Clinical Utility of Intestinal Ultrasound for Guiding Therapy in Inflammatory Bowel Disease: A Retrospective Real-World Cohort from a Swiss Tertiary Center

The Use of Intestinal Ultrasound in Ulcerative Colitis—More Than a Mucosal Disease?

P530 Early Intestinal Ultrasound changes to predict treatment response to anti-TNF therapy in paediatric Inflammatory Bowel Disease; a pilot study

P182 Bowel wall thickness as seen on point-of-care intestinal ultrasound correlates with endoscopic severity in children with Inflammatory Bowel Disease: A North American diagnostic cross-sectional study

P370 Correlation of the IBD Disk with intestinal ultrasound in patients with inflammatory bowel disease

P310 Intestinal ultrasound as a tool to assess treatment response in patients with Inflammatory Bowel Diseases

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.

BACKGROUND There are few FDA-approved therapies for pediatric patients with inflammatory bowel disease (IBD). Clinical remission rates plateau at 60%, even with the currently available biologic therapies. Nutraceuticals are novel alternative treatments that can be used as adjunct treatments. AIM In this case series of 8 patients, we aim to present the clinical and radiological response to a novel nutraceutical agent, CurQD, composed of QingDai (Indigo Naturalis) and Curcumin. METHODS Patients included required a baseline pre-treatment clinical assessment and at least a single follow-up examination. Clinical status was evaluated based on the Physician General Assessment (PGA, determined independently from the clinical scoring systems) and the pediatric Crohn’s disease activity index (PCDAI) or the pediatric ulcerative colitis activity index (PUCAI), as appropriate. Baseline biomarkers (Hgb, ESR, CRP, albumin, and calprotectin(FC)) were collected pre and post-treatment when available. When available, intestinal ultrasound (IUS) features were also noted. On the IUS, bowel wall thickness (BWT, in mm) and color Doppler signaling (measured by the modified Limberg score graded 0,1,2, or 3 based on severity) were collected. The longitudinal changes were demonstrated on the most inflamed segment. Considering the small sample size, only descriptive statistics were applied. RESULTS Primary therapies received included anti-TNFα for 3 patients, ustekinumab in 3 patients, 1 on vedolizumab, and mesalamine in 1. Baseline assessment was done at a median time of 1.8 weeks (IQR 0.9-3.6 weeks) before starting the supplement, and the follow-up was 3.9 weeks (IQR 2.8-5.4 weeks) after starting the supplement. Two patients were in clinical remission at baseline but had active disease based on Doppler activity on IUS, 3 patients had mild active disease, and 3 patients had either moderate or severe disease activity. At follow-up, all patients but one were in clinical remission. (Table 1) Median baseline FC decreased from 1047.4 ug/g (IQR 532.4-1107) to 27.1 (IQR 27.5-341.3). Five patients had complete IUS information. When isolating the most inflamed segment on IUS, all patients demonstrated a response to treatment, noted by a decrease in BWT and/or a decrease in Doppler signaling. (Figure 1) No patient had a baseline therapy change after their follow-up. One patient reported abdominal bloating after starting CurQD and discontinued the product after five weeks. CONCLUSION CurQD is a promising nutraceutical that may assist in breaking the therapeutic ceiling of biological therapies in IBD. Based on this small experience, a larger randomized controlled trial in children would be needed to assess the safety and efficacy of this product in this vulnerable patient group. Furthermore, IUS is a practical tool for evaluating response to therapy in a pragmatic clinical setting. Table 1 Change in clinical disease scores in patients receiving CurQD Figure 1 Description of changes in a) bowel wall thickness (BWT) and b) color Doppler signaling (measured by the modified Limberg score) in patients treated with CurQD.

DOP10 Intestinal Ultrasound at IBD diagnosis predicts major disease events – A Copenhagen IBD cohort study

Inflammatory bowel disease patients are exposed to frequent procedures and hospital admissions as well as recurrent need for radiological examinations with a high risk of exposure to radiation and contrast. Our objective was to evaluate the role of a combination of both intestinal ultrasound (IUS) and colour Doppler with different parameters for monitoring changes in inflammation over time and to reveal their potential role in the assessment of response to biologic therapy in inflammatory bowel disease (IBD) patients. Before the induction of biological therapy, IUS together with colour Doppler of the intestine was conducted. Response to therapy was defined following the international guidelines. A total of 45 patients with histopathological diagnosis of IBD were enrolled in the study. All patients received biological therapy and were assessed for response after 3 months. Out of those patients, 34 (75.6%) had good response while 11 (24.4%) failed to respond to the treatment. Our findings point to a strong association between bowel wall thickening (BWT) and serum albumin, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). The overall sensitivity of IUS varied from 54 to 93% when evaluating bowel affection, with a specificity of 97-100%, in comparison to our results, which showed a sensitivity of 64-74% and specificity of 79-82%. Doppler parameters could predict the response to the biologic therapy in IBD patients. Intestinal ultrasound and colour Doppler provide a safe, non-invasive way to monitor changes in inflammation and blood flow in the digestive tract.

Background Inflammatory Bowel Disease (IBD) refractory to first-line agents is challenging in pediatrics due to limited therapeutic options, especially in Acute Severe Colitis (ASC). Upadacitinib (UPA) is a selective Janus-Kinase (JAK) inhibitor approved for use in adults. Its use in pediatrics for refractory moderate to severe colitis is off label, but its oral route of administration and quick onset of action make it a promising therapy. Intestinal Ultrasound (IUS) in this context may be a useful tool for monitoring treatment response. Aims To describe the efficacy of UPA as a second-line agent for pediatric ASC and report IUS findings to demonstrate its use in monitoring IBD. Methods Single-center chart and literature review of pediatric patients with IBD on UPA. Results Case 1: A 12-year-old female with pancolonic Ulcerative Colitis (UC) since age 9 maintained on Infliximab (IFX). Despite adequate IFX levels, re-induction and steroids, she had a Pediatric Ulcerative Colitis Activity Index (PUCAI) of 50, elevated C-Reactive Protein (CRP) and fecal calprotectin (FC) leading to repeat admissions. Intravenous (IV) steroids, followed by UPA 45mg for 8 weeks, led to rapid clinical response by Day 4. At discharge, PUCAI was 5 and CRP <5. On Day 20 of UPA, IUS showed normal bowel wall thickness (BWT) and Modified Limberg (ML) score of 0. At 6 months, she remains in steroid-free remission with a normal FC. Case 2: A 16-year-old female presented with a Pediatric Crohn’s Disease Activity Index (PCDAI) of 45 and was diagnosed with Crohn’s colitis with perianal fistula. Due to inadequate response to 6 days of IV steroids, she received IFX. Despite robust IFX levels, IUS showed pancolonic inflammation with increased BWT of 4.6 mm and ML score of 1-2. [1] She was readmitted with severe anemia and elevated CRP. Concurrent C. jejuni infection was treated without symptom resolution. Given severe colitis despite IFX and steroids, UPA 45mg for 12 weeks was started with clinical response and discharge by Day 4; PCDAI of 20. At 1 month, she remains asymptomatic on a steroid taper with a normal hemoglobin. Repeat IUS and FC is pending. Case 3: A 15-year-old male with IBD favouring UC since age 14, who initially did well on steroids and IFX was re-admitted with a PUCAI of 65 and elevated FC while weaning steroids. Repeat endoscopy showed Mayo 2 colitis to hepatic flexure correlating to increased BWT of 3.5 mm and ML score of 2 on IUS. Despite appropriate IFX levels, due to steroid dependence at discharge (PUCAI 25), UPA 45mg for 8 weeks was started as an outpatient. By Day 21 his PUCAI was 0, with normal FC. At 2 months, IUS showed normal BWT and ML Score 0 with steroid-free remission. Conclusions These cases demonstrate the efficacy of UPA in refractory pediatric ASC with rapid clinical response, normalization of biochemical tests and IUS findings. Funding Agencies None

P1096 The predictive value of intestinal ultrasound for treatment response in Inflammatory Bowel Disease: a systematic review and pooled data analysis

P0519 Enhanced diagnostic performance of intestinal ultrasound in elderly patients with Ulcerative Colitis

P0372 Access to intestinal ultrasound reshapes diagnostic pathways and healthcare costs in Crohn’s disease and ulcerative colitis: analysis of clinician decision-making at the point of referral

P476 Correlation between fecal calprotectin and inflammation on ultrasound in fibrostenotic Crohn’s Disease

Background Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype particularly due to the absence of intestinal anti-fibrotic therapies. Differentiating between strictures that are predominantly fibrotic as opposed to inflammatory remains a diagnostic dilemma. The ability to make this differentiation is critical to inform decisions for therapeutic approach. Fecal calprotectin (FC) is a stool marker reflective of intestinal inflammation. Very few studies have evaluated the relationship of FC concentration in ileal CD strictures and parameters of inflammation on intestinal ultrasound (IUS). Strictures on imaging are defined as 1) increased bowel wall thickness (BWT), 2) narrowed luminal apposition, and 3) pre-stenotic dilation (PSD). BWT and hyperemia (color Doppler signal (CDS)) are the most sensitive markers for CD inflammation on IUS. It is predicted that FC will match CDS in ileal strictures, similar to non-stricture phenotypes. Aims We aim to correlate FC levels with IUS inflammation of ileal CD strictures. Methods We performed a retrospective cohort pilot study exploring the relationship between FC levels and IUS inflammatory parameters in ileal strictures. FC levels were obtained ≤ 60 days of index IUS in fibrostenotic ileal CD patients. Individuals who underwent medication changes or experienced a clinical flare during this period were excluded. Inflammation was measured as BWT and CDS using a modified Limberg (ML) score. Pearson correlation for continuous variables, Spearman rank correlation and a Kruskal-Wallis test for FC and Limberg scale were completed. Results A total of 25 fecal samples were obtained from 17 patients with ileal strictures (47% male, median age 59 years (range 18-76)) were assessed. Median FC concentrations was 204.9 ug/g, IQR: 250.4. Median ileal stricture BWT was 7.0 mm (range 3.0–10.0). 40% (10/25) had ML1 (short chains in bowel), 32% (8/25) ML2 (long chains in bowel), and 28% (7/25) ML3 (long chains and perienteric fat). There was no correlation between FC and BWT (r= .02, p = 0.92), nor FC with ML scores (r=0.20, p= 0.25). In those with ML1, median FC was 232.4, while those with ML2 or 3, had a FC of 155.6 and 469.7, respectively. FC values were significantly different between the ML scores, pampersand:003C0.0001. Conclusions FC levels were not correlated with inflammatory parameters as seen on IUS in ileal CD. This unexpected finding may be due to ML2 scores having lower FC than anticipated, and small sample size. Other imaging factors such as loss of wall stratification need to be taken into account, and are perhaps more reflective of inflammation than BWT and CDS. This study provides the initial data to assess accuracy of FC and hyperemia of ileal CD strictures on IUS compared to histologic measures of inflammation on resected specimens. Funding Agencies None