Facing Terminal Ileitis: Going Beyond Crohn's Disease

Terminal ileitis (TI) is an inflammatory condition of the terminal portion of the ileum that may occur acutely with right lower quadrant pain followed or not by diarrhea, or exhibit chronic obstructive symptoms and bleeding and normally it is associated to Crohn's disease (CD) although it may be associated to other different conditions. This review intended to contribute to a better understanding of TI in order to help in the diagnosis, medical approach and patient care. This work was performed on a survey of articles collected in different databases and a retrospective search was carried out to identify relevant studies in the field. Pathological conditions such as ulcerative colitis, the intake of non-steroidal anti-inflammatory drugs, infectious diseases, eosinophilic enteritis, malignant diseases, spondyloarthropathies, vasculitides, ischemia, sarcoidosis, amyloidosis and others may be related to ileitis but it is commonly referred to CD. To a correct therapeutic approach, it is necessary to understand the causes of this inflammation process. The performance of a clinical, laboratory, endoscopic, and histopathological evaluation of the individuals is crucial to the correct diagnosis and treatment once the inflammation of the ileum may occur due to different pathological conditions besides CD, leading to difficulties in the diagnosis. Thus, an individual approach is necessary once the correct diagnosis is crucial for the immediate therapeutic approach and recovering of the patient.