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Background Intestinal ultrasound (IUS) is an increasingly used non-invasive tool to monitor Crohn‘s disease (CD) activity. Currently, there is no widely accepted, reproducible IUS activity index to evaluate inflammatory activity. In 2020, two new scores emerged: the Simple Ultrasound Activity Score for CD (SUS-CD) and International Bowel Ultrasound Segmental Activity Score (IBUS-SAS). We aimed to compare the accuracy of SUS-CD, IBUS-SAS and contrast ultrasound (CEUS) in predicting inflammatory activity in the terminal ileum in ileocolonoscopy. Methods Retrospective study including all IBD patients submitted to conventional IUS and CEUS with contrast SonoVue® directed to the terminal ileum performed by a single operator between April 2016 and March 2020. Examinations were performed using an ultrasound Hitachi HI VISION Avius®. Qualitative and quantitative parameters from the conventional IUS analysis including wall thickness, stratification, colour Doppler and inflammatory fat were evaluated, and segmental SUS-CD and IBUS-SAS were calculated. A quantitative measurement of contrast bowel wall enhancement, peak intensity, was evaluated using CEUS. The CD activity was assessed with ileocolonoscopy by Simple Endoscopic Score for CD (SES-CD). Disease activity was graded as inactive (SES-CD Results Fifty patients were included, 54.0% female, with mean age of 33±12years. Patients had a mean SUS-CD of 3.4±1.0, IBUS-SAS of 58.9±25.9 and CEUS peak intensity of 12.6±12.2. SUS-CD and IBUS-SAS were not different between patients with active or inactive disease (p=0.15; 0.57, respectively) with a poor capability to predict endoscopic activity (AUC 0.62, 95% CI 0.45–0.78; 0.55, 95% CI 0.38–0.72, respectively). Peak intensity in CEUS was significantly different in patients with active or inactive disease (p=0.004) with a good capability to predict endoscopic activity (AUC 0.80; 95% CI 0.64–0.92). A peak intensity optimal cut-off to predict active disease was 8.2 with a sensitivity of 71.4% and a specificity of 78.9%. Conclusion SUS-CD and IBUS-SAS were not able to predict with good accuracy endoscopic activity in terminal ileum in CD. On the other hand, CEUS with peak intensity assessment showed a good diagnostic accuracy for active inflammation in CD. Therefore, CEUS is a non-invasive emerging method, that should be routinely integrated in the ultrasonographic evaluation in CD.

AIM To evaluate the role of small bowel capsule endoscopy (SBCE) on the reclassification of colonic inflammatory bowel disease type unclassified (IBDU). METHODS We performed a multicenter, retrospective study including patients with IBDU undergoing SBCE, between 2002 and 2014. SBCE studies were reviewed and the inflammatory activity was evaluated by determining the Lewis score (LS). Inflammatory activity was considered significant and consistent with Crohn's disease (CD) when the LS >= 135. The definitive diagnosis during follow-up (minimum 12 mo following SBCE) was based on the combination of clinical, analytical, imaging, endoscopic and histological elements. RESULTS Thirty-six patients were included, 21 females (58%) with mean age at diagnosis of 33 +/- 13 (15-64) years. The mean follow-up time after the SBCE was 52 +/- 41 (12-156) mo. The SBCE revealed findings consistent with significant inflammatory activity in the small bowel (LS >= 135) in 9 patients (25%); in all of them the diagnosis of CD was confirmed during follow-up. In 27 patients (75%), the SBCE revealed no significant inflammatory activity (LS < 135); among these patients, the diagnosis of Ulcerative Colitis (UC) was established in 16 cases (59.3%), CD in 1 case (3.7%) and 10 patients (37%) maintained a diagnosis of IBDU during follow-up. A LS >= 135 at SBCE had a sensitivity = 90%, specificity = 100%, positive predictive value = 100% and negative predictive value = 94% for the diagnosis of CD. CONCLUSION SBCE proved to be fundamental in the reclassification of patients with IBDU. Absence of significant inflammatory activity in the small intestine allowed exclusion of CD in 94% of cases., info:eu-repo/semantics/publishedVersion

Background: Pan-intestinal capsule endoscopy (Pan-CE) has been used to assess both the small and large bowel inflammation in Crohn's disease (CD) patients in a single examination. The capsule endoscopy Crohn's disease activity index (CECDAI) was initially developed to measure mucosal disease activity in the small bowel, although in 2018, it was extended to the colon for standardization of inflammatory activity (CECDAIic). The aim of this study was to apply the CECDAIic in a cohort of CD patients that underwent Pan-CE to evaluate the inter-observer agreement and the correlation between this score and inflammatory parameters.Methods: The videos were read and scored using the CECDAIic by three independent experienced operators, blinded to the results of the standard workup. Statistical analysis was performed with SPSS®, using Kendall's coefficient to evaluate the inter-observer agreement. Spearman correlation (rs) was used to access the correlation between the score and inflammatory biomarkers.Results: Included 22 patients, 59.1% males with mean age of 30.7 ± 11.1 years. The median CECDAIic score was 9.17 (0-37). The overall CECDAIic score Kendall coefficient was 0.94, demonstrating a statistically significant (p

Recent studies suggest an increased prevalence of hepatic steatosis (HS) in patients with inflammatory bowel disease (IBD). Features such as chronic inflammation, previous surgeries, drug-induced hepatotoxicity, malnutrition, and intestinal dysbiosis seem to be involved in its pathogenesis. Background Recent studies suggest an increased prevalence of hepatic steatosis (HS) in patients with inflammatory bowel disease (IBD). Features such as chronic inflammation, previous surgeries, drug-induced hepatotoxicity, malnutrition, and intestinal dysbiosis seem to be involved in its pathogenesis. Aims The aim of this study was to assess the frequency of HS in patients with IBD quantified by controlled attenuation parameter (CAP) and by clinical–analytical scores: Hepatic Steatosis Index (HSI) and Fatty Liver Index (FLI). The secondary aim was to investigate risk factors associated with HS in patients with IBD. Patients and methods A cross-sectional study was carried out including consecutive outpatients observed in our department between January and March 2017. HS was defined as HSI of at least 36 or FLI of at least 60 or CAP of greater than 248. Results A total of 161 patients were included, with a mean age of 40.6±12.8 years. There were 86 (53.4%) female patients. Overall, 62.7% had Crohn’s disease and 37.1% had ulcerative colitis. Moreover, 73 (45.3%) patients had CAP greater than 248, 27 (16.8%) had FLI greater than 60, and 46 (28.6%) had HSI greater than 36. We found that patients with CAP of greater than 248 were more frequently obese (28.8 vs. 0.0% P

Introduction: Small bowel capsule endoscopy (SBCE) is the gold standard for mid-gastrointestinal bleeding (MGIB). No score has been developed to predict the risk of small bowel rebleeding after SBCE. Objective: Creating a predictive small bowel rebleeding risk score for MGIB, after initial SBCE. Methods: Retrospective, single center study, including SBCEs for MGIB, from June 2006 to October 2016. The minimum follow-up was 12 months. Univariate analysis and a multivariable Cox regression model tested the association with rebleeding. Statistically significant variables were used to compute the score. The score’s accuracy was tested through a receiver operating characteristic (ROC) curve. A classification tree identified risk groups. For internal validation, we performed a 5-fold cross validation. Results: We assessed 357 SBCEs for MGIB, of which 88 (24.6%) presented rebleeding during follow-up. Seven variables were used to compute a risk-predicting score – the RHEMITT score – namely, renal disease; heart failure; endoscopic capsule P1/P2 lesions; major bleeding; incomplete capsule; tobacco consumption; and endoscopic treatment. The score presented good accuracy toward the outcome (area under the curve ROC 0.842, 95% CI 0.757–0.927). We established 3 rebleeding risk groups: low (0–3 points); intermediate (4–10 points); and high (+11 points). Conclusion: A new MGIB score, named RHEMITT, accurately anticipates the individual risk of small bowel rebleeding after initial SBCE.

Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. Predicting relapses in Crohn's disease (CD) patients can allow earlier changes in therapy. The aim of this study was to evaluate the role of FC in predicting relapse in CD patients in clinical remission within six months follow-up. Background and aim: Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. Predicting relapses in Crohn’s disease (CD) patients can allow earlier changes in therapy. The aim of this study was to evaluate the role of FC in predicting relapse in CD patients in clinical remission within six months follow-up. Methods: Patients with CD who were in clinical remission at least ≥3 months were included in this study. The first FC sample during the remission period was evaluated and was used as the baseline value. Relapse was defined as an unexpected escalation in therapy, hospitalization or need for surgery for active CD. The accuracy and optimal cutoff FC values for predicting clinical relapse at six months were assessed by the area under the ROC curve (AUC). Results: One hundred and forty-four patients were evaluated, with mean age of 38.4 years. Of these, 13 (9%) had a relapse during the follow-up period. The mean FC value was significantly lower for non-relapsers (203.2 μg/g) than for relapsers (871.3 μg/g), p

Background An appropriate disease classification is essential for the management of Crohn’s disease (CD) patients. Recently, a new classification of colon-involving versus non-colon-involving disease extension was considered to be more predictive of adverse outcomes than the Montreal classification (MRC). We aimed to investigate the association of a colon-based classification with clinically relevant outcomes in patients with CD compared with the MRC. Methods Retrospective cohort-study which consecutively included adult CD patients with at least 1 year of follow-up. Patients were categorized into colon-involving and non-colon-involving disease and according to the MRC. Patients’ demographic, clinical, biochemical, and imaging data were recorded and compared between the two classifications. The primary outcome was the need for treatment with steroids or biologics, hospitalization and major abdominal surgery. Results Of 327 patients, 52.3% were female with a mean age of 43.3±13.1 years. The most common disease location according to MRC was L1 (48.9%), followed by L3 (41.3%) and L2 (9.8%). Overall, 51.1% of patients had colon-involving disease. Although patients with colon-involvement at diagnosis had higher frequency of perianal lesions (27.5% vs 16.9%, P Conclusion Although simpler, defining Crohn’s disease extension by colon-involving versus non-colon-involving is not more predictive of adverse outcomes than the Montreal classification. Therefore, the use of Montreal Classification should still be considered essential in the adequate management of IBD patients.

Background The platelet-to-lymphocyte ratio (PLR) index has been a recent focus of investigation as a reliable marker of inflammation. This score was recently shown to have a good accuracy upon predicting endoscopic remission in patients with colonic Crohn’s Disease (CD). We aimed to assess the discriminative power of PLR index in patients with isolated small bowel CD. Methods Single center study of consecutive patients with isolated small bowel CD (L1 ± L4 disease according to Montreal classification) who underwent small bowel capsule endoscopy (SBCE) for assessment of endoscopic activity between January 2019 and December 2020. Only complete SBCEs were considered. CD endoscopic activity was classified according to the Lewis score (LS) value. Complete blood count, C-reactive protein and fecal calprotectin values were collected within 1 month of SBCE. Results Final sample included 49 patients, 35 (71.4%) of them females, with a mean age of 35.1±11.8 years. SBCE reported mucosal healing (LS PLR index positive correlation with LS was significant and moderate (k=0.597; p In particular, PLR index presented an excellent accuracy for predicting patients with a moderate-to-severe endoscopic activity (AUC=0.908; 95%CI=0.816–0.999; p Conclusion PLR index demonstrated an excellent acuity for predicting patients with moderate to severe disease in small bowel CD. Moreover, it also demonstrated good acuity for predicting mucosal healing on this set of patients. These results come from a significant correlation of PLR index with endoscopic activity in small bowel CD. Our findings establish this index as a promising and easy-to-apply tool for non-invasive and regular follow-up of patients with small bowel CD.

Background Azathioprine (AZA)-induced pancreatitis (AIP) is a common, idiosyncratic side effect, whose incidence, clinical course and risk factors data in inflammatory bowel disease (IBD) patients are scarce. We aimed to establish the incidence, describe the clinical course and identify risk factors for AIP. Methods Retrospective study including all IBD patients on AZA between January 2013 and July 2020. Patients with AIP were considered. Demographic, clinical, biochemical and imaging data were collected. Results AIP occurred in 33 patients (7.5%; 442 patients on AZA): 81.8% had Crohn’s disease, 54.5% were male, and the mean age was 35±13 years. The mean time under AZA till AIP was 25±11 days, with a mean dosage of 88±44mg. Eighteen patients (54.4%) were hospitalized, with a mean hospital stay of 4±2days. All patients had a mild course of disease which resolved with suspension of AZA, and with no complications or need of invasive interventions or complications. Smoking (p=0.02), single daily dose of AZA (p Conclusion Although AIP was a relatively common side effect, it presented a mild course in all patients. Smoking, concomitant treatment with budesonide and single daily dose of AZA were risk factors for AIP. This study suggests that smoking, concomitant use of budesonide and single dose regimen of AZA should be avoided in IBD patients treated with AZA.

Background Bowel wall thickness (BWT) is an accurate sonographic parameter to assess disease activity in Crohn’s disease (CD). International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) was developed to allow a reproducible assessment of intestinal inflammation in CD using bowel ultrasound (IUS). Aim to assess BWT and IBUS-SAS variation after induction therapy with infliximab (IFX) and their correlation with clinical and laboratory parameters. Methods Prospective multicentre study including patients with active CD starting IFX. Harvey-Bradshaw index (HBI), C-reactive protein (CRP), faecal calprotectin (FC) and IUS were performed at week 0 (W0) and 14 (W14). IUS response and remission were defined as a reduction in BWT ≥25% and its normalization(≤3mm) in the most affected segment, respectively. IBUS-SAS was calculated using BWT, Doppler signal, bowel wall stratification (BWS) and inflammatory fat. Results We included 37 patients (62% males; median age 30 years, range 16–73). According to Montreal classification, most patients were A2 (70%), had ileocolonic disease (L3 57%) and an inflammatory phenotype (B1 60%); 41% had perianal disease. Most were anti-TNF therapy naive(84%), and combination therapy was used in 62%. Terminal ileum was the most affected segment identified by IUS (60%). Table 1 shows clinical, laboratory and sonographic parameters [median (IQR)]. At W14, 81% were in clinical remission, 43% in laboratorial remission (normal CRP and FC), 24% had IUS response and 11% had IUS remission. There was a significant reduction in HBI, CRP, FC and sonographic parameters (except for BWS) between W0 and W14. We found a fair to good correlation between BWT and HBI(r=0.363, p=0.03), CRP(r=0.391, p=0.02) and FC(r=0.373, p=0.03) at W14. IBUS-SAS had also a fair to good correlation with CRP(r=0.340, p=0.04) and FC(r=0.527, p=0.001) at W14. The area under the curve of IBUS-SAS for predicting clinical and laboratorial remission was 0.60; best-cut off 64.65 (sens. 57%; specif. 63%). Conclusion There was a significant reduction in sonographic parameters after 14 weeks of IFX and one quarter of our patients had an IUS response, suggesting that reduction in BWT could be an early marker of response to therapy. We found a good correlation between IUS and clinical and laboratory parameters at W14. IUS evaluation after induction therapy can be a helpful tool to monitor disease activity and guide CD patient management in our daily practice.

Background Inflammatory arthritis is frequent as an extraintestinal manifestation of IBD, as well as a paradoxical reaction to biological treatment. Anti-nuclear antibody (ANA) and Anti-dsDNA antibody have been associated with inflammatory arthritis. We aim to assess the correlation between the presence of ANA and Anti-dsDNA antibody and the diagnosis of inflammatory arthritis in patients with IBD under biological treatment. Methods We present a cohort study, including IBD patients under biological treatment, presenting at least a treatment session in the first 2 months of 2020. Data was gathered from medical records, laboratorial analysis, namely ANA and Anti-dsDNA, were collected in the treatment session, and every patient posteriorly answered telephonically validated questionnaires to assess the presence of inflammatory arthritis, the outcome variable. A univariate analysis followed by a multivariate logistic regression, including statistically significant variables, tested the correlation towards inflammatory arthritis. A ROC curve tested the performance of the final model. Results We included 122 patients, 64 (52.5%) were women, and the mean age was 39 years old. Eighty-six (70.5%) patients presented Crohn’s Disease and 36 (29.5%) Ulcerative Colitis. A hundred (82%) patients were under Infliximab, 21 under Vedolizumab (17.2%) and only 1(0.8%) under Adalimumab. Thirty-three patients (27%) met questionnaire criteria for inflammatory arthritis, either peripheric or axial. The variables age, ANA and ANA’s title, age at IBD diagnosis and number of symptomatic articulations involved were associated with the presence of inflammatory arthritis. The multivariate model including ANA (OR 4.149 [1.03–16.711] p=0.045); number of articulations involved (OR 2.683 [1.783–4.038] p Conclusion The presence of ANA antibodies and a higher number of symptomatic articulations involved independently increased the rate of inflammatory arthritis diagnosis in up to 4 times, in a cohort of patients with IBD under biological treatment. The inclusion in a multivariate model displayed an excellent accuracy and performance towards the diagnosis of inflammatory arthritis. ANA antibodies together with validated questionaries may aid in the identification of IBD patients suffering from inflammatory arthritis.

A 42-year-old woman with left-side ulcerative colitis (E2 – rectum to splenic flexure) was diagnosed with pyoderma gangrenosum (PG) on a persistent ulcerated wound with peripheral erythema, in the left leg’s gemelar surface, associated with tenderness and pain. Due to incomplete response to wound care and oral prednisolone, treatment with infliximab was initiated. As PG remained unresponsive after 12 weeks, the patient was switched to adalimumab with concomitant oral prednisolone. Before the second induction dosage of adalimumab, the refractory PG complicated with a superinfection by Pseudomonas aeruginosa. A course of wide spectrum antibiotic therapy, daily wound care including negative pressure bandages and a physiotherapy rehabilitation programme controlled the infection, but the pyoderma persisted non-healed, with visible deep muscle layers and tendons. We proposed hyperbaric oxygen therapy in addition to weekly adalimumab, achieving full remission of the PG and recovering of the left foot’s function.

Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of the gastric antrum and an infrequent cause of chronic gastrointestinal blood loss and iron deficiency anemia. The authors describe a case report of GAVE in a female cirrhotic patient presenting with severe symptomatic iron deficiency anemia. After failure of argon plasma coagulation (APC), the patient was treated with endoscopic band ligation (EBL) with resolution of anemia, without new episodes of rebleeding and no need for further hospitalizations or transfusion requirements. Even though APC is the current treatment of choice for GAVE recurrence-free survival at one year is achieved in less than 50% of the patients and failed therapy has been described in up to 14% of the patients. EBL has been reported to be a relatively easy technique for GAVE therapy and has been shown to be safe and effective with lower complication rates in comparison with APC. This technique may in the future be used as the initial endoscopic treatment to eradicate GAVE., (undefined)

Background and Aims: Histological healing has emerged as a promising therapeutic goal in ulcerative colitis. This is especially important in the context of biological therapies. The objectives of the present study were to investigate the ability of infliximab to induce histological remission in ulcerative colitis [UC] patients and to explore the utility of faecal calprotectin and lactoferrin in predicting histological activity. Methods: Multi-centre, single-cohort, open-label, 52-week trial including moderately to severely biological-naive UC patients receiving intravenous infliximab [5mg/kg]. The primary outcome was the proportion of patients with histological remission [Geboes index ≤ 3.0] after 8 weeks of treatment, scored by two independent pathologists. Results: Twenty patients were included. The rate of histological remission increased from 5% at baseline to 15% and 35% at Week 8 and Week 52, respectively. At Week 8, 40% of patients were in clinical remission [Mayo ≤ 2] and 45% achieved mucosal healing [Mayo endoscopy subscore 0–1]. At Week 52, 25% of patients had clinical, endoscopic and histological remission. Faecal calprotectin and lactoferrin showed the highest correlation with histological activity at Week 8 (area under the curve [AUC] 94%, p = 0.017; and 96%, p = 0.013, respectively) and both markers revealed an excellent positive predictive value for this outcome at this time point [100%, p = 0.017; and 94%, p = 0.013, respectively]. Conclusions: Infliximab was able to induce histological remission. There was a good agreement between histology and faecal biomarkers. Faecal calprotectin and lactoferrin were good predictors of histological remission. Our data support inclusion of histology as a treatment target complementary to endoscopy in clinical trials when evaluating therapeutic response in UC.

Background Terminal ileitis (TI), is a common condition in clinical practice and may be associated with a wide variety of diseases. Small bowel capsule endoscopy (SBCE) is a valuable diagnostic tool for small bowel diseases; however, data regarding its diagnostic impact on isolated TI are sparse. The aim of the study was to evaluate the diagnostic value of SBCE for isolated TI detected during ileocolonoscopy. Methods Retrospective study including consecutive patients undergoing SBCE after diagnosis of TI without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019. Demographic, clinical, biochemical, endoscopic and imaging data were collected. Results One hundred and two patients with isolated ileitis on ileocolonoscopy were included. Positive findings on SBCE were found in 84 (82.4%) patients, being ulcers the most common finding (76.5%). Endoscopic abnormalities proximal to terminal ileum were found in 36.3% of patients. After SBCE, 63.7% of patients had a final diagnosis, Crohn’s disease (CD) was the most common (34.3%), followed by NSAIDs enteropathy (12.7%). Elevated faecal calprotectin (p = 0.001) was independently associated with positive SBCE findings. There was a tendency for high levels of erythrocyte sedimentation rate be associated with positive findings (p = 0.07). However, the presence of symptoms, imaging abnormalities and other laboratory findings such as leukocytosis, anaemia, and elevated C-reactive protein were not predictors of positive SBCE findings. At multivariate analysis, only elevated faecal calprotectin (OR 6.0, IC 95% 1.9–18.7; p = 0.002) was a significant predictive factor for positive SBCE findings. Conclusion SBCE revealed a high diagnostic yield in patients with isolated ileitis on ileocolonoscopy enabling a definite diagnosis in almost two-thirds of patients. Approximately one-third of patients had findings proximal to terminal ileum and a similar percentage was diagnosed with CD. In patients with isolated ileitis on ileocolonoscopy, SBCE should be considered to evaluate small bowel lesions, particularly when there is an elevated faecal calprotectin, even when other clinical, imagiological or laboratorial abnormalities are absent.

Background Biologic therapy has demonstrated efficacy for induction and maintenance of remission in ulcerative colitis (UC). However, it remains unclear whether oral aminosalicylates (5-ASA) should be continued or stopped after treatment escalation to biologics. The aim of the study was to evaluate differences in inflammatory biomarkers or the occurrence of complications in UC patients being treated with a combination of 5-ASA and biologics vs. biologics alone. Methods Retrospective study, including patients with UC and on biologic therapy with a minimum follow-up of 6 months. Collected inflammatory biomarkers were faecal calprotectin, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The occurrence of complications was defined as the need of hospitalisation, need of corticosteroids or other top-up therapy, surgery and the occurrence of dysplasia or colorectal cancer. Results We included 65 patients with UC, 56.9% female with a mean age of 32.8 (±12.8) years. The median follow-up was 30 (6–132) months. Regarding extension, 61.5% were E3, 35.4% E2 and 3.1% E1. While 44 patients (67.7%) were on 5-ASA and biologics (infliximab = 32, adalimumab = 6, vedolizumab = 6), 21 (32.3%) were on biologics alone (infliximab = 13, adalimumab = 3, vedolizumab = 5). The median duration of biologic therapy was 30 (6–126) months. Regarding baseline characteristics, including age, gender, duration of the disease or biologic therapy and age at UC diagnosis, there were no differences between groups. No differences regarding inflammatory biomarkers were observed – fecal calprotectin (p = 0.39), CRP (p = 0.9) and ESR (p = 0.61). No differences were found regarding complications, namely the need of hospitalisation (p = 0.06) or need of corticosteroids (p = 0.89). Only one patient developed dysplasia (under infliximab and 5-ASA). Any of the included patients needed surgery or developed colorectal cancer. Conclusion About two-thirds of the UC patients under biologics are co-treated with 5-ASA. No differences between UC patients under combination biologics+5-ASA vs. biologics alone were found regarding inflammatory biomarkers or the occurrence of complications. These results raise the question if continuing 5-ASA in UC patients under biologics is really necessary.

Background Terminal ileitis (TI) is a common condition in clinical practice and may be associated with a wide variety of diseases, mostly Crohn’s disease (CD). Data regarding predictors of CD diagnosis in isolated TI are lacking, particularly concerning small bowel capsule endoscopy (SBCE) findings. Aim To evaluate predictive factors for CD diagnosis in patients with isolated TI detected during ileocolonoscopy, submitted to SBCE. Methods Retrospective study including consecutive patients undergoing SBCE after diagnosis of TI without colonic mucosal abnormalities on ileocolonoscopy between January 2016 and September 2019. Demographic, clinical, biochemical, endoscopic and imaging data were collected. The diagnosis of CD was based on clinical evaluation, endoscopic, histological, radiological, and/or biochemical investigations. Results One hundred and two patients with isolated ileitis on ileocolonoscopy were included. After performing SBCE, 34.3% of the patients had a diagnosis of CD. All CD diagnosed patients had positive SBCE findings. Extraintestinal manifestations (p = 0.003), weight loss (p = 0.01), abnormal imaging (p = 0.04) and positive SBCE findings (p = 0.005) were independently associated with CD diagnosis. Regarding SBCE, presence of proximal small-bowel disease (p = 0.02), diffuse findings (p = 0.002) and presence of moderate to severe inflammatory activity (Lewis Score≥790) (p < 0.001) were independently associated with CD diagnosis. Conclusion SBCE is a valuable tool that should be systematically used in patients presenting with isolated TI, since it enabled CD diagnosis in approximately one-third of patients. A diagnosis of CD should be considered when a patient with TI shows extraintestinal manifestations, weight loss, abnormal imaging and positive SBCE findings, especially proximal involvement, diffuse findings and the presence of moderate to severe inflammatory activity.

Background The use of combination therapy of anti-TNF and thiopurines in inflammatory bowel disease (IBD) is associated with greater efficacy and lower immunogenicity. However, the dose of thiopurine in this setting remains to be elucidated. The aim of the study was to compare the trough levels, anti-TNF antibodies and the inflammatory biomarkers between two groups in combotherapy: one with low dose (LDA) and one with standard dose (SDA) of azathioprine. Methods A retrospective study was performed, selecting all patients with an established diagnosis of IBD, who were on combined maintenance treatment (at least 6 months of therapy) with azathioprine and anti-TNF. We divided the population into two groups according to the azathioprine dose: LDA Results We included 99 patients, 52.5% female with a median age of 33 (17–61) years. Eighty patients (80.8%) were diagnosed with Crohn’s Disease and 19 (19.2%) with ulcerative colitis. Seventy-one (71.8%) patients were on infliximab (IFX) and 28 (28.3%) were on adalimumab (ADA). In the IFX group, there were no differences between trough levels (6.86 vs. 6.70 mg/ml, p = 0.892) or formation of antibodies anti-IFX (6.3% vs. 5.1%; p = 0.838) in SDA vs. LDA. Moreover, there were no differences between inflammatory biomarkers: CRP (p = 0.315) and faecal calprotectin (p = 0.48) among the two groups. Regarding ADA group, there were no differences in trough levels of ADA (10.15 vs. 10.65 mg/ml, p = 0.836), the formation of antibodies anti-ADA (7.7% vs. 6.7%; p = 0.916) and in inflammatory biomarkers: CRP (p = 0.525) and faecal calprotectin (p = 0.496) among the two groups. Conclusion In our cohort, there were no differences between anti-TNF trough levels, formation of antibodies anti-TNF and in inflammatory biomarkers among patients in combotherapy with azathioprine in a standard dose vs. lower dose. In terms of immunogenicity, lower doses of azathioprine seem sufficient to inhibit the formation of antibodies, with better tolerance and better safety profile.

Background Tumour necrosis factor (TNF) inhibitors are potent drugs effective for the treatment of both luminal disease and perianal fistulas in Crohn’s disease (CD). Recently, there is some evidence that patients with perianal disease might need higher concentrations of anti-TNF levels compared with patients without perianal disease. The aim of this study was to compare anti-TNF serum concentrations: IFX (infliximab) or ADA (adalimumab) between patients with active and closed perianal fistulas with CD. Methods Retrospective study including that was on anti-TNF for at least 6 months. Fistula closure was defined as absence of active drainage at gentle finger compression and/or fistula healing on magnetic resonance imaging/ultrasound. Results We included 55 patients with CD and perianal disease, 54.5% males, median age of 31 (interquartile range: 18–71) years. Forty-two were on IFX and 13 on ADA. Median IFX serum concentrations [IQR] were higher in patients with closed fistulas (n = 19) compared with patients with actively draining fistulas (n = 23): 7.7 mg/ml [0–32.6] vs. 1.5 mg/ml [0–9.5], respectively (p < 0.001). A similar difference was seen in patients treated with ADA: median serum concentrations were 9.6 mg/ml [6–21.9] in 10 patients with closed fistulas vs. 4 mg/ml [4–4.3] in 3 patients with producing fistulas, p = 0.007. Serum concentrations superior or equal to 4.68 mg/ml for IFX (AUC of 0.87; 95% CI: 0.73–0.96) were associated with fistula closure. Conclusion Higher serum levels of anti-TNF drugs were associated with perianal fistula closure. Patients with CD and perianal disease may benefit from intensification of biological therapy.

Common variable immunodeficiency (CVID) is the most frequent form of immunodeficiency in adults. Clinical manifestations are heterogeneous with an increased susceptibility to infections and inflammatory conditions, namely autoimmune diseases, such as inflammatory bowel disease. We present the clinical case of a Caucasian female patient, 21 years old, with a past medical history of CVID, with multiple visits to the emergency department due to abdominal pain in the lower quadrants and diarrhea. Her biochemical analysis showed elevated inflammatory parameters. Stool cultures and parasitological examination of feces were negative. Ileocolonoscopy revealed lymphoid nodular hyperplasia of the terminal ileum, and the small bowel capsule endoscopy demonstrated edema and multiple pleomorphic ulcers (Lewis score = 1,104). CVID-associated inflammatory enteropathy was suspected. Budesonide 9 mg/day was started, but no positive clinical response was observed. It was decided to initiate biological therapy with infliximab. The patient's condition is currently clinically improved with no complications due to biological therapy., (undefined)

Small bowel capsule endoscopy (SBCE) is a firstline examination in patients with suspected Crohn's disease (CD) after negative ileocolonoscopy. Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. The aim of this study was to evaluate the predictive value of FC in inflammatory activity detected by SBCE in patients with suspected CD., info:eu-repo/semantics/publishedVersion

Background: Crohn’s disease (CD) is a chronic and progressive disease that changes its behaviour over time. Transmural inflammation in CD leads to stricturing and/or penetrating complications. Aim: To evaluate the frequency of long-term progression of CD phenotypes, the need of abdominal surgery, and the main factors associated with these outcomes. Methods: A retrospective study was conducted with a prospective follow-up. Montreal classification was assessed at the moment of the diagnosis and at the end of the follow-up period. Results: Two hundred and ninety patients were included, with mean follow-up duration of nine years. A change in behaviour was observed in 46 patients (15.9%). Ileocolic location (60.9% vs. 45.1%; p = .049), age at diagnosis, (undefined), info:eu-repo/semantics/publishedVersion

Perianal Crohn's disease (CD) prevalence varies according to the disease location, being particularly frequent in patients with colonic involvement. We aimed to evaluate small bowel involvement and compare small bowel capsule endoscopy findings and inflammatory activity between patients with and without perianal disease., Objectives: Perianal Crohn’s disease (CD) prevalence varies according to the disease location, being particularly frequent in patients with colonic involvement. We aimed to evaluate small bowel involvement and compare small bowel capsule endoscopy findings and inflammatory activity between patients with and without perianal disease. Materials and methods: Retrospective single-center study including 71 patients – all patients with perianal CD (17 patients) who performed a small bowel capsule endoscopy were included, and non-perianal CD patients were randomly selected (54 patients). Clinical and analytical variables at diagnosis were reviewed. Statistical analysis was performed with SPSS v21.0 and a two-tailed p value, info:eu-repo/semantics/publishedVersion

Aim: To compare the findings and completion rate of PillCam(r) SB2 and SB3. Methods: This was a retrospective single-center study that included 357 consecutive small bowel capsule endoscopies (SBCE), 173 SB2 and 184 SB3. The data collected included age, gender, capsule type (PillCam(r) SB2 or SB3), quality of bowel preparation, completion of the examination, gastric and small bowel transit time, small bowel findings, findings in segments other than the small bowel and the detection of specific anatomical markers, such as the Z line and papilla. Results: The mean age of the patients was 48 years and 66.9% were female. The two main indications were suspicion/staging of inflammatory bowel disease (IBD) and obscure gastrointestinal bleeding (OGIB) (43.7% and 40.3%, respectively). Endoscopic findings were reported in 76.2% of examinations and 53.5% were relevant findings. No significant differences were found between SB2 and SB3 with regard to completion rate (93.6% vs 96.2%, p = 0.27), overall endoscopic findings (73.4% vs 78.8%, p = 0.23), relevant findings (54.3% vs 52.7%, p = 0.76), first tertile findings (43.9% vs 48.9%, p = 0.35), extra-SB findings (23.7% vs 17.3%, p = 0.14), Z line and papilla detection rate (35.9% vs 35.7%, p = 0.97 and 27.1% vs 32.6%, p = 0.32, respectively). With regard to the patient subgroups with suspicion/staging of IBD, significant differences were found in relation to the detection of villous edema and the 3rd tertile findings, thus favoring SB3 (26.3% vs 43.8%, p = 0.02 and 47.4% vs 66.3%, p = 0.02, respectively). Mucosal atrophy was significantly more frequently diagnosed with the PillCam(r) SB3 in patients with anemia/OGIB (0% vs 8%, p = 0.03). Conclusions: Overall, PillCam(r) SB3 did not improve the diagnostic yield compared to SB2, although it improved the detection of villous atrophy and segmental edema., info:eu-repo/semantics/publishedVersion

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Background and study aims: Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding.Patients and methods: Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score4) or low/intermediate-risk (ORBIT score

Iron deficiency anemia remains one of the main indications to perform small bowel capsule endoscopy. Literature suggests that diagnostic yield is influenced by patient's age but with conflicting results regarding age cutoff., CONTEXTO: A anemia ferropénica constitui uma das principais indicações para realização de enteroscopia por cápsula. A literatura sugere que o rendimento diagnóstico é influenciado pela idade do doente, contudo, não é consensual o grupo etário para o qual o rendimento diagnóstico é maior. OBJETIVO: Clarificar as diferenças de rendimento diagnóstico e incidência de achados específicos de acordo com a idade. MÉTODOS: Estudo retrospetivo unicêntrico. Incluídos 118 doentes que realizaram sistematicamente enteroscopia por cápsula no estudo de anemia ferropénica. Todos os vídeos foram revistos e foram reportados os achados no intestino delgado que pudessem ser a causa da anemia ferropénica. Excluídas enteroscopia por cápsula incompletas. Comparados os achados entre doentes com ≤60 e >60 anos. RESULTADOS: Doentes com idade média de 58 anos (SD ±17,9), 69,5% do género feminino (n=82). O rendimento diagnóstico global foi de 49% (58/118), sendo superior em doentes >60 anos (36/60, rendimento diagnóstico 60%) do que em doentes ≤60 anos (20/58, 34%). As angiectasias foram mais frequentemente reportadas em doentes >60 anos (45% vs 9%, P135 em 10,3% vs 1,7%, P, (undefined), info:eu-repo/semantics/publishedVersion

Background and aims: Small bowel capsule endoscopy (SBCE) allows mapping of small bowel inflammation in Crohn’s disease (CD). We aimed to assess the prognostic value of the severity of inflammatory lesions, quantified by the Lewis score (LS), in patients with isolated small bowel CD. Methods: A retrospective study was performed in which 53 patients with isolated small bowel CD were submitted to SBCE at the time of diagnosis. The Lewis score was calculated and patients had at least 12 months of follow-up after diagnosis. As adverse events we defined disease flare requiring systemic corticosteroid therapy, hospitalization and/or surgery during follow-up. We compared the incidence of adverse events in 2 patient subgroups, i.e. those with moderate or severe inflammatory activity (LS ≥790) and those with mild inflammatory activity (135 ≤ LS < 790). Results: The LS was ≥790 in 22 patients (41.5%), while 58.5% presented with LS between 135 and 790. Patients with a higher LS were more frequently smokers ( p = 0.01), males ( p = 0017) and under immunosuppressive therapy ( p = 0.004). In multivariate analysis, moderate to severe disease at SBCE was independently associated with corticosteroid therapy during follow-up, with a relative risk (RR) of 5 ( p = 0.011; 95% confidence interval [CI] 1.5–17.8), and for hospitalization, with an RR of 13.7 ( p = 0 .028; 95% CI 1.3–141.9). Conclusion: In patients with moderate to severe inflammatory activity there were higher prevalences of corticosteroid therapy demand and hospitalization during follow-up. Thus, stratifying the degree of small bowel inflammatory activity with SBCE and LS calculation at the time of diagnosis provided relevant prognostic value in patients with isolated small bowel CD.

Background: Inflammatory bowel disease (IBD) has a physical, psychological and social impact, often compromising the patient’s ability to perform daily activities. Recently a new measurement for disability in IBD was developed. The Inflammatory Bowel Disease-Disability Score (IBD-DS) comprises the following domains: mobility, self-care, major daily life activities, gastrointestinal-related problems, mental health and interaction with the environment. The aim of our study was to translate to Portuguese and to validate the IBD-DS. Methods: Eighty-five patients, 55 with Crohn’s disease (CD) and 30 with ulcerative colitis (UC), completed the Portuguese version of the IBD-DS and the short inflammatory bowel disease questionnaire (SIBDQ-10 questions). Disease activity was assessed using the Harvey-Bradshaw (HB) for CD and partial Mayo score (pMayo) for UC. Pearson’s correlation coefficient was used to assess the correlation between the IBD-DS and SIBDQ. The Student’s t-test was used to compare the mean of IBD-DS between active and inactive disease. Statistical analysis was performed with SPSS 21.0 and the statistical level of significance (˛) was established at 5%. Results: In our study, a significant negative correlation between the IBD-DS and the SIBDQ was observed (r =−0.858, p < 0.001 for CD and r =−0.933, p < 0.001 for UC). There was a statistically significant difference of the mean of IBD-DS between inactive vs. active disease (93.78 vs. 117.57, p = 0.016 for CD and 78.96 vs. 137.14, p < 0.001 for UC). Conclusion: The Portuguese version of the inflammatory bowel disease-disability score has a strong correlation with patients’ quality of life and clinical disease activity and was shown to be a valid tool to measure disability in patients with inflammatory bowel disease. Introdução: O impacto físico, psicológico e social da doença inflamatória intestinal (DII) compromete frequentemente a capacidade do doente realizar as suas atividades de vida diária. Foi desenvolvido recentemente um novo questionário de avaliação de incapacidade na DII. O ‘‘Inflammatory Bowel Disease - Disability Score’’ (IBD-DS) contempla a avaliação de Diferentes domínios de incapacidade na DII: mobilidade, autocuidado, principais atividades de vida diária, saúde mental, problemas gastrointestinais e impacto social. O objetivo deste estudo foi a tradução do IBD-DS para a língua portuguesa e a validação das suas propriedades de avaliação de incapacidade em doentes portugueses com DII. Material e Métodos: Um total de 85 doentes, 55 com doença de Crohn (DC) e 30 com colite ulcerosa (CU), preencheram a versão portuguesa do IBD-DS e um questionário de qualidade de vida na DII (SIBDQ-10 questões). A actividade da doença foi avaliada usando o índice de Harvey-Bradshaw (HB) para a DC, e o score parcial de Mayo (pMayo) para a CU. A correlação entre o IBD-DS e o SIBDQ foi determinada através do coeficiente de correlação de Pearson. O teste t para amostras independentes foi utilizado para comparar a média do IBD-DS entre os doentes com doença ativa e inativa. A análise estatística foi realizada com o SPSS 21.0, o nível de significância (˛) foi estabelecido em 5%. Resultados: No nosso estudo verificou-se uma forte correlação negativa entre o IBD-DS e o SIBDQ (r =−0.858, p < 0,001 para a DC e r =−0.933, p < 0,001 para a CU). Foi observada uma diferença estatisticamente significativa do valor médio do IBD-DS entre doentes com doença inativa vs. ativa (93.78 vs. 117.57, p = 0,016 para a DC e 78.96 vs. 137.14, p < 0,001 para a CU). Conclusão: A versão portuguesa do IBD-DS apresentou uma boa correlação com a qualidade de vida e atividade da DII, apresentando-se, deste modo, como uma ferramenta válida na avaliação de incapacidade na DII.

"Article in Press"; "Epub 2014 Mar 14", BACKGROUND AND AIMS: Small bowel capsule endoscopy (SBCE) may detect proximal small bowel lesions that have been previously missed by ileocolonoscopy and small bowel imaging in patients with known ileal and/or colonic Crohn's disease (CD). We aimed to evaluate whether the therapeutic management is influenced by SBCE findings. METHODS: Retrospective single center study. Inclusion of consecutive patients with known non-stricturing and non-penetrating ileal and/or colonic CD, submitted to SBCE to evaluate disease extension and activity, with ≥ 1year follow-up. Lesions were classified with the Lewis score (LS) as non-significant (LS790). Therapeutic changes were assessed three months after SBCE. RESULTS: Fifty consecutive patients (35±13years, 52% females) were included. At ileocolonoscopy, disease location was ileal (L1) in 60%, colonic (L2) in 10% and ileocolonic (L3) in 30% of the patients. In 33 patients (66%) SBCE detected significant proximal lesions previously missed by other modalities. The proportion of patients on thiopurines and/or biologics before SBCE was 2/50 (4%); this was significantly higher three months after SBCE, 15/50 (30%), p=0.023. Treatment with thiopurines and/or biologics was started more often in patients with proximal small bowel lesions [13/33 (39%) vs. 1/17 (6%), p=0.011, relative risk (RR) 6.5], particularly when severe (6%, 36% and 45% of patients with non-significant, mild and moderate-to-severe inflammation, respectively). CONCLUSIONS: SBCE diagnoses previously undetected lesions and it influences therapeutic management of CD, triggering an earlier introduction of immunomodulators and/or biological therapy.

Background/Aims: Identifying predictors of endoscopic recurrence (ER) has become very important to guide the decision of postoperative strategy. This study aimed to determine the rate of endoscopic recurrence until 12 months after ileocolic resection for Crohn disease (CD) in a cohort and identify its possible predictors. Materials and Methods: We conducted a retrospective single-center study that included patients with CD who underwent ileocolic resection between 2003 and 2014. ER was defined according to the Rutgeerts' score, defined as i2, i3, or i4 at ileocolonoscopy that was performed 6-12 months after surgery. The patients were classified into two groups according to the Rutgeerts' score: non-ER (Rutgeerts i0/i1) and ER (Rutgeerts >= i2). Multivariate logistic regression analysis was performed, including significant variables on univariable analysis, to identify ER predictors. Results: Forty-two patients were included. The mean period of the first postoperative colonoscopy was 9 months, and ER was observed in 25 patients (59.5%). The perianal disease and shorter duration of CD were the only ER predictors (p=0.024; OR, 8.36; 95% CI, 1.329-52.642 and p=0.039; OR, 0.965; 95% CI, 0.933-0.998, respectively). Conclusion: Endoscopic recurrence affects almost two-thirds of patients with CD after ileocolic resection, with perianal involvement and a shorter duration of disease being significant risk factors. These factors may indicate a more aggressive disease associated with rapid progression and support the need of intensive early treatment to improve patients' outcomes., info:eu-repo/semantics/publishedVersion

Crohn's disease (CD) is characterised by a transmural inflammatory process, which can affect any part of the digestive tract; however, CD with oesophageal presentation is rare. We report a case of a previously healthy young woman with symptoms of dysphagia, odynophagia, chest pain and weight loss, who presented oesophageal ulcers at upper endoscopy and whose histology revealed granulomatous oesophagitis. After complementary study, a mild ileocaecal involvement of CD was demonstrated. The patient became asymptomatic with proton pump inhibitor and a course of prednisolone. Mucosal healing was obtained after maintenance therapy with azathioprine. In the absence of extraoesophageal symptoms, oesophageal CD may be overlooked. CD must always be considered as differential diagnosis in the presence of oesophageal ulcers., (undefined), info:eu-repo/semantics/publishedVersion