Mangiferin, A Naturally Occurring Glucosylxanthone, Induces Apoptosis in Caco-2 Cells In Vitro and Exerts Protective Effects on Acetic Acid-Induced Ulcerative Colitis in Mice through the Regulation of NLRP3

Inflammatory bowel diseases (IBD), an inflammatory disease, include Crohn's disease and ulcerative colitis. Dysregulated autoimmune response to gut dysbiosis is mainly involved in the pathogenesis of IBD and is triggered by various inciting environmental factors. With its rising prevalence in every continent, IBD has evolved into a global disease, which is on the rise, affecting people of all ages. There is a growing incidence of IBD in the elderly population, as evidenced by epidemiological data. IBD is characterized by an inflammatory process that requires a lifelong treatment. The main challenge in IBD management is the adverse side effects associated with almost all of the currently available drugs. Hence, there is a search for drugs with more efficacy and fewer side effects. Natural products with great structural diversity and ease of modification chemically are being explored, as they were shown to control IBD by safely suppressing pro-inflammatory pathways. The present study aims at understanding the role of mangiferin, a COX-2 inhibitor isolated from tubers of Pueraria tuberosa in the treatment of IBD and colon cancer, in vitro on the Caco-2 human colon cancer cell line and in vivo in the acetic acid-induced IBD mouse model. In the acetic acid-induced colitis model, it prevented the decrease in length of the colon, mucosal erosion, and cellular infiltration in a dose-dependent manner. The expression levels of various pro-inflammatory markers like COX-2, IL1β, TNF-α, INF-γ, IL-6, NLRP3, and caspase-1 were downregulated in an acetic acid-induced mouse model on treatment with mangiferin in a dose dependent manner. Mangiferin also showed anticancer effects on Caco-2 cells by increasing the expression of Fas ligand, Fas receptor, FADD, caspase-8, and caspase-3 proteins, whereas Bid and Bcl-2 proteins showed decreased expression. These data suggest that mangiferin, an inhibitor of COX, induces apoptosis in colon cancer cells in vitro and protects mice from acetic acid-induced colitis in vivo.

Exploring the Interconnections of Functional Gut Disorders and Inflammatory Bowel Disease: A Narrative Review Article

This review reveals details of the interaction between disorders of gut-brain interaction (DGBI) and inflammatory bowel disease (IBD) by providing an in-depth review of that relationship. The review provides a nuanced understanding of this multifaceted dynamic by spanning shared symptomatology, the impact of inflammation on functional aspects, and addressing diagnostic challenges, psychological influences, treatment strategies, and emerging research directions. By synthesizing current knowledge and identifying gaps in understanding, this article aims to contribute to the evolving discourse surrounding the interplay between IBD and DGBI, offering valuable insights for clinicians, researchers, and healthcare professionals navigating the complexities of gastrointestinal health.

Inflammatory Bowel Disease and X (Formerly Twitter) Influencers: Who Are They and What Do They Say?

Background and objective More than half of the population suffering from inflammatory bowel disease (IBD) use the internet as a primary source of information on their condition. X (formerly Twitter) has been increasingly used to disseminate healthcare-related information. In this study, we aimed to identify top influencers on the topic of IBD on X and correlate the relevance of their social media engagements with their professional expertise or academic productivity. Methods X (formerly Twitter) influence scores for the search topic IBD were obtained using Cronycle API, a proprietary software employing multiple algorithms to rank influencers. Data regarding gender, profession, location, and research productivity represented as h-index was collected. Results We collected information on the top 100 IBD influencers on X. The majority of influencers were gastroenterologists, followed by IBD advocates. Of note, 62% of the IBD influencers were from the US followed by the UK and Canada. A positive correlation was observed between the X topic score and the h-index of the influencer (r=+0.488, p<0.001) Conclusions The strong correlation observed between the X topic score and h-index suggests that social media is a viable platform for gaining information regarding IBD. Further research aimed at counteracting misleading information by providing facts and data in a succinct manner about IBD on social media is required to improve disease awareness.

Revolutionizing Inflammatory Bowel Disease Management: A Comprehensive Narrative Review of Innovative Dietary Strategies and Future Directions

This comprehensive narrative review delves into the intricate interplay between diet and inflammatory bowel disease (IBD), shedding light on the potential impact of dietary interventions in disease management. By analyzing nutritional interventions, risks, challenges, and future perspectives, this review serves as a vital resource for clinicians, researchers, and patients alike. The amalgamation of evidence underscores the significance of customizing dietary strategies for individual patients, considering disease phenotype and cultural factors. Through an exploration of dietary components' effects on IBD, including exclusive enteral nutrition and omega-3 fatty acids, this review offers pragmatic implementation advice and outlines avenues for further research. Bridging the gap between research findings and clinical applications, the review facilitates informed decision-making and patient-centric care. In the face of escalating IBD prevalence, this review emerges as an indispensable guide for healthcare professionals, empowering them to navigate the complexities of dietary management while enabling patients to actively participate in their care trajectory. Ultimately, this narrative review advances the understanding of diet's pivotal role in IBD management, fostering a more integrated approach to patient care and paving the way for improved research and policy initiatives in the field of inflammatory bowel diseases.

Meckel's Diverticulum Charading as Crohn's Disease: A Single-Institution Case Series

Meckel's diverticulum is the most common gastrointestinal congenital anomaly and may present with lower gastrointestinal bleeding, abdominal pain, and nausea. Imaging and endoscopic findings can be similar to those of Crohn's disease, including transmural inflammation, stricturing, and superficial ulceration frequently in the distal ileum. Here, we present a case series of three patients who were initially diagnosed with Crohn's disease and ultimately found to have Meckel's diverticulum alone on final pathology. This single-institution case series, the largest in the literature, highlights the importance of maintaining a high index of suspicion for Meckel's diverticulum, especially in the absence of microscopic evidence of inflammatory bowel disease.

Clinical outcomes for Clostridioides difficile associated diarrhea in inflammatory bowel disease patients versus non-IBD population: A retrospective cohort study

Patients with inflammatory bowel disease (IBD) have a higher incidence of Clostridioides difficile infection (CDI). Previous studies have demonstrated negative clinical outcomes in IBD patients with CDI compared to patients without CDI. The clinical presentation of CDI is indistinguishable from IBD exacerbation, thus posing a frequent clinical dilemma on the role of Clostridioides infection in the testing, diagnosis, and treatment of these patients. To compare clinical outcomes of CDI in patients with IBD to those without IBD. Retrospective cohort of adult patients admitted to Rabin Medical Center Israel between the years 2014 and 2020 with a concurrent diagnosis of IBD and CDI. Matching 1:2 was performed between the IBD patients and the non-IBD population with respect to age and sex. Sixty-seven patients with IBD and 134 patients without IBD were included in the study. The groups' median age was 40.6 (interquartile range [IQR] of 29.8-68.9), with 45.8% male and 54.2% female. The non-IBD group had a higher Charlson score with 2 (IQR 0; 5) versus 0 (IQR 0; 4) in the IBD group (P value <.01). Patients with IBD had more exposure to systemic antibiotics, 71.1% versus 26.3% (P value <.01). In a multivariable analysis we found no difference in 90-day mortality and rate of relapse between the 2 study groups with an odds ratio of 1.709 (95% confidence interval 0.321-9.905) and odds ratio of 0.209 (95% confidence interval 0.055-1.513) respectively. In our cohort patients with IBD who present with diarrhea and concomitant CDI have similar rates of relapse and mortality compared with patients without IBD.

A Comparison of the Effects of COVID-19 on Irritable Bowel Syndrome and Inflammatory Bowel Disease Patients While Working at Home and in the Office: A Retrospective Study

Background Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) have a strong relationship with psychological stress. Studies have shown increased stress levels in patients with IBS and IBD during the SARS-CoV-2 (COVID-19) pandemic. The current literature on the impact of work environment on IBD and IBS symptoms is limited, particularly during the current pandemic. Objective This study aims to analyze how the pandemic impacted patients with IBS and IBD in the setting of staying home versus working outside the home. Methods After Institutional Review Board (IRB) approval, a retrospective review of 245 patients with IBS and IBD who followed with our gastroenterology clinic in the past year was performed. Patients were asked about symptoms including, but not limited to, worsening diarrhea, constipation, and abdominal pain. Pearson's chi-squared test was used for analysis. Results Of the 245 patients in our study, 67 had IBS, 166 had IBD, and 12 had both. The male-to-female ratio was 1:1.4. A total of 136 (55.5%) patients worked from home during the pandemic, while 109 (44.5%) patients worked outside. Eighty-three patients working from home reported no change in symptoms, 35 reported worsening symptoms, and 18 reported an improvement in symptoms. Sixty-eight patients working outside the home reported no change in symptoms, 26 reported worsening symptoms, and 15 reported improvements. Working outside the home had a statistically significant relationship with COVID-19 infection. Thirty patients were infected, of which 22 (73.3%) worked outside the home (p=0.01). Overall, 203 (82.8%) patients received the vaccine, and only 14 of these patients reported worsening gastrointestinal (GI) symptoms one week after receiving the vaccine. Comparable results were seen after dividing the data into cohorts of IBS and IBD patients. Of the patients with IBD staying at home, 15.9% had depression (p=0.01). Conclusion Most patients had symptoms at baseline. There was no statistically significant correlation between change in symptoms and work settings. Patients were less likely to be infected with COVID-19 while staying home. Our patient population showed a high vaccination rate of 82.9% as compared to the national average of 59.2% (source: Centers for Disease Control and Prevention (CDC)). Only 5.7% of the patients reported new or worsening gastrointestinal symptoms in the week following vaccination. The limitations of the study included its retrospective design and poor correlation in general between symptoms and disease activity in IBD patients.

The natural history of COVID-19 in patients with inflammatory bowel disease: a nationwide study by the Hellenic Society for the study of IBD

OBJECTIVES

COVID-19 has evolved into a global health crisis, variably affecting the management of patients with chronic illnesses. Patients with inflammatory bowel disease (IBD) may represent a vulnerable population due to frequent administration of immune-modifying treatments. We aimed to depict the natural history of COVID-19 infection in Greek patients with IBD at a nationwide level via unbiased reporting of all cases that were registered during the sequential waves of the pandemic.

METHODS

Following a national call from the Hellenic Society for the study of IBD, we enrolled all IBD patients with established diagnoses of COVID-19. Clinical and epidemiological data, including COVID-19 modifying factors and IBD-associated therapies, were analyzed against adverse outcomes (hospitalization, ICU admission and death).

RESULTS

We identified 154 IBD patients who were diagnosed with COVID-19 (men: 58.4%; mean age=41.7 years [SD = 14.9]; CD: 64.3%). Adverse outcomes were reported in 34 patients (22.1%), including 3 ICU admissions (1.9%) and two deaths (1.3%). Multivariate logistic regression analysis showed that age (OR = 1.04, 95% CI, 1-1.08) and dyspnea at presentation (OR = 7.36, 95% CI, 1.84-29.46) were associated with worse outcomes of COVID-19 infection. In contrast, treatment with biologics, in particular anti-TNF agents, exerted a protective effect against an unfavorable COVID-19 disease course (OR = 0.4, 95% CI, 0.16-0.99). Patients on subcutaneous biologics were more likely to halt treatment due to the infection as compared to those on intravenous biologics.

CONCLUSIONS

IBD patients who developed COVID-19 had a benign course with adverse outcomes being infrequent. Treatment with anti-TNF biologics had a protective effect, thus, supporting continuation of therapy during the pandemic.

IFIH1 loss-of-function variants contribute to very early-onset inflammatory bowel disease

Genetic defects of innate immunity impairing intestinal bacterial sensing are linked to the development of Inflammatory Bowel Disease (IBD). Although much evidence supports a role of the intestinal virome in gut homeostasis, most studies focus on intestinal viral composition rather than on host intestinal viral sensitivity. To demonstrate the association between the development of Very Early Onset IBD (VEOIBD) and variants in the IFIH1 gene which encodes MDA5, a key cytosolic sensor for viral nucleic acids. Whole exome sequencing (WES) was performed in two independent cohorts of children with VEOIBD enrolled in Italy (n = 18) and USA (n = 24). Luciferase reporter assays were employed to assess MDA5 activity. An enrichment analysis was performed on IFIH1 comparing 42 VEOIBD probands with 1527 unrelated individuals without gastrointestinal or immunological issues. We identified rare, likely loss-of-function (LoF), IFIH1 variants in eight patients with VEOIBD from a combined cohort of 42 children. One subject, carrying a homozygous truncating variant resulting in complete LoF, experienced neonatal-onset, pan-gastrointestinal, IBD-like enteropathy plus multiple infectious episodes. The remaining seven subjects, affected by VEOIBD without immunodeficiency, were carriers of one LoF variant in IFIH1. Among these, two patients also carried a second hypomorphic variant, with partial function apparent when MDA5 was weakly stimulated. Furthermore, IFIH1 variants were significantly enriched in children with VEOIBD as compared to controls (p = 0.007). Complete and partial MDA5 deficiency is associated with VEOIBD with variable penetrance and expressivity, suggesting a role for impaired intestinal viral sensing in IBD pathogenesis.

Mycophenolate-induced Colitis: A Case Report with Focused Review of Literature

Mycophenolate mofetil (MMF) is an immunosuppressive medication used for the management of various autoimmune diseases, and patients with bone marrow and solid organ transplants. Gastrointestinal side effects are seen 45% of the time and they include nausea (29%), vomiting (23%), constipation (38%), diarrhea (50%-92%), and colitis (9%). In 98% of cases, resolution of diarrhea occurs within 20 days upon discontinuation of the MMF. Data is scarce regarding approach in the treatment of MMF-induced colitis. We report a case of MMF-induced colitis diagnosed by colonoscopy and histopathology. This case illustrates the challenges encountered while managing MMF-induced colitis.

Helicobacter pylori is Associated with Less Fistulizing, Stricturing, and Active Colitis in Crohn's Disease Patients

Introduction A potential protective role of Helicobacter pylori (HP) infection against the development of Crohn's disease (CD) has been postulated. There is a lack of studies evaluating the association of HP with CD phenotypes. The aim of this study was to investigate the clinical features and disease activity of patients with CD who were diagnosed with HP infection. Methods The charts of 306 consecutive patients from the inflammatory bowel disease (IBD) database at the University of Florida College of Medicine, Jacksonville from January 2014 to July 2016 were reviewed. Ninety-one CD patients who were tested for HP were included, and the frequencies of strictures, fistulas, and colitis in surveillance biopsies in these patients were evaluated. Results Of the 91 CD patients tested for HP, 19 had HP infection. A total of 44 patients had fistulizing/stricturing disease, and 62 patients had active colitis. In the univariate analysis, patients with HP infection had less fistulizing/stricturing disease (21.1% vs. 55.6%, p = 0.009) and less active colitis (42.1% vs. 77.1%, p = 0.005). In the multivariate analysis, HP infection remained as a protective factor for fistulizing/stricturing disease phenotype (OR: 0.22; 95%CI: 0.06-0.97; p = 0.022) and active colitis (OR: 0.186; 95%CI: 0.05-0.65; p = 0.010). Conclusion HP infection was independently associated with less fistulizing/stricturing disease and less active colitis in CD patients. Our study suggests CD patients with a history of HP infection are less prone to complications.

Epidemiology and Outcomes of Hospitalized Inflammatory Bowel Disease Patients with Asthma in the United States

Introduction Research on the epidemiology and outcomes of hospitalized inflammatory bowel disease (IBD) patients with a history of asthma in the United States (US) is limited. This study aimed at identifying the sociodemographic and clinical characteristics of hospitalized IBD patients with a diagnosis of asthma. We also examined the association between an asthma diagnosis and the length of stay (LOS) and in-hospital mortality among hospitalized IBD patients. Method Using the National Inpatient Sample (NIS) for the years 2008-2013 and the ninth edition of the International Classification of Diseases codes, we identified adult hospitalized patients with IBD (N = 370,636) and used weighted multilevel hierarchical logistic regression models. Results The overall prevalence of asthma in our cohort of hospitalized IBD patients was 8%. Hospitalized IBD patients with asthma were more likely to be female, <45 years old, have Crohn's disease, and a higher Elixhauser comorbidity index (ECI). IBD patients with ECI of 3 or more had higher odds of having a prior diagnosis of asthma compared to those with no comorbidities (OR 63.33, 95% CI: 54.51-73.58). Having a prior diagnosis of asthma among hospitalized IBD patients was associated with lower odds of prolonged hospital stay and in-hospital mortality (OR 0.72, 95% CI: 0.69-0.74; OR 0.49, 95% CI: 0.43- 0.56, respectively). Patients with both IBD and asthma are more likely to seek medical care with earlier and aggressive treatment modalities, which may explain the lower in-hospital mortality in this group. Conclusion Lower in-hospital mortality and geographic variation are notable in the outcomes of IBD patients with asthma. Future prospective studies are necessary to improve our understanding of the management and interplay of IBD patients with asthma.

Inflammatory Bowel Disease and Risk of Osteoporotic Fractures: A Meta-Analysis

Introduction Inflammatory bowel disease (IBD) and its complications have been well-established. The literature shows an association between IBD and decreased bone mineral density in the adult population. However, most studies have reported an association between IBD and osteoporosis, while the risk of fractures has not been well-studied. The aim of this meta-analysis is to summarize the best available evidence regarding IBS and osteoporotic fractures. Methods A review of the literature using the MEDLINE and EMBASE databases was performed during November 2017. We included cross-sectional and cohort studies that reported the relative risks, odds ratios, and hazard ratios comparing the risk of developing osteoporotic fractures among patients with IBD patients, both ulcerative colitis (UC) and Crohn's disease (CD), versus patients without IBD as controls. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using the generic inverse-variance method. Results After a review of the literature, seven studies fulfilled the eligibility criteria established during the analysis. A significant association was found between IBD and osteoporosis, with a pooled OR of 1.32 (95% CI, 1.2 - 1.4). Low heterogeneity among the studies was found, I²=42.3. No publication bias was found using the Egger regression test p=0.18. Sensitivity analysis showed that the inclusion of data on children by Kappelman et al. (2007) did not change the results. Conclusion A significant association between IBD and the risk of developing osteoporotic fractures was observed in this study. There is a 32% increased risk, which is consistent with different cohort studies previously done.

Acute Myopericarditis with Crohn's Disease Flare-up

Cardiac involvement is rare in inflammatory bowel disease (IBD) but can occur as a complication of either the disease itself or drug therapy. We describe an interesting clinical scenario of acute myopericarditis during Crohn’s flare-up.
 A 37-year-old patient with severe Crohn's disease started having multiple bloody bowel movements associated with abdominal pain. These symptoms were attributed to Crohn's disease flare-up, prompting the addition of steroids and an increase in the dose of mesalamine without any significant relief. Two weeks later, he presented to the emergency department with pleuritic chest pain. Electrocardiogram (EKG) revealed ST segments elevation in leads I and aVL. Laboratory work revealed elevated troponin I of 1.82 ng/mL, with increased erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) of 121 mm and 180.1 mg/L, respectively. Cardiac magnetic resonance imaging (MRI) revealed early gadolinium enhancement consistent with myocarditis. The patient was started on colchicine with an increase in the dose of steroids, resulting in clinical improvement. The patient reported having similar chest pain during a previous episode of Crohn's disease flare-up, suggesting underlying IBD as the likely etiology.

Mesalamine-induced Myocarditis in a Young Athlete: Can He Run Again?

Mesalamine is often used in the treatment of inflammatory bowel disease (IBD). Mesalamine-induced cardiotoxicity has been reported in the literature and is a rare entity. The mechanism of cardiotoxicity remains unclear, however, it is believed to be due to a humoral-mediated hypersensitivity reaction. Patients with mesalamine-induced cardiotoxicity could present with a wide range of cardiovascular symptoms ranging from mild chest pain and shortness of breath (SOB) to cardiogenic shock secondary to left ventricular systolic dysfunction. Symptoms could be associated with elevation in cardiac biomarkers and electrocardiogram (EKG) changes including ST-segment or T-wave abnormalities. We report a case of mesalamine-induced myocarditis in a young athlete presenting with chest pain 10 days after mesalamine therapy was initiated for recently diagnosed Crohn's disease. Workup was significant for elevated cardiac biomarkers. The diagnosis was confirmed with cardiovascular magnetic resonance imaging (CMR). Immediate cessation of the medication resulted in resolution of symptomatology and normalization of cardiac biomarkers over a 48-hour period. Mesalamine-induced cardiotoxicity is a rare, yet serious side effect that necessitates medical community awareness. CMR is the confirmatory diagnostic modality of choice.

Oculomotor Nerve Palsy After Influenza Vaccine in Inflammatory Bowel Disease

Influenza and pneumococcal vaccines are recommended in inflammatory bowel disease patients. Several neurologic complications have been reported after influenza vaccines, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and acute disseminated encephalomyelitis; however, rarely, oculomotor palsy will occur. We report the case of a 23-year-old male with a past medical history of ulcerative colitis on sulfasalazine who presented to the hospital with a complaint of blurry vision five days after an influenza vaccine. Most of the possible causes of oculomotor nerve palsy, such as stroke, intracranial space-occupying lesions, aneurysms, and infections, were ruled out by history, physical exam, blood work, and imaging studies, thus leading to the influenza vaccine as the most likely cause.

The Use of Vedolizumab in Patients with Concomitant Cirrhosis and Crohn's Disease

Vedolizumab is a humanized monoclonal α4β7 integrin antibody used in patients with Crohn's disease (CD) and ulcerative colitis (UC). Limited data are available on the use of vedolizumab in patients with concurrent cirrhosis and inflammatory bowel disease (IBD). Patients with cirrhosis are unique, as they have a predilection for developing opportunistic infections and malignancies. Additionally, it is not known if vedolizumab alters the natural course of cirrhosis. We report our experience in three patients with concomitant CD and cirrhosis, who were treated with vedolizumab. In our limited cohort, all the three patients tolerated vedolizumab well. None of them experienced significant infectious complications, nor did any have decompensated cirrhosis. Our limited series suggest that vedolizumab is well tolerated in patients with compensated cirrhosis.

What can we learn from top-cited articles in inflammatory bowel disease? A bibliometric analysis and assessment of the level of evidence

BACKGROUND AND OBJECTIVES

Despite increasing number of publications in inflammatory bowel disease (IBD), no bibliometric analysis has been conducted to evaluate the significance of highly cited articles. Our objectives were to identify the top-cited articles in IBD, assessing their characteristics and determining the quality of evidence provided by these articles.

DESIGN AND OUTCOME MEASURES

IBD and related terms were used in searching the Web of Science to identify English language articles. The 50 top-cited articles were analysed by year, journal impact factor (JIF), authorship, females in authorship, institute, country and grants received. The level of evidence was determined using the Oxford Centre for Evidence-Based Medicine guidelines.

RESULTS

The number of citations varied from 871 to 3555 with a total of 74 638, and a median 1339.50 (IQR=587). No correlations were found between the number of citations and number of years since publication (r=0.042, p=0.771), JIF (r=0.186, p=0.196), number of authors (r=0.061, p=0.674), females in authorship (r=0.064, p=0.661), number of institutes (r=0.076, p=0.602), number of countries (r=0.101, p=0.483) or number of grants (r=-0.015, p=0.915). The first authors were from the USA (n=24), the UK (n=6), Germany (n=5), France (n=5), Belgium (n=3) and Canada (n=3). The levels of evidence were 12 articles at level 1b, 9 articles at level 3a and 15 articles at level 3b and fewer were at other levels.

CONCLUSIONS

Research papers represented 66% of articles. The majority of items have reasonably high levels of evidence, which may have contributed to the higher number of citations. The study also shows a gender gap in authorship in this area.

Low Incidence of Dysplasia and Colorectal Cancer Observed among Inflammatory Bowel Disease Patients with Prolonged Colonic Diversion

BACKGROUND

In inflammatory bowel disease (IBD), many scenarios call for fecal diversion, leaving behind defunctionalized bowel. The theoretical risk of colorectal cancer (CRC) in this segment is frequently cited as a reason for resection. To date, no studies have characterized the incidence of neoplasia in the diverted colorectal segments of IBD patients.

METHODS

A retrospective cohort analysis was conducted for IBD patients identified through a tertiary care center pathology database. Patients that had undergone colorectal diversion and were diverted for ≥ 1 year were included. Incidence of diverted dysplasia/CRC was calculated for Crohn's disease (CD) and ulcerative colitis (UC) with respect to diverted patient-years (dpy) and patient-years of disease (pyd).

RESULTS

In total, 154 patients comprising 754 dpy and 1984 pyd were analyzed. Only 2 cases of diverted colorectal dysplasia (CD 1, UC 1) and 1 case of diverted CRC (UC) were observed. In the UC cohort (n = 75), the rate of diversion-associated CRC was 4.5 cases/1000 dpy (95% CI 0.11-25/1000) or 1.5 cases/1000 pyd (95% CI 0.04-8.2/1000). In the CD cohort (n = 79), no patients developed CRC, although a dysplasia rate of 1.9 cases/1000 dpy (95% CI 0.05-11/1000) or 0.77 cases/1000 pyd (95% CI 0.02-4.3/1000) was observed. All patients developing neoplasia had disease duration > 10 years and microscopic inflammation.

CONCLUSIONS

Diverted dysplasia occurred infrequently with rates overlapping those reported in registries for IBD-based rectal cancers. Neoplasia was undetected in patients with < 10 pyd, regardless of diversion duration, suggesting low yield for endoscopic surveillance before this time.

A Unique Triad: Ulcerative Colitis, Primary Sclerosing Cholangitis, and Autoimmune Hemolytic Anemia

Ulcerative colitis is an autoimmune disorder leading to chronic intestinal inflammation. It can present with a wide range of associated extra-intestinal manifestations. We present a case of an 18-year-old man diagnosed with ulcerative colitis, autoimmune hemolytic anemia and primary sclerosing cholangitis during the same hospitalization. The unique triad of these diseases gives important clues to the immunological factors involved in the pathogenesis of these diseases.

Novel insights into microbiome in colitis and colorectal cancer

PURPOSE OF REVIEW

Microbiota is a major player in the pathogenesis of inflammatory bowel diseases (IBD) and colorectal cancer (CRC). Here, we summarize the key advances achieved in the past 18 months (ending June 2017) toward a better understanding of the role of microbiota in colitis and CRC development.

RECENT FINDINGS

Accumulating evidence shows the essential role of intestinal barrier function (e.g. mucus, IgA, LCN2, LYPD8) in protecting against bacteria-induced inflammation and tumor development. Numerous signaling pathways (e.g. TLRs and NLRs), metabolites (e.g. indole, bile acids, retinoic acid) and small noncoding RNAs (e.g. miRNA) have been identified as key mediators regulating host-microbe interactions in the intestine. Novel microbial drivers of colitis and tumorigenesis (e.g. Alistipes finegoldii, Atopobium parvalum, Peptostreptococcus anaerobius) have been identified and their disease-promoting activities have been described.

SUMMARY

IBD-associated colorectal cancer results from a complex breakdown of communication between the host and its microbiota, involving barrier function, immune signaling and metabolites.

Crohn's Disease and Ulcerative Colitis Show Unique Cytokine Profiles

Introduction

Networks of cytokines have been implicated in both forms of inflammatory bowel disease (IBD): Crohn’s disease (CD) and ulcerative colitis (UC). While CD has associated with T-helper type 1 (Th1) immune responses, UC shows Th2 patterns. Recent studies reported that the inflamed intestinal regions in both CD and UC are significantly infiltrated with a newly described set of T helper, the Th17 cells. These cells have unique cytokine responses. These findings prompted us to further explore the cytokine profiles of CD and UC with a special focus on the Th2 and Th17 related mediators.

Methods

Cytokine transcripts were compared using real-time polymerase chain reaction (PCR) in both inflamed and non-inflamed mucosal specimens from patients with active CD (n=35) or UC (n=20) and without CD or UC (Control, n=54).

Results

In both CD and UC, interleukin (IL)-12 (p40), IL-18, IL-21 and IL-27 transcript levels were higher than in Control. The highest levels of cytokines were found in the diseased areas of CD and UC with only one exception; IL-12 (p40) in CD was more up-regulated in the non-diseased areas compared to diseased CD and Control specimens. CD samples but not UC specimens showed significant IL-17, IL-23, and IL-32 mRNA expression indicating a trend toward Th17 responses. In UC, however, IL-5, IL-13, IL-15 and IL-33 mRNA levels were significantly increased when compared to both CD and Control.

Conclusions

The unique patterns of cytokine networks can help us to better understand the differential expression of their characteristic pathophysiology. In addition, the pharmacological regulation of these small molecules may hold promise to more effective and personalized therapies.

Cross-talk between type 3 innate lymphoid cells and the gut microbiota in inflammatory bowel disease

PURPOSE OF REVIEW

Innate lymphoid cells (ILCs) are a newly-identified population of immune cells prevalent in, but not limited to, mucosal tissues that not only play a significant role in immune homeostasis and host defense, but also in disease pathogenesis. This review highlights the importance of type 3 ILCs (ILC3s) and their interactions with the intestinal microflora, both in maintaining gut health and in the development of inflammatory bowel disease (IBD).

RECENT FINDINGS

Distinct lineages of ILCs are defined based on the presence of cell surface proteins, secretion of effector cytokines and expression of master transcription factors that determine their differentiation and inflammatory behavior. These ILC subgroups mirror corresponding CD4 T-cell subsets, with which they share many phenotypic, morphologic and functional attributes. ILC3s, in particular, through direct and indirect interactions with the gut microbiota, have been identified to promote protection and maintenance of epithelial integrity, as well as to regulate intestinal inflammation and fibrosis, such as that observed in IBD.

SUMMARY

Gut mucosal ILCs respond to environmental cues, such as diet and microflora composition, which can shape downstream immune function. As such, ILCs represent attractive targets for the development of therapeutic modalities to maintain gut health and to potentially treat IBD.

Oxytocin modulates markers of the unfolded protein response in Caco2BB gut cells

We have shown that oxytocin receptor (OTR) expression in neonatal rat enterocytes is robust from birth to weaning, but OTR function during this period is unknown. We previously reported that oxytocin (OT) stimulation of Caco2BB cells (enterocytes in vitro) inhibits the mammalian target of rapamycin complex 1 (mTORC1) signaling. The unfolded protein response (UPR) is known to protectively reduce translation during endoplasmic reticulum (ER) stress. Because the mTORC1 pathway is linked to cellular stress, we investigated markers of UPR in OT-stimulated Caco2BB cells. We report that OT modulates several factors involved in sensing and translation of ER stress. High OT (62.5 nM) reduced translation initiation factor 4E-BP1 phosphorylation (Ser65), which is known to inhibit cap-dependent translation via its rate-limiting eukaryotic translation initiation factor 4E (eIF4E). Importantly, high OT increased phosphorylation of eukaryotic translation initiation factor 2a (eIF2a) phospho-Ser51, which inhibits eIF2a. High OT also increased protein kinase RNA-like endoplasmic reticulum kinase phosphorylation, a sensor of ER stress and a kinase of eIF2a. Both high and low OT activated inositol requiring enzyme1 (IRE1), which generates the transcription factor X-box binding protein 1 (XBP1) and induces the UPR. We also show that OT modulates XBP1 splicing and induces tribbles 3 (TRIB3; a negative regulator of Akt and protein involved in autophagy) and immunoglobulin binding protein (BiP; ER-chaperone). Taken together, these results indicate that OT modulates sensors of ER stress and autophagy. These findings support our hypothesis that transiently elevated OTR expression in neonatal gut may serve a protective function during a critical postnatal developmental period.

The emerging role of leptin antagonist as potential therapeutic option for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic relapsing immune-mediated inflammatory disorder that affects millions of people around the world. Leptin is a satiety hormone produced primarily by adipose tissue and acts both centrally and peripherally. Leptin has been shown to play a major role in regulating metabolism, which increases during IBD progression. Leptin mediates several physiological functions including elevated blood pressure, tumorogenesis, cardiovascular pathologies and enhanced immune response in many autoimmune diseases. Recent development of a leptin mutant antagonist that blocks leptin activity raises great hope and opens up new possibilities for therapy in many autoimmune diseases including IBD. To this end, preliminary data from an ongoing study in our laboratory on pegylated leptin antagonist mutant L39A/D40A/F41A (PEG-MLA) treatment shows an inhibition of chronic colitis in IL-10-/- mice. PEG-MLA effectively attenuates the overall clinical scores, reverses colitis-associated pathogenesis including a decrease in body weight, and decreases systemic leptin level. PEG-MLA induces both central and peripheral leptin deficiency by mediating the cellular immune response. In summary, after blocking leptin activity, the correlative outcome between leptin-mediated cellular immune response, systemic leptin levels, and amount of adipose tissue together may provide new strategies for therapeutic intervention in autoimmune diseases, especially for intestinal inflammation.

Early life stress triggers persistent colonic barrier dysfunction and exacerbates colitis in adult IL-10-/- mice

BACKGROUND

It has become increasingly evident that disease flares in the human inflammatory bowel diseases are influenced by life stress. It is known that life stress can trigger disturbances in intestinal barrier function and activate proinflammatory signaling pathways, which are important contributors to intestinal inflammation and clinical disease; however, the exact mechanisms of stress-induced inflammatory bowel disease exacerbations remain to be elucidated. Here, we presented a model of early life stress-induced exacerbation of colitis in interleukin (IL)-10 mice.

METHODS

C57Bl/6 wild-type and IL-10 mice were exposed to neonatal maternal separation (NMS) stress on postnatal days 1 to 18 and reared under normal conditions until 10 to 12 weeks of age. At this time, histopathology, colitis scores, intestinal barrier function, proinflammatory cytokine expression, and mast cell activity were evaluated.

RESULTS

NMS increased the severity of colitis IL-10 mice indicated by greater colitis scores and colonic proinflammatory cytokine concentrations. NMS and IL-10 increased colonic permeability; however, NMS alone did not induce colitis. Increased mast cell activation and colonic tryptase release were observed in IL-10 mice exposed to NMS, indicating mast cell activation.

CONCLUSIONS

This study demonstrates that colitis in IL-10 mice can be exacerbated by NMS stress. The precise mechanisms of enhanced colitis severity in NMS IL10 mice are unclear but persistent defects in intestinal barrier function likely play a contributing role. NMS serves as a novel model to investigate the mechanisms by which early life stress influences the development and course of inflammatory bowel disease in adulthood.

Role of commensal gut bacteria in inflammatory bowel diseases

Aberrant immune responses toward commensal gut bacteria can result in the onset and perpetuation of inflammatory bowel diseases (IBD). Reduced microbiota diversity in conjunction with lower proportion of Gram positive and higher proportion of Gram negative bacteria than in healthy subjects is frequently reported in IBD patients. In a subset of IBD patients, E. coli strains with specific features trigger disease. Important molecular mechanisms underlying this effect have been identified. However, in the majority of patients the exact nature of host-microbe interactions that contribute to IBD development has so far not been defined. The application of metagenomic techniques may help to identify bacterial functions that are involved in the aggravation or alleviation of IBD. Subsequently, the relevance for disease development of bacterial candidate genes may be tested taking advantage of reductionist animal models of chronic gut inflammation. This approach may help to identify bacterial functions that can be targeted in future concepts of IBD therapy.

Localized colonic stem cell transplantation enhances tissue regeneration in murine colitis

Many patients suffer from chronic gastrointestinal diseases characterized by chronic inflammation, increased intestinal permeability and visceral pain in which there is no definitive treatment. Adult stem cells have recently been used in various disease states to contribute wound-healing processes. In the current study we investigated the ability of intra-colonic adult stem cells application to heal colonic inflammation in IL-10(-/-) mice with active colitis. The aims of this study were to determine whether intra-colonic infusion of adult colonic stem cells (CSCs) (local stem cell transplantation): (i) restores intestinal permeability; (ii) attenuates visceral hypersensitivity; (iii) heals murine colitis. IL-10(-/-) mice with active colitis were transplanted with adult stem cells. Mice received either a single intracolonic infusion of CSCs or colonic epithelial cells. Two weeks after transplantation, we measured visceral hypersensitivity and intestinal permeability and correlated these with histological improvement of colitis. IL-10(-/-) mice that received stem cell transplantation showed histopathologic evidence of recovery from colitis. Improvement in colitis as graded by pathology scores correlated with restoration of intestinal permeability and decreased visceral hypersensitivity. Intra-colonic administration of CSCs is a potential therapeutic method for treating refractory symptoms in patients with chronic gastrointestinal diseases associated with chronic inflammation and visceral hypersensitivity. This method may be safer and should have far fewer side effects than systemic stem cell administration.

Alternative medicines as emerging therapies for inflammatory bowel diseases

Inflammatory bowel disease (IBD) can be divided into two major categories, ulcerative colitis (UC) and Crohn disease (CD). While the main cause(s) of IBD remain unknown, a number of interventional and preventive strategies have been proposed for use against CD and UC. Many reports have focused on the use of alternative natural medicines as potential therapeutic interventions in IBD patients with minimal side effects. While the use of alternative medicines may be effective in IBD patients that are refractory to corticosteroids or thiopurins, alternative treatment strategies are limited and require extensive clinical testing before being optimized for use in patients.

Synergy of IL-23 and Th17 cytokines: new light on inflammatory bowel disease

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, involve an interplay between host genetics and environmental factors including intestinal microbiota. Animal models of IBD have indicated that chronic inflammation can result from over-production of inflammatory responses or deficiencies in key negative regulatory pathways. Recent research advances in both T-helper 1 (Th1) and T-helper 17 (Th17) effect responses have offered new insights on the induction and regulation of mucosal immunity which is linked to the development of IBD. Th17 cytokines, such as IL-17 and IL-22, in combination with IL-23, play crucial roles in intestinal protection and homeostasis. IL-23 is expressed in gut mucosa and tends to orchestrate T-cell-independent pathways of intestinal inflammation as well as T cell dependent pathways mediated by cytokines produced by Th1 and Th17 cells. Th17 cells, generally found to be proinflammatory, have specific functions in host defense against infection by recruiting neutrophils and macrophages to infected tissues. Here we will review emerging data on those cytokines and their related regulatory networks that appear to govern the complex development of chronic intestinal inflammation; we will focus on how IL-23 and Th17 cytokines act coordinately to influence the balance between tolerance and immunity in the intestine.

Local immune regulation of mucosal inflammation by tacrolimus

PURPOSE

Tacrolimus is a potent immunomodulator that is effective in the treatment of inflammatory bowel disease (IBD). However, potential toxicity and systemic effects with oral intake limit its use. Local tacrolimus treatment is effective in a subgroup of proctitis patients. This study aimed to evaluate whether colonic mucosal immune cells are susceptible to locally applied tacrolimus in vitro. Our in vivo studies aimed at evaluating whether local tacrolimus treatment in mice would bring about local immune suppression and to compare colonic and systemic tacrolimus levels after locally and systemically applied tacrolimus.

RESULTS

In vitro tacrolimus inhibited the activation of multiple cell types present in colonic tissue; lamina propria T cells, NKT cells, and both classical- and non- classical antigen presenting cells. However, the cytokine production of epithelial cells was not inhibited by tacrolimus at these concentrations. After rectal administration in mice, tacrolimus blood levels were comparable to those obtained by oral intake. However, rectally treated mice exhibited a 14-fold higher concentration of tacrolimus within their colonic tissue than orally treated mice. Moreover, rectally applied tacrolimus resulted in a local but not a systemic immune suppression in mice.

CONCLUSIONS

Tacrolimus inhibits activation of several pivotal immune cells of the intestinal mucosa. Murine studies indicate that colonic application of tacrolimus induces local rather than systemic immune suppression.

Substance P, obesity, and gut inflammation

PURPOSE OF REVIEW

The purpose of this review is to present recent data on the effects of substance P on the development of two common pathological conditions, namely obesity and gut inflammation, and elucidate the role of this neuropeptide as a potential regulator between increased adiposity and exacerbated inflammatory responses during inflammatory bowel disease.

RECENT FINDINGS

We present data that demonstrate a role for substance P in both obesity and inflammatory bowel disease and investigate potential effects on fat tissue that may influence the progression of intestinal inflammation. More specifically, we discuss new evidence for direct effects of substance P on fat tissue that determine fat depot size and overall weight in mice and analyze some of the potential mechanisms. Furthermore, we present data that describe changes in the intestinal sensory innervation, in particular substance P-positive innervation, during gut inflammation and new direct evidence of the effects of preestablished obesity in the outcome of experimental inflammation of the colon in mice. In the end we propose a link between the role of substance P in the promotion of obesity and the potential consequences on inflammatory bowel disease.

SUMMARY

We propose that substance P may promote fat tissue expansion either centrally or peripherally and thus create a proinflammatory environment (as is the case with obesity) which may in turn affect the progression (exacerbate) of gut inflammation. Further studies are required on the effects of 'creeping fat' in inflammatory bowel disease in order to decipher the role of this type of fat-depot expansion in the development of the disease.