ECCO Guidelines Research Articles

ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment.

ECCO Guidelines on Therapeutics in Crohn's Disease: Medical Treatment.

ECCO Guidelines on Therapeutics in Crohn's Disease: Surgical Treatment.

This article is the second in a series of two publications on the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery. It also provides technical advice for a variety of common clinical situations. Both articles together represent the evidence-based recommendations of the ECCO for Crohn's disease and an update of prior ECCO guidelines.

Accuracy of Information given by ChatGPT for Patients with Inflammatory Bowel Disease in Relation to ECCO Guidelines.

As acceptance of artificial intelligence [AI] platforms increases, more patients will consider these tools as sources of information. The ChatGPT architecture utilizes a neural network to process natural language, thus generating responses based on the context of input text. The accuracy and completeness of ChatGPT3.5 in the context of inflammatory bowel disease [IBD] remains unclear. In this prospective study, 38 questions worded by IBD patients were inputted into ChatGPT3.5. The following topics were covered: [1] Crohn's disease [CD], ulcerative colitis [UC], and malignancy; [2] maternal medicine; [3] infection and vaccination; and [4] complementary medicine. Responses given by ChatGPT were assessed for accuracy [1-completely incorrect to 5-completely correct] and completeness [3-point Likert scale; range 1-incomplete to 3-complete] by 14 expert gastroenterologists, in comparison with relevant ECCO guidelines. In terms of accuracy, most replies [84.2%] had a median score of ≥4 (interquartile range [IQR]: 2) and a mean score of 3.87 [SD: ±0.6]. For completeness, 34.2% of the replies had a median score of 3 and 55.3% had a median score of between 2 and <3. Overall, the mean rating was 2.24 [SD: ±0.4, median: 2, IQR: 1]. Though groups 3 and 4 had a higher mean for both accuracy and completeness, there was no significant scoring variation between the four question groups [Kruskal-Wallis test p > 0.05]. However, statistical analysis for the different individual questions revealed a significant difference for both accuracy [p < 0.001] and completeness [p < 0.001]. The questions which rated the highest for both accuracy and completeness were related to smoking, while the lowest rating was related to screening for malignancy and vaccinations especially in the context of immunosuppression and family planning. This is the first study to demonstrate the capability of an AI-based system to provide accurate and comprehensive answers to real-world patient queries in IBD. AI systems may serve as a useful adjunct for patients, in addition to standard of care in clinics and validated patient information resources. However, responses in specialist areas may deviate from evidence-based guidance and the replies need to give more firm advice.

Potential Diagnostic Role of Hepcidin in Anemic Patients Affected by Inflammatory Bowel Disease: A Systematic Review.

Anemia is the main extraintestinal comorbidity of Inflammatory Bowel Disease (IBD). Differentiating the type of anemia in these disorders is still a challenge. Hepcidin could be a promising biomarker to identify iron deficiency anemia (IDA), anemia of chronic disease (ACD) and the concomitant presence of both IDA and ACD. To evaluate the potential role of hepcidin dosage in the management of anemia in IBD patients, we performed a systematic review by a comprehensive literature analysis of original papers reporting the dosage of hepcidin in IBD patients. In all the articles reviewed, the dosage of ferritin was reported, and the correlation between hepcidin and ferritin has been used to compare these two biomarkers. A total of 12 articles concerning the dosage of hepcidin in IBD were included, comprising in total of 976 patients. The results of the hepcidin values in IBD patients when compared with controls were conflicting. In fact, four articles described an increase in this biomarker, three showed a decrease and five did not find significant differences. The correlation with ferritin was positive and significant. In three studies, some differences between hepcidin dosages and ferritin levels indicate a possible role when IDA and ACD could be present at the same time. Considering the contradictory data of the studies, the diagnostic role of hepcidin as a biomarker remains elusive in IBD patients. These differences could be due to the clinical characteristics of the patients enrolled that should be better defined in the future. A suitable clinical trial should be designed to outline the possible role of hepcidin in differentiating IDA, ACD and concomitant IDA and ACD in IBD patients. At the moment, ferritin still remains the best marker to diagnose these conditions, in addition to hemoglobin, transferrin saturation and CRP as recommended by the ECCO guidelines.

P666 Accuracy of information given by ChatGPT for patients with Inflammatory Bowel Disease in relation to ECCO guidelines

Abstract Background As acceptance of AI platforms increases, more patients will consider these tools as sources of information. The ChatGPT architecture utilizes a neural network to process natural language, thus generating responses based on the context of input text. The accuracy and completeness of ChatGPT3.5 in the context of Inflammatory Bowel Disease (IBD) remains unclear. Methods In this prospective study, 38 questions worded by IBD patients were inputted into ChatGPT3.5. The following topics were covered: 1) Crohn’s Disease, Ulcerative Colitis, and malignancy, 2) maternal medicine 3) infection and vaccination 4) complementary medicine. Responses given by ChatGPT were assessed for accuracy (1 – completely incorrect to 5 – completely correct) and completeness (3-point Likert scale; range 1 – incomplete to 3 – complete) by 14 expert gastroenterologists, in comparison with relevant ECCO guidelines. Results In terms of accuracy, most replies (84.2%) had a median score of ≥4 (IQR:2) and a mean score of 3.87 (SD: +/- 0.6). For completeness, 34.2% of the replies had a median score of 3 and 55.3 % had a median score of between 2 and &amp;lt;3. Overall, the mean rating was 2.24 (SD: +/- 0.4, Median:2 IQR :1). Though group 3 and 4 had a higher mean for both accuracy and completeness, there was no significant scoring variation between the 4 question groups (Kruskal-Wallis test p:&amp;gt;0.05) (Table 1). However, statistical analysis for the different individual questions revealed a significant difference both for accuracy (p&amp;lt;0.001) and completeness (p&amp;lt;0.001). The questions which rated the highest for both accuracy and completeness were related to smoking, while the lowest rating was related to screening for malignancy and vaccinations especially in the context of immunosuppression and family planning. Conclusion This is the first study to demonstrate the capability of an AI-based system to provide accurate and comprehensive answers to real-world patient queries in IBD. AI systems may serve as a useful adjunct for patients, in addition to standard of care in clinic and validated patient information resources. However, responses in specialist areas may deviate from evidence-based guidance and the replies need to give more firm advice.

P464 Could Chat Generative Pre-Trained Transformer (ChatGPT) be an AI-provided friend of the patients for frequently asked questions concerning their IBD management? An evidence- and guidelines-controlled textual analysis of AI-provided outputs

Abstract Background Artificial intelligence (AI) is gradually and potentially entering the everyday lives of patients with Inflammatory Bowel Disease (IBD). Systems such as Chat Generative Pre-Trained Transformer (ChatGPT), based on large language models (LLM), are now within reach. It is necessary to weigh whether these LLM systems can be real generators of medical information and whether the latter is generated based on credible databases and evidence. This study evaluated and analysed whether the outputs of ChatGPT to common questions from IBD patients can provide credible and scientifically reliable outputs. Methods IBD-expert physicians retrieved a list of ten IBD frequently asked questions in their clinical practice. The ten with the highest frequency (Q1-10) were collected from the total number of questions and then input on ChatGPT (see Table) on three different days (18th, 19th, and 20th August 2023), and each output generated by the chatbot was categorised as O1, O2, and O3. The same research team evaluated the AI-generated responses by ChatGPT for each question by objectively comparing them with the available evidence (provided by meta-analyses, systematic reviews and ECCO guidelines). Results Q1 O1-3 were reliable, with a correct definition of the absence of definitive therapy for IBD. In Q2 O1-3, ChatGPT failed to clarify the lack of solid evidence for nutritional therapy in IBD. Q3 O1-3 provided corrected guidance on repeat endoscopic examinations for IBD. Q4 O1-3 did not provide reliable answers on removing topical therapy in ulcerative colitis. In Q5 O1-3 good advice was given to the IBD patient on how to plan a pregnancy. Q6 O1-3 brought out the lack of ChatGPT update (stopped in September 2021), limiting the range of new oral small molecule therapies available for the IBD patient. In Q7 O1-3 ChatGPT correctly outlined the need for individual risk stratification for endoscopic surveillance of colorectal cancer. In Q8 and Q9 O1-3 ChatGPT correctly weighed the risk of infection/cancer during biologic therapy and how heritability is only one piece of the pathogenetic puzzle of IBD. Finally, in Q10 he correctly elucidated the possibility of biological therapy preventing post-operative recurrence of Crohn's disease. Conclusion ChatGPT is a potentially useful complementary tool for communicating with IBD patients. It is necessary to improve the degree to which it is updated and sources on appropriate databases (e.g., Scopus, Web of Science, and MEDLINE). Ultimately, there are still significant limitations. Much of the latest findings, in fact, are excluded from ChatGPT evaluation. A portion of the outputs provided are partially incorrect or not fully detailed and not yet ready to be released to the patient without a physician filter.

P926 Improved standards of colonoscopy for Inflammatory Bowel Disease through implementation of key performance measures - A quality improvement initiative

Abstract Background Improving the quality of colonoscopy in inflammatory bowel disease is expected to improve clinical outcomes for patients. The European Society of Gastrointestinal Endoscopy (ESGE) recently published key performance measures for IBD colonoscopy assessment. This study aimed to assess the impact of implementing key performance measures and assess for sustainable improvement through a multimodal education intervention. Methods A baseline retrospective analysis was performed in patients with established IBD between June and August of 2022 at a tertiary hospital. The key performance measures included 1) pre-procedure metrics including indication, consent, and safety checklist (target of 100%) and 2) bowel preparation score, photo-documentation, disease activity scores, adequate biopsies, use of high-definition endoscopy and chromoendoscopy. There were six proceduralists involved and data was collected from electronic medical records including endoscopy and histopathology results. The ESGE performance measures were used to set minimum standards and we have adopted overall standards for our unit based on the ECCO and SCENIC consensus guidelines. Over 12 months, proceduralists and endoscopy nursing staff were engaged with educational interventions including didactic teaching for one hour and diagrammatic reminders in the endoscopy suites of the ESGE key performance measures. A post-implementation analysis was conducted at 1 year from baseline, from August to November of 2023. Results Baseline standards showed suboptimal performance in the use of disease activity scores and chromoendoscopy. Educational interventions were implemented and after 12 months, a repeat analysis of 50 consecutive patients showed significant improvement in all performance measures (see Table 1). Conclusion Quality metrics are important and underrecognised components in colonoscopy for IBD patients and form an integral part of improving patient care. Our study demonstrated that the implementation of the ESGE key performance measures is effective in improving the quality of colonoscopy assessment in IBD patients, identifying areas requiring further development and increasing the dysplasia detection rate. Acknowledging quality attrition over time, we recognise that regular teaching and education are required in addressing the challenge of sustainable long-term improvement.

P1178 Detection of occult liver disease in patients with Inflammatory Bowel Disease

Abstract Background Investigation of liver disease is recommended in the ECCO Guidelines for Extraintestinal Manifestations in Inflammatory Bowel Disease (IBD). The aim of this study was to analyse the prevalence of liver disease in IBD patients, to examine the frequency of different aetiologies, and to investigate a possible correlation between the severity of liver disease and IBD. Methods Cross-sectional descriptive study including all patients with inflammatory bowel disease (IBD) of nine hospitals in Spain. The study of liver disease was carried out in two phases: patients with FIB-4 greater than 1.3 (greater than 2 in those aged 65 years or more), as well as those with APRI greater than 0.5 and/or elevated transaminases were selected as those at risk of liver disease. In the second phase, these patients underwent a medical history, comprehensive blood tests, abdominal ultrasound with SWE elastography and Fibroscan® (including transitional elastography (TE) and Controlled Attenuation Parameter (CAP)). Results In total, 5302 patients were enrolled and 1640 (31%) were identified as at risk for liver disease. The University Hospital of Burgos has completed the second phase of the study in patients diagnosed with IBD between 2010 and 2021 (n=151). Of these patients, 72.2% were male and the median age was 61 years. Ulcerative colitis (57%) was the most common type of IBD and 62% of the patients were overweight or obese, while 12% of the patients had high-risk alcohol consumption. Metabolic hepatic steatosis was the most frequent cause of liver disease (35%). Moderate/severe steatosis was detected in 44.3% of patients by CAP and 24% by ultrasound. The prevalence of advanced fibrosis was 10.6% and 12% when assessed by ET and SWE, respectively. Notably, 12.6% displayed ultrasound signs of chronic liver disease. A positive correlation was found between the ET and the SWE for liver fibrosis, with a correlation coefficient of ĸ = 0.663. On univariate analysis, an increased risk of significant fibrosis (p=0.011) and moderate/severe steatosis (p=0.00) was found only in those who were overweight or obese. However, no association with severity of liver disease was found for perianal disease, use of immunosuppressants or history of previous surgery. Conclusion The incidence of unrecognised liver disease in IBD patients is substantial, with metabolic hepatic steatosis being the most common cause. The severity of liver disease in these patients cannot be ignored, with one in ten patients having advanced fibrosis. In the univariate study, only obesity was found to correlate with the severity of steatosis and fibrosis, while IBD severity showed no significant association with liver disease severity.

P580 Iron deficiency anaemia and quality of life in Inflammatory Bowel Disease: Prospective cohort study of ferric derisomaltose on quality of life and work productivity in patients with IBD

Abstract Background Iron-deficiency anaemia is a frequent complication of inflammatory bowel disease (IBD), affecting approximately 10% of patients at any one time. Quality of life scores in patients with IBD and anaemia are similar to those reported in malignancy. ECCO guidelines recommend assessment and treatment of iron deficiency anaemia, with a goal of normalising haemoglobin and iron stores. Methods We conducted a prospective observational cohort study of patients with IBD being treated for iron deficiency anaemia with ferric derisomaltose. Patients were included who were anaemic as per World Health Organisation criteria with a ferritin of &amp;lt;30 µg/L and/or a transferrin saturation of &amp;lt;18%. Variables collected included haematological parameters, the 12-item Short Form survey (SF-12) as a generic health-related quality of life measure, the Work Productivity and Activity Impairment (WPAI) questionnaire and the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) as a disease-specific quality of life measure. Patients were assessed at baseline, 12 weeks and 52 weeks. We present here the outcomes at week 12. Comparative statistics have been conducted using Wilcoxon signed rank tests and Pearson’s correlation coefficient. Results We recruited 124 patients given between 700 and 1900 mg of ferric derisomaltose, each as a single infusion. Of these, 60% (74/124) were female and the median age was 43 years (IQR 31 – 58). Just under half (46%) of participants had Crohn’s disease, the remainder had ulcerative colitis (49%) or IBD unclassified (5%). Median (IQR) baseline haemoglobin was 114 (109 – 123) g/L in men and 110 (104 – 116) g/L in women. By week 12, haemoglobin, ferritin, SIBDQ, the WPAI, and both the mental and physical component scores of the SF-12 had improved significantly (all p values &amp;lt;0.0001; see Figure 1). Change in the physical score of SF-12 correlated positively with change in haemoglobin (r = 0.38, p&amp;lt;0.0001), while the change in WPAI correlated negatively with change in haemoglobin (r = -0.30, p=0.013). Conclusion Treatment with intravenous ferric derisomaltose in patients with iron deficiency anaemia and IBD was associated with significant improvements in haematological, work productivity, and quality of life parameters.

What Should We Know about Drug Levels and Therapeutic Drug Monitoring during Pregnancy and Breastfeeding in Inflammatory Bowel Disease under Biologic Therapy?

Data on the real long-term influences of in utero drug exposure in pregnant women on childhood development are scarce and remain not well determined and depend on the duration of in utero drug exposure and maternal drug levels. Therapeutic drug monitoring (TDM) during pregnancy may help limit fetal drug exposure while maintaining an effective dose for the treatment of the underlying inflammatory bowel disease (IBD) in women. Most antibody therapies used in patients with IBD are IgG molecules which are actively transported across the placenta, especially during the third trimester of the pregnancy. Here, we propose an up-to-date clinical review to summarize the available findings of serum drug levels in maternal blood during pregnancy, in the cord blood, infants at delivery and in breast milk of patients with IBD treated with biologics. Conversely, in comparison to adalimumab (ADA) levels, which are relatively stable during pregnancy, infliximab (IFX) drug clearance decreased significantly during the last two trimesters of the pregnancy, leading to increasing drug concentrations in the blood of the pregnant women. As most guidelines recommend using live vaccines in infants at the age of one or earlier in case of negative serum drug levels in newborns, statistical models could help clinicians in making a decision to adjust the last dose of the biologic during pregnancy and to determine the optimal date to vaccinate. Altogether, data from the literature offers strong reassurance in terms of safety for anti-TNFα therapies during pregnancy not only for IBD patients who intend to conceive, but also for pregnant women and for the physicians taking care of these patients. ADA and IFX levels in breast milk are detectable, but at very low levels, and therefore, it is recommended to pursue breast feeding under anti-TNFα therapy. Our knowledge on ustekinumab or vedolizumab levels in pregnant women remains unclear and scarce. These drugs are currently not recommended for patients with IBD in clinical practice. Therefore, TDM and proactive dose adjustment are not necessary during pregnancy since its impact on making a clinical decision have not yet been clearly demonstrated in routine practice. Overall, drug concentrations in the cord blood, an infant at birth and postpartum serum concentrations in infants, due to active placental drug transfer, may have a greater impact than the limited drug transfer in breast milk during lactation on the risk of infection and developmental outcomes. Ustekinumab and vedolizumab exposure during pregnancy and lactation are both considered low risk by the recent ECCO guidelines despite the limited data that are currently available.

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

Long-term disease course, cost and prognosis of inflammatory bowel disease: epidemiological studies of a European and a Danish inception cohort.

P154 A novel serum protein signature as biomarker for Inflammatory Bowel Disease: A diagnostic performance and prediction modelling study using data from two independent inception cohorts

Abstract Background The diagnosis of inflammatory bowel disease (IBD) is often delayed since existing biomarkers in blood are imprecise and faecal tests are poorly accepted by patients. Therefore, we aimed to identify a diagnostic serum protein signature and validate its performance and utility. Methods Proximity extension immunoassay (PEA) methodology (Olink Proteomics, Uppsala, Sweden) was used to measure 184 immune and inflammatory markers in serum samples from adult patients with suspected IBD in the Swedish inception cohort SIC IBD (discovery cohort, n=451) and the Norwegian population-based inception cohort IBSEN III (validation cohort, n=554). Samples were obtained at presentation, i.e., almost all patients were treatment naïve. Diagnostic assessment was performed following the ECCO guidelines. Supervised machine learning with smoothly clipped absolute deviation (SCAD) regularised logistic regression and random forest (RF) models were employed in nested cross-validation to identify a diagnostic signature of IBD. Results The discovery cohort included 310 IBD patients and 141 symptomatic controls without any discernible evidence of IBD, and the validation cohort included 354 IBD patients and 200 symptomatic controls (Table 1). The regularised regression identified a signature of 26 proteins that distinguished IBD from symptomatic controls with an area under the curve (AUC) of 0.78 in the discovery cohort. Contributions of individual proteins for the diagnostic signature are shown in Figure 1. Next, we validated the diagnostic capacity of the protein signature in the validation cohort (AUC=0.82) and compared it to high-sensitivity C-reactive protein (hsCRP) (Figure 2, AUC=0.69, p=1.1×10-7). The RF model yielded similar results. Only 422/554 patients in the validation cohort provided a stool sample. Among these patients, the diagnostic accuracy of the protein signature (AUC=0.82) and faecal Calprotectin (AUC=0.86) did not differ (p=0.07). A complex protein signature may preclude its introduction into clinical practice. Simplified models were therefore constructed using discovery cohort data and stepwise forward logistic regression with hsCRP as the null model. When applied to the validation cohort, the diagnostic accuracy of the shortest signature, comprising hsCRP and interleukin (IL)-17A (AUC=0.80), was superior to hsCRP (Figure 3, AUC=0.69, p=1.7×10-8). Conclusion A serum protein signature of hsCRP and IL-17A was superior to hsCRP in differentiating treatment-naïve IBD from symptomatic controls. Taking into account that many patients do not accept to provide faecal samples, we believe this signature has the potential to become an accessible and scalable test that can shorten the diagnostic delay in IBD.

P271 Variability in histologic activity of paired same-segment biopsies in Crohn’s disease dictates multiple biopsies needed to accurately evaluate histological status

Abstract Background At present, the significance of histologic remission in Crohn’s disease [CD] is unclear. One of the main reasons is the heterogeneous distribution of the lesions. This contrasts with ulcerative colitis, where histologic scoring systems have been applied with success on limited numbers of biopsies. We assessed the variability of histologic activity in paired same-segment biopsies from CD patients. Methods All CD patients undergoing ileocolonoscopy between January 2020 and July 2022 at our tertiary referral center were eligible for inclusion. Clinical data were retrospectively collected from medical records. Endoscopies were video-recorded and the Simple Endoscopic Score for Crohn’s Disease [SES-CD] was used to evaluate endoscopic activity. Paired biopsies were taken within the most affected area per segment, in accordance with ECCO guidelines. The Global Histology Activity Score (GHAS), the Geboes Score [GS], the Robart’s Histopathology Index [RHI] and the Nancy Histological Index [NHI] were determined for each biopsy by an experienced IBD pathologist [GDH] blinded to the endoscopic scores. The cut-off values for histologic remission were set at GHAS ≤4, GS &amp;lt;2B.1, RHI ≤3 and NI ≤1 (absence of neutrophils for RHI and NI). Variability was assessed by intraclass correlation coefficient [ICC] and Kappa statistics. Association between histologic and endoscopic scores was studied with Spearman’s rank correlation coefficient. Results A total of 151 biopsy pairs from 128 patients were analysed. Patient characteristics are summarised in Table 1. Endoscopic activity was observed in 79% of segments. In patients with endoscopic remission, histologic activity (presence of neutrophils) was found in 29% of cases. There was a moderate association between the endoscopic and histologic assessment, with correlation levels ranging from 0.48 to 0.52 [p&amp;lt;0.001]. Histologic indices showed fair agreement between paired biopsies [Table 2]. Looking at the predefined cut-offs, moderate variability across the different histological scores was seen [Table 3]. When comparing biopsies from segments with endoscopic activity and those without, overall higher variability in active segments and substantial agreement in paired biopsies from inactive segments was observed [Table 4]. Conclusion The patchy nature of microscopic inflammation in CD is reflected in the histologic scores of paired same-segment biopsies, with only moderate agreement across histologic scoring indices, although lower variability was seen in biopsies from endoscopic inactive segments. Endoscopic activity only moderately reflects histological status. Multiple biopsies per segment are therefore needed for accurate histological evaluation, the optimal number necessary remains to be explored.

P399 Detection of iron restricted erythropoiesis in patients with IBD: How can we disentangle effects of inflammation?

Abstract Background Iron deficiency and anaemia are among the most common complications of IBD. While the distinction between functional and absolute iron deficiency (AID) is vital for therapeutic decision-making, inflammation is a frequent confounder in their diagnosis: An indirect indicator of body iron stores, serum ferritin is the most specific biomarker of AID. However, it is also an acute-phase reactant and can thus be obscured by IBD-related inflammation. Patients with active IBD often have anaemia of inflammation (AOI), i.e., reduced availability of iron for erythropoiesis (iron-restricted erythropoiesis, IRE) despite adequate stores. ECCO guidelines suggest adding biomarkers to distinguish functional from absolute ID in AOI. Here, we compared the utility of red cell indices and biochemical markers to detect IRE in IBD and define a decision threshold for the selection of biomarkers to discriminate AID and iron sequestration. Methods In an observational cross-sectional study, routine blood samples of patients with IBD were collected. CBC, iron status (serum ferritin, SF; transferrin saturation, TSAT; serum iron % of hypochromic red cells, %HYPO; reticulocyte haemoglobin content, CHr; soluble transferrin receptor, sTfR) and high sensitivity CRP (hsCRP) as inflammatory marker were determined by standard methods. sTfR-F index was calculated (sTfR (mg/L)/log10 SF(μg/L)). Patients with SF&amp;lt;30μg/L were assigned as AID-consistent controls to define decision thresholds for iron markers in patients with SF≥30μg/L which were then used to evaluate IRE in patients with SF≥30μg/L. The accuracy of the markers in the presence/absence of inflammation were assessed and contextual diagnostic thresholds determined. Results Samples were collected from 312 patients with IBD (159f/153m;163CD/149UC;42.7±14.5y), of whom 122(39.1%) had inflammation. 43 patients with SF&amp;lt;30μg/L were selected as AID-control group. Results in this group were: TSAT (cut-off 20%; AUCROC 0.730; sens.65%, spe.34%), %HYPO (3.5%; 0.733; 42%, 93%), CHr (32pg; 0.713; 51%, 86%), sTfR (2.70mg/L; 0.775; 81%, 63%), sTfR-F (2.01; 0.914; 88%, 88%). sTfR-F was used as reference for IRE in patients with SF ≥30μg/L. Accuracy of the markers as detectors of IRE is shown in Table 1. Conclusion sTfR was the most accurate sole marker of IRE in patients both with and without inflammation, its cut-off being higher in the presence of inflammation. In patients without inflammation, SF was a valuable additional parameter. Relative cost-effectiveness of the markers alone or in combination is under investigation.

P275 Anastomotic technique drives endoscopic recurrence in Postoperative Crohn's Disease: a systematic review and meta-analysis

Abstract Background Patients with Crohn's disease (CD) after Ileo-colic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches approximately 70% of incidence within six months. ECCO guidelines favour a stapled side-to-side anastomosis. However, the advent of the Kono-S ileocolic anastomosis, a hand-sewn antimesenteric functional end-to-end anastomosis, seems to reduce clinical risk and ePOR. Whilst the majority of the studies have assessed the rate of ePOR individually, currently there is limited data comparing surgical techniques of the anastomosis. Hence, we aimed to assess the impact of different surgical techniques on ePOR in CD Methods We searched PubMed and Embase in October 2022 for eligible studies reporting the surgical types of anastomosis and, based on these, the rate of endoscopic recurrence at a minimum of six months. Studies were grouped by conventional anastomosis vs Kono, and comparisons were made between these groups. Pooled incidence rates of ePOR were computed using random-effect modelling. Meta-regression and subgroup analyses were performed to examine the impact of the type of anastomosis on the incidence of ePOR ≥ 6 months Results Thirteen studies, including 1816 patients who underwent ileocolic resection for CD, were included. Among these patients, 282 (15.5%) received a Kono-S anastomosis, while 1534 (84.4%) had a conventional anastomosis. ePOR at ≥≥ six months showed a pooled incidence of 31.8% (95% CI, 24.8 to 39.2), with significant heterogeneity among the studies (p&amp;lt;0.01). Meta-regression analysis showed that Kono-S anastomosis was associated with a significant reduction in the ePOR at endoscopic follow-up (p=0.001). In detail, patients receiving a Kono-S anastomosis had a pooled incidence of ePOR of 12% (95% CI, 3.1 to 24.9), while patients receiving a conventional anastomosis had an ePOR of 38.2 (95% CI, 30 to 46.9%) [Figure1]. Funnel plot asymmetry [Figure 2] and Egger's regression test (p=0.118) indicated the absence of a publication bias Conclusion Kono-S anastomosis was associated with a significant reduction of ePOR at ≥ six months compared to the conventional anastomosis. Our findings highlight the need to standardize and implement the use of Kono-S anastomosis, particularly for difficult-to-treat patients with high risk for a post-operative recurrence

P171 Subfertility in young patients with Crohn′s disease. A case-control study.

Abstract Background Inflammatory bowel disease (IBD) commonly affects women and men during the reproductive years.The effect of the disease burden on fertility in these patients is a common concern for them. ECCO guidelines establish that active disease is associated with decreased fertility in women but studies regarding this topic are of low quality and outdated. Aims to investigate the effect of CD on fertility, studying ovarian reserve in women as well as global Sertoli cell function in men, - To compare these results of CD patients with the healthy control group. (HC) - To assess the related factors to subfertility in women and males with CD. Methods This was a cross-sectional, prospective and case-control study, including CD patients, aged 18-40 years-old, and HC matched by gender and age (ratio 2:1). Morning baseline IB was measured in men using ELISA. Serum anti-Müllerian hormone (AMH) was measured by ECLIA. Sociodemographic and phenotypic features of CD patients and controls were collected.Subfertility was defined as IB &amp;lt; 89pg/mL, AMH &amp;lt;1.66 ug/L in 0-24 years old group; &amp;lt;1.18 ug/L in 25-29 years old group; &amp;lt;0.67 ug/L in 30-34 years old group; &amp;lt;0.77 ug/L in 35-39 years old group; and &amp;lt;0.01 ug/L in 40-44 years old group. AMH &amp;lt;2 ug/L in women under 40 was considered low. Results A total of 163 individuals were included: 83 men (58 CD, median 28 years old, RIQ 24-36; 25 HC, median 31 years old, RIQ 26-37) and 80 women (50 CD, median 26 years old, RIQ 21-36; 30 HC, median 28, RIQ 26-32). Sedentary lifestyle was more frequent in women with CD vs HC (46% vs 3,3%, p&amp;lt;0,001). 24% of women with CD and 8% of males had clinical activity (IHB &amp;gt;4). Low AMH (&amp;lt;2ug/L) in women older than 30 was more frequent in CD vs HC: 95% (18/19) vs 44% (4/9) p=0.001, with an OR of presenting AMH &amp;lt; 2 ug/L of 3.28 (IC 95%, 1.6-6.4) for women with CD &amp;gt;30 years old. The average AMH serum level was similar between women with CD and HC [1.83 (1.04-3.34) vs. 2.74 (1.05-4.12) g/L, p=0.4]. Abnormal AMH rate by age rank was not different between groups in global population (11/50, 22% EC vs. 7/30, 23% in CS, p=0.9,). IB levels were significantly lower in men with CD vs HC [169 (140-217) vs 232 ug/L (178-274) p=0.001]. IB &amp;lt;89 pg/mL was not detected in any control vs 6% (n=3) in CD. In multivariate analysis, only AMH was associated with lower levels of IB in CD men, no association with clinical activity or treatments in CD was found. Conclusion Women with CD and &amp;gt;30 years old have a higher risk than general population of presenting low AMH (&amp;lt;2).These data could be helpful at council of women with CD that desire to have progeny. IB concentration was lower in men with CD compared to HC.

TREATMENT PATTERNS OF PEDIATRIC AND ADULT PATIENTS WITH ULCERATIVE COLITIS

Abstract OBJECTIVE Ulcerative Colitis (UC) is a chronic disease characterized by continuous inflammation of the colonic and rectal mucosa. Children with UC are more likely to present with extensive disease and have more rapid clinical progression than adults.1 This study compared treatment patterns between pediatric and adult patients with UC. METHODS This retrospective, claims-based, cohort study used data from the Merative L.P Marketscan® Research Database to identify newly diagnosed patients with a confirmed UC diagnosis from January 1, 2014 through December 31, 2021. Pediatric (≤ 17 years) and adult (≥ 18 years) patients with continuous enrollment for 12 months before and 12 months following the first UC diagnosis (index date) who also received at least 1 medication related to inflammatory bowel disease (aminosalicylates, corticosteroids, immunomodulators, or biologics) after the first diagnosis date, were included. Descriptive statistics described treatment patterns for both cohorts. RESULTS This analysis included 1343 pediatric and 37,617 adult patients with UC. The mean (SD) ages (years) for pediatric and adult patients were 13.7 (3.3) and 48.8 (15.3) years, respectively (Table 1). The time from diagnosis to initiation of corticosteroids was numerically shorter in children in contrast to adults (median days between index date and corticosteroids initiation: 15 vs 56). Among all UC patients, aminosalicylates (74.0% adults vs 72.5% children) were the most prescribed monotherapy, followed by corticosteroids (16.6% adults vs 15.3% children) and immunomodulators (5.1% adults vs. 7.4% children). Additionally, children were started on combination therapies numerically more often than adults (32.3% vs 16.7%). The most used combination therapies for both cohorts were aminosalicylates plus corticosteroids (63.0% adults vs 62.4% children), followed by aminosalicylates and immunomodulators (15.3% adults vs 8.3% children). Children had numerically higher utilization of biologics than adults (22.6% vs 10.8%). The persistence rates of all drug therapies within 6 months following initiation in both cohorts were similar (Table 2). Notably, a small proportion of pediatric patients were on ustekinumab, vedolizumab, or tofacitinib as add-on therapy (0.2%, 2.0%, and 0.2%, respectively), despite those medications not being currently approved in this population. CONCLUSION More children with newly diagnosed UC receive combination therapies and have higher utilization of biologics compared to adults. This may reflect greater disease progression and complications in children. REFERENCE 1. Ruemmele, F., Turner, D. Differences in the management of pediatric and adult-onset ulcerative colitis – lessons from the joint ECCO and ESPGHAN consensus guidelines for the management of pediatric ulcerative colitis. Journal of Crohn’s and Colitis, 8(1), January 2014, pages 1-4.

Prognostic Factors of Biologic Therapy in Pediatric IBD.

This was a retrospective cohort study aimed at identifying parameters measured at diagnosis of pediatric IBD to predict subsequent biologic therapy, as an equivalent to an unfavorable clinical course. Identification of predictors of poor outcomes is an important issue in current ECCO guidelines on pIBD. The study population consisted of 119 children with Crohn’s disease and 112 with ulcerative colitis, diagnosed and monitored for at least 1 year from 2009–2019. The population was divided into the study groups separately: 39 children with CD and 14 with UC who received biologics before the age of 18 y compared to 80 with CD and 98 with UC who did not. The combined analysis of 53 biologic therapy recipients vs. 178 non-recipients with IBD was also conducted. Logistic regression tests (OR, RR) and sensitivity, specificity, PPV, and NPV were used. Factors significantly correlated with subsequent biologic therapy were perianal disease, complicated disease behavior, high PCDAI (CD), fatigue, hypoalbuminemia, high PUCAI (UC) and fever, fatigue, hypoalbuminemia, hypoproteinemia, and elevated CRP (IBD). Marginally significant factors were ileocecal disease, elevated serum IgA, anemia, and L4a–L4b coexistence. Apart from parameters already accepted as POPO (B2/3, perianal disease), interesting observations are the significance of IgA, L4a–L4b in CD, and hypoalbuminemia in UC.

Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study

BackgroundThe aim of this study was to analyze the effect of a personalized prehabilitation (PP) before ileocolic resection (ICR) on the postoperative anastomotic complications in patients with Crohn's Disease (CD) with high risk of post-operative complications. Materials and methodsAll high-risk patients who required ICR with primary anastomosis for CD between January 2010 and March 2020 were retrospectively analyzed. PP included nutritional support, antibiotic therapy or drainage of an abscess, stopping or decreasing corticosteroid treatments. Patients were considered as high risk for complications when they had at least one or more of these 3 risk factors (RF) (hypoalbuminemia <30 g/L or weight loss of >10% over the last 6 months, treatment with corticosteroids before surgery (within 4 weeks before surgery), or presence of preoperative intra-abdominal sepsis (abscess or enteral fistula)) according to ECCO guidelines 2020. ResultsNinety high-risk patients were included in our cohort and the anastomotic complication rate was 11.1%. Sixty-four (71.1%) had preoperative prehabilitation (median duration of 37 days), and the mean albumin level (34 g/L vs 37 g/L; p < 0.001) and the number of RF (1.21 vs 1.06; p = 0.001) were improved by PP during the preoperative period. The rate of anastomotic complications at 90 days from surgery (6.25% vs 23.1%; p = 0.031) as well as the re-operation rate (3.1% vs 19.2%; p = 0.019) were lower after PP. No difference was found on the rate of readmission and the length of stay in this subgroup analysis. Biological treatment administration within 3 months before surgery was not a risk factor for postoperative complication. ConclusionPP reduces the number of preoperative risk factors before ICR in high-risk patients with CD and allows primary anastomosis with a lower complication rate than in upfront operated patients.

Synopsis of ECCO and ESPGHAN Guidelines in the Management of Ambulatory Pediatric Ulcerative Colitis

Synopsis of ECCO and ESPGHAN Guidelines in the Management of Ambulatory Pediatric Ulcerative Colitis