Shaping surgical decisions in IBD - Unveiling the power of intestinal ultrasound across the perioperative pathway.

Introduction: Severe forms of ulcerative colitis (UC), pseudomembranous colitis (PMC), and ischemic colitis (IC) often exhibit clinical and morphological mimicry, complicating the differential diagnosis. In severe and fulminant cases, pathological changes in the colonic wall become increasingly uniform, thereby diminishing the impact of initial etiological factors on therapeutic decision-making. Currently, there are no clear clinical and laboratory criteria for predicting failure of conservative treatment in severe colitis. Aim: To identify factors associated with unfavorable outcomes of conservative therapy in patients with severe and fulminant UC, PMC, and IC. Methods: This was a single-center retrospective comparative cohort study in patients with severe and fulminant UC, PMC, and IC undergoing conservative treatment at the Loginov Moscow Clinical Scientific Center from 2015 to 2024. Based on a multidisciplinary team consensus on the presence of relative indications for surgery, two groups matched by sex, age (± 5 years), and diagnosis were formed: the main group (n = 36) included patients who declined surgery and continued their conservative management; the control group (n = 36) was selected via 1:1 propensity matching from the cohort without any surgical indications. Results: The cohort’s diagnostic distribution was as follows: UC (n = 42), PMC (n = 22), and IC (n = 8). Fulminant disease was significantly more frequent in the main group (15/36) than in the control group (2/36; p 0.001). The patients with relative surgical indications more often exhibited a systemic inflammatory response syndrome (12 vs 2 cases; p = 0.003) and in-hospital deaths (6 vs 0; p = 0.011). We were able to identify key predictors of mortality, such as PMC (odds ratio [OR] 8.0; 95% confidence interval [CI] 1.17–54.50), severe multiorgan dysfunction defined by a SOFA score ≥ 4 (OR 22.0; 95% CI 1.54–314.29), history of prior colonic resection (OR 20.0; 95% CI 1.95–204.73), the requirement for high-volume albumin infusion (≥ 1350 mL), being a marker of systemic decompensation and therapeutic intensity (OR 10.5; 95% CI 1.41–78.06), elevated serum creatinine (≥ 102.0 µmol/L; OR 28.8; 95% CI 2.62–315.30), and elevated serum urea (≥ 7.9 mmol/L; OR 40.0; 95% CI 3.42–468.07). Conclusion: Thus, in the patients with severe and fulminant colitis under conservative treatment, the risk stratification based on the predictors identified, reflecting the severity of systemic decompensation and multiorgan failure enables timely surgical decision-making when there is no clinical improvement during medical therapy.

Infliximab (IFX) is commonly used in the management of acute severe ulcerative colitis (ASUC), yet up to 30% of individuals still require colectomy within 1 year. Clinical data characterizing these patients, however, are limited. We aimed to determine risk factors for colectomy among patients with ASUC who received in-hospital IFX treatment. We performed a retrospective analysis of patients with ASUC who were treated with at least one dose of IFX while admitted between 2014 and 2022. Cox proportional hazards (PH) models were used to assess demographic, clinical, and laboratory risk factors for colectomy within 30 days and 1 year of IFX initiation. Overall, 36/170 (21.2%) patients underwent colectomy within 1 year of IFX initiation, with 22 (12.9%) individuals requiring colectomy within 30 days. On univariable analysis, concomitant Clostridioides difficile infection during admission, a ≤50% decrease in C-reactive protein (CRP) and experiencing 3 or more bowel movements per day within 48 hours after an initial IFX dose were significantly associated with 1-year colectomy. On multivariable Cox PH analysis, C. difficile infection during admission (aHR=2.92, 95% CI: 1.12-7.58) and a higher CRP/albumin ratio on admission (aHR=1.13, 95% CI: 1.01-1.27) were associated with increased colectomy risk within 1 year of IFX initiation. C. difficile infection and a higher CRP/albumin ratio on admission are associated with decreased time to colectomy within 1 year of IFX among patients presenting with ASUC. These factors may aid in early risk stratification to minimize delays in JAK-inhibitor initiation or surgical referral.

Comparative efficacy of immunomodulators, biologics, and advanced therapies for steroid-refractory acute severe ulcerative colitis: A network meta-analysis and time-to-event analysis.

Acute Severe Ulcerative Colitis Patients From Asia Have Lower Colectomy Risk Than Patients From Australasia.

Update on IBD management: What's new in acute severe UC? - Modern management of perianal disease.

Upadacitinib as rescue therapy for acute severe ulcerative colitis and severe Crohn's disease - current knowledge and future directions.

BACKGROUNDUlcerative colitis (UC) is a chronic relapsing inflammatory bowel disease with rising global incidence. Current therapies for UC often provide incomplete relief and are associated with adverse side effects, highlighting the need for alternatives with increased safety and effectiveness. Compound spleen-tonifying composition (CSTC) contains ingredients, such as Pulsatilla chinensis (Bunge) Regel and Glycyrrhiza uralensis Fisch, that have been shown to be efficacious in the treatment of UC. Its mechanism needs to be investigated further.AIMTo study the therapeutic effect and mechanism of CSTC in dextran sulfate sodium (DSS)-induced UC in rats.METHODSSprague-Dawley rats were freely given 4% DSS solution for seven days to establish the UC model. After intervention with CSTC and its different solvent extracts, body weight changes, the disease activity index (DAI), and colon histopathology were assessed to evaluate therapeutic outcomes. The contents of superoxide dismutase (SOD), malondialdehyde (MDA), myeloperoxidase (MPO), glutathione peroxidase (GSH-px), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6) in colon tissue were determined to investigate changes in biochemical indicators.RESULTSDSS administration triggered severe UC symptoms, including weight loss, colon shortening, elevated DAI scores, and histological damage. These symptoms were accompanied with oxidative stress (reduced SOD and GSH-px levels and increased MDA and MPO levels), inflammation (elevated TNF-α, IL-1β, and IL-6 levels), and a reduction in the expression levels of tight junction proteins [zonula occludens-1 (ZO-1) and occluding]. High- and medium-dose CSTC treatment significantly alleviated clinical symptoms, restored colon morphology, normalized oxidative stress markers, suppressed proinflammatory cytokines, and enhanced ZO-1 and occludin levels, demonstrating dose-dependent efficacy. Notably, solvent extraction critically influenced bioactivity: Nonpolar extracts (chloroform and petroleum ether) showed minimal effects, whereas polar extracts (ethyl acetate and n-butanol) remarkably improved clinical symptoms.CONCLUSIONThe above findings highlight CSTC’s multifaceted anti-UC effects, which are mediated through oxidative stress mitigation and cytokine modulation, while emphasizing the polarity-dependent efficacy of its extracts.

Data on acute severe ulcerative colitis (ASUC) management in patients with prior anti-TNF exposure are limited. We compared medical management, colectomy risk and mortality between anti-TNF-exposed and bio-naive patients. This retrospective, multicenter GETECCU study included two ASUC cohorts (2010-2020): anti-TNF-exposed (cohort 1) and bio-naive (cohort 2). Patients previously treated with other advanced therapies were excluded. Steroid response was defined by reduced bowel movements and C-reactive protein. Rescue therapies were used for steroid failure. Maintenance therapy was initiated post-ASUC. Clinical effectiveness was assessed using the partial Mayo score (remission ≤2). Colectomy rates were analyzed through survival analysis and Cox regression. Mortality at 12 months were also evaluated. A total of 461 patients were included: 149 in cohort 1 and 312 in cohort 2. Steroid use was lower in cohort 1 (82% vs 97%, p < 0.001), but clinical response rates were similar. Rescue therapy rates were comparable (52% vs 57%, p = 0.88); infliximab use was lower in cohort 1 (25% vs 54%, p < 0.01). At 12 months, cohort 1 showed lower remission (44% vs 59%, p = 0.03) and higher colectomy (17% vs 8.7%, p = 0.01). Overall colectomy was higher in cohort 1 (34% vs 17%; HR 2.46, p = 0.001). One-year mortality was 1.52% (no significant differences between cohorts). ASUC management in anti-TNF-exposed patients is heterogeneous and differs from that of bio-naive patients, with increased risk of treatment failure and colectomy.

Introduction Acute severe ulcerative colitis (ASUC) is a medical emergency associated with high morbidity and around 1% mortality. Left-sided colitis (LSC) is a subtype of ulcerative colitis that requires timely multidisciplinary management, often involving gastroenterologists and colorectal surgeons. When corticosteroids and rescue therapies such as infliximab or cyclosporine fail, surgery is frequently indicated. Operative options include total proctocolectomy with ileal pouch–anal anastomosis (TPC-IPAA), total proctocolectomy with ileostomy (TPC-I), total abdominal colectomy (TAC), and subtotal colectomy (STC). In the United Kingdom, STC is the most common emergency operation, but it may not be optimal for patients with left-sided disease. This review aimed to determine the most appropriate surgical approach for acute LSC. Methods A systematic review was conducted in accordance with PRISMA guidelines. Searches of Ovid MEDLINE, EMBASE, Cochrane Library, Web of Science, and Scopus identified studies published between 2001 and 1 November 2023. Eligible studies involved adult patients with LSC refractory to medical therapy who underwent surgery. Primary outcomes were patient-centred measures; secondary outcomes included short- and long-term surgical results. Studies on medical management alone, isolated proctitis, rectal cancer, non-human subjects, or non-English publications were excluded. Screening and data extraction were performed independently by two reviewers, with plans for GRADE assessment and meta-analysis if data permitted. Results Of 6,606 records screened, no study met full inclusion criteria. Six related studies were narratively reviewed. Outcomes were mixed: TAC was associated with higher complications in some studies but lower infection rates than TPC in others. Segmental colectomy carried a 35% reoperation rate and 4.2% mortality. Conclusion Evidence is insufficient to define the optimal emergency surgical strategy for acute LSC. While TAC remains the standard approach, its suitability for this subset is unclear. Disease-specific research is urgently needed. Registration: PROSPERO CRD42023473654.

Background. Colonoscopy with biopsy remains the gold standard for the diagnosis of inflammatory bowel disease (IBD). However, this method has a number of limitations, especially in severe clinical conditions. In this regard, there is a growing need for less invasive imaging methods. One of these methods is transrectal ultrasound (TRUSD), which provides high-resolution imaging of the wall of the rectum and distal sigmoid colon. TRUSD allows for quantitative assessment of the intestinal wall thickness, stratification of its layers, detection of hypervascularisation characteristic of active inflammation, as well as identification of infiltrative and fibrotic changes. The data of modern clinical trials demonstrate the high sensitivity and specificity of this method, which makes it advisable to use TRUSD more widely in clinical practice. Despite its numerous advantages, TRUSD remains an underutilised method in clinical practice, although it is a promising non-invasive tool for the diagnosis and monitoring of patients with IBD. The aim of the study was to analyse the possibilities and clinical effectiveness of transrectal ultrasound in the diagnosis of ulcerative colitis (UC) and Crohn’s disease (CD). Materials and methods. TRUSD was performed on an expert-class ultrasound scanner SonoScape S60 using a 3.5 MHz low-frequency convection transducer and a 6 MHz recto-vaginal convection transducer. Transperineal and trans­rectal approaches were used. Results. Thickening of the rectal wall &gt; 5 mm was typical for 100 % of patients. The wall thickness was significantly lower in patients with CD compared to those with UC — (5.99 ± 0.42) mm vs. (7.12 ± 0.20) mm, respectively (p = 0.01). The thickness of the mucosal layer in UC was 1.8 times higher than in CD (p = 0.05), and the thickness of the submucosal layer was 1.3 times higher (p = 0.01). On the contrary, the thickness of the muscular layer in patients with CD was significantly higher than in those with UC — (1.69 ± 0.21) mm vs. (1.17 ± 0.04) mm (p = 0.05). The wall thickness ((6.80 ± 0.21) mm vs. (8.15 ± 0.42) mm, p = 0.04) and submucosal layer thickness ((4.14 ± 0.21) mm vs. (5.28 ± 0.28) mm, p = 0.008) significantly differed between moderate and severe UC. Almost 86.7 % of the examined patients with severe UC had grade 3 blood flow density in the rectal wall, whereas in moderate UC, 61.5 % of patients had grade 1. When performing elastometry of the intestinal wall, there was a tendency to increase the strain coefficient in patients with CD compared to UC. The ROC analysis allowed us to establish the high quality of the diagnostic indicator — the thickness of the muscular layer — for the differential diagnosis of UC and CD. High diagnostic value was also obtained for the thickness of the submucosal layer in assessing the severity of UC. Conclusions. TRUSD is an effective non-invasive method for evaluating inflammatory bowel diseases. Doppler scanning allows to assess the degree of vascularisation of the intestinal wall, which correlates with the clinical activity of IBD. Intestinal wall elastometry is useful in determining the severity of inflammation. The thickness of the intestinal wall and submucosa have a high prognostic value in detecting severe UC. A muscular layer thickness of 1.3 mm can be used as an auxiliary criterion for the differential diagnosis between UC and CD.

ABSTRACTHerein, we report a rare case of gastroduodenitis associated with ulcerative colitis (UC). A 42‐year‐old man was diagnosed with UC 1 year prior to admission to our hospital. The patient underwent a 3‐stage total colectomy and ileal pouch‐anal anastomosis for severe UC. Two months after the second surgery, the patient was admitted to our hospital with nausea, appetite loss, abdominal pain, and frequent bloody diarrhea. Blood analysis showed an increase in white blood cell count and C‐reactive protein levels. Esophagogastroduodenoscopy (EGD) revealed diffuse UC‐like inflammation from the stomach to the duodenum and ulcers in the descending and horizontal regions of the duodenum. Pouchoscopy revealed ulcers and friable mucosa within the pouch. The patient was diagnosed with gastroduodenitis associated with UC (GDUC) and diversion pouchitis based on endoscopic and pathological findings. Inflammation in the GDUC was resistant to oral crushed mesalazine and prednisolone (60 mg/day) infusion, resulting in arterial bleeding from the duodenal ulcer and bloody stool in the stoma. Endoscopic hemostasis was performed for the duodenal ulcer. Oral tacrolimus was initiated because the inflammation was steroid‐resistant. Approximately 2 weeks after the initiation of tacrolimus, abdominal symptoms, including bloody diarrhea, disappeared, and EGD showed improvement in the GDUC.

Ulcerative colitis (UC) is a chronic relapsing-remitting disease that results in not only physical, mental and social, but also a significant financial burden to patients and their caregivers. The present study aimed to analyse the monthly cost of care for patients with UC in remission during their regular follow-up and compare this to the expenses born during an episode of acute exacerbation in order to estimate the costs of such episodes of acute severe UC (ASUC). Patients in remission defined using the simple clinical colitis activity index (SCCAI) of <3 were recruited from the outpatient department. Patients with flares were those requiring admission for ASUC. Demographic and clinical data were recorded for each patient. A prevalence-based, micro-costing, human capital approach was used to estimate the direct and indirect monthly per capita mean cost-of-illness. The present study enrolled 25 patients with UC who were in remission (SCCAI of <3) and 51 patients with UC who presented with flares and required hospitalisation for ASUC between January, 2022 to June, 2024. The average monthly cost of care for patients with UC in remission in a tertiary government setup was calculated to be 4,112/- INR. The direct medical cost was 3,676/- INR and the direct non-medical cost was 435/- INR. The cost of management of an episode of ASUC was 44,634/- INR per individual per episode. The direct medical cost was 20,038/- INR, the direct non-medical cost was 4,087/- INR and the indirect cost was 20,509/- INR. The cost of the flares managed surgically was 155,967±100,554/- INR, which was significantly higher than that of flares managed medically (26,922±22,751/- INR; P<0.001). The cost of illness during episodes of acute flares contribute disproportionately to a high financial burden in care of patients with UC. Direct medical costs due to the cost of medications is a major contributor to the cost of care for patients with UC in remission whereas during a period of flares, the indirect cost due to productivity loss is responsible for the majority of the financial burden.

Objective Medical rescue therapy (MRT) is effective in intravenous corticosteroid refractory acute severe ulcerative colitis (ASUC). Our aim was to identify predictors of response to MRT and avoid colectomy in the index admission or within 12 months. Methods Two cohorts were studied retrospectively. Analysis of 49 adults receiving MRT between 2015 and 2019 at two tertiary Australian hospitals was first performed. Clinical, endoscopic and laboratory data were collected. Response was defined as avoiding colectomy during the same admission. Univariable and multivariable logistic regression were employed to identify predictors of response. The predictors were validated in 88 patients receiving MRT between 2020 and 2023. Results In the development cohort, 40/49 (81.6%) patients responded to MRT. On multivariable analysis, Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score at admission (Coef −0.105 (−0.19 to –0.007), p=0.03) and C-reactive protein (CRP) on day 3 of post commencement of MRT (CRP-R+3) (Coef −0.004 (−0.0008 to −0.0004), p=0.03) identified response to MRT. All patients (n=17) with a UCEIS score &lt;6 (UCEIS &lt;6) and 100% (n=28) patients with a CRP-R+3 &lt;22 mg/L responded to MRT. In the validation cohort, 82/88 (93.1%) patients responded to MRT; 90.5% (19/21) with UCEIS &lt;6 and 100% (70/70) patients with CRP-R+3 &lt;22 mg/L responded to MRT. At 12 months after hospitalisation for ASUC, in the development cohort, 16/17 (94%) patients with a UCEIS &lt;6 and 23/28 (82.1%) patients with CRP-R+3 &lt;22 mg/L avoided colectomy. In the validation cohort, 18/21 (85.7%) with UCEIS &lt;6 and 64/70 (91.4%) patients with CRP-R +3 &lt;22 mg/L avoided colectomy at 12 months. Conclusions UCEIS &lt;6 and CRP-R+3 &lt;22mg/L identify responders to MRT, and colectomy is extremely unlikely either on the index admission or within 12 months.

ABSTRACTBackground/AimsTacrolimus is an effective treatment option for refractory ulcerative colitis; however, some patients still require colectomy due to insufficient response. Early assessment of surgical risk is clinically important, as delayed decision‐making may worsen the patient's condition and increase the risk of postoperative complications. This study aimed to identify predictors of colectomy within 3 months of initiating tacrolimus therapy and to develop a clinically applicable prediction model.MethodsWe conducted a retrospective analysis of hospitalized patients with severe ulcerative colitis treated with tacrolimus between 2011 and 2025. Fourteen clinical background variables were evaluated using LASSO‐penalized logistic regression with cross‐validation to construct the prediction model.ResultsAmong 114 patients, 24 (21.1%) underwent colectomy, including 16 (14.0%) within 3 months of treatment initiation. The LASSO regression identified three predictive variables: serum albumin level, hemoglobin level, and age at tacrolimus initiation. The resulting model demonstrated good discriminative performance, with an area under the curve of 0.78. Using a cutoff value of logit(p), the model achieved a sensitivity of 87.5% and a specificity of 63.4%. Kaplan–Meier analysis revealed a significantly higher cumulative colectomy rate in the high‐risk group (p < 0.001), supporting the model's predictive utility.ConclusionWe developed a clinical prediction model that accurately estimates the risk of early colectomy based on baseline clinical factors at the start of tacrolimus therapy. This model may serve as a practical tool to guide decision‐making regarding surgical timing and overall treatment strategy.

Background/Objectives: Cytomegalovirus (CMV) is an opportunistic pathogen, complicating acute severe ulcerative colitis (ASUC), and its role in ASUC prognosis remains a debate. This study aims to report the rates and identify predictors for colectomy at 12 months, following an episode of ASUC with concomitant CMV colonic infection. Methods: This is a retrospective cohort study of patients with ASUC and CMV colonic infection confirmed by PCR or Immunohistochemistry. Baseline clinical, biochemical, endoscopic and disease-related characteristics were recorded. Patients were followed-up for 12 months to calculate the one-year colectomy rate. Predictors of colectomy were identified via multivariate logistic regression. Results: Forty-five cases of CMV colonic infection in 37 patients with ASUC were recorded [66.7% men, mean age: 47.0 years (SD = 18.5)]. At diagnosis, 20% were on monotherapy with advanced treatment and 37.8% on advanced treatment plus corticosteroids and/or immunomodulators. Twenty-three (51.1%) were receiving corticosteroids, while 17.8% did not receive any immunosuppressive agent. Forty (88.9%) patients were treated with ganciclovir and valganciclovir and one (2.2%) with foscarnet for at least 21 days. Eleven patients (24.4%) required colectomy, two (4.4%) during their initial hospitalization and nine (20%) during the follow-up period. The recurrence of CMV was recorded in nine (20.9%) cases, three of which required colectomy. Patients with hemoglobin < 12 g/dL (p = 0.023) and patients on vedolizumab at diagnosis (p = 0.050) had a higher probability of colectomy. Conclusions: We report a 25% one-year colectomy rate in our cohort with ASUC and superimposed CMV colonic infection. At baseline, anemia and vedolizumab treatment were associated with a higher probability of colectomy.

S313 Accelerated vs Standard Infliximab Induction in Acute Severe Ulcerative Colitis: An Updated Meta-Analysis of Colectomy Outcomes

Diverting Loop Ileostomy as an Alternative to Emergent Colectomy in Acute Severe Ulcerative Colitis Flare following Checkpoint-Inhibitor Therapy.

Background/Objectives: Ustekinumab (UST) has shown to be effective and safe in patients with moderate-to-severe UC in the UNIFI trials. However, real-life data on its effectiveness, particularly for histological remission, are still limited. To assess the real-world effectiveness and safety of UST in refractory UC patients. Methodology: This multicentric, retrospective cohort study included UC patients treated with UST from September 2020 to June 2023. The primary endpoint was steroid-free clinical remission (partial Mayo score of ≤2 with no subscore > 1) at week 16. Secondary endpoints included clinical, endoscopic, histological response and remission. Results: 120 patients with moderate–severe UC were included across 16 centers. Median disease duration was 11 years (1–74 y), and 81 (68%) patients had previously failed ≥2 biological therapies. At week 16, steroid-free clinical remission was achieved in 34% (41/120) of patients, with endoscopic and histological remission in, respectively, 19% (23/120) and 8% (3/37). By week 52, 44% (38/85) of patients were in steroid-free clinical remission, with endoscopic and histological remission, respectively, in 25% (13/52) and 11% (5/45). Active smoking was a negative predictor for steroid-free remission (OR 0.412, p = 0.011). UST drug persistence by week 52 was 70.8%. Active smoking (aOR 3.058, p = 0.02), prior vedolizumab non-response (OR 2.592, p = 0.03) and a high Nancy baseline score (OR 2.46, p = 0.04) were associated with early UST failure. No new safety signals were observed. Conclusions: In this real-life cohort, UST shows acceptable remission rates and high treatment persistence in refractory UC patients, with a favorable safety profile.

Traditional Chinese medicine combined with biologic therapy for refractory severe ulcerative colitis: A case report.