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Background The platelet-to-lymphocyte ratio (PLR) index has recently been a focus of investigation as a reliable marker of inflammation, being shown to have a good accuracy upon predicting endoscopic remission in patients with colonic Crohn’s Disease (CD). We aimed to evaluate and validate the discriminative power of PLR index in patients with small bowel CD. Methods Single center study including patients with isolated small bowel CD (L1 ± L4 disease according to Montreal classification) undergoing small bowel capsule endoscopy (SBCE) for assessment of endoscopic activity. 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. A retrospective sample was used for initial assessment of PLR index performance, followed by a prospective 2-years application on a distinct sample. Results The initial sample included 49 and the validation sample 48 patients, both groups being age- and gender-matched. On the initial cohort, PLR index presented a positive moderate correlation with LS (k=0.597; p These results were confirmed on the prospective validation cohort, as the correlation of LS with PLR index (k=0.631; p Conclusion PLR index demonstrated an excellent acuity in predicting moderate-to-severe disease and good acuity in predicting mucosal healing in patients with small bowel CD, with both associations confirmed on a prospective validation cohort. 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 The endoscopic Mayo score (MS) is the most frequent score used for the evaluation of inflammatory activity in Ulcerative Colitis (UC), varying from 0 to 3 points. Recently the DUBLIN score (DS) emerged, which varies from 0 to 9 points and results from the product of the MS and the disease extent, according to Montreal classification, E1-E3. In this study we aimed to evaluate and compare the predictive ability of MS and DS for long term treatment failure. Methods A retrospective and unicentric study was conducted, including patients with left-sided or extensive UC, asymptomatic and without the need for steroid therapy or therapy changes in the 6 months prior to undergoing total colonoscopy with calculation of MS and DS. Treatment failure was evaluated, defined by the need for therapy changes and/or hospitalization because of disease exacerbation, over a follow-up period of a minimum of 24 months and a maximum of 84 months. Results A total of 204 patients were included, 104 (51%) females and with a mean age at diagnosis of 36.4±12.7 years. In the initial evaluation, 48 (23.5%) were being treated with anti-TNFα medication. The mean values of MS were 1.0±1.1 points and of DS were 2.2±2.6 points. During follow-up, 32 (15.7%) patients experienced treatment failure and patients initially treated with anti-TNFα medication had 2.3 times higher risk of treatment failure (p=0.042). MS values (AUC 0.809; p Conclusion MS and DS had good discriminative abilities in predicting treatment failure. However, the integration of the disease extent in the DS as a complement of MS in the evaluation of UC was not associated with a higher predictive ability of long term treatment failure.

Background Contrary to the Simple Endoscopic Score for Crohn’s Disease (SES-CD), Modified Multiplier SES-CD (MM-SES-CD) is a new endoscopic severity assessment tool that was able to predict one-year endoscopic remission in patients with Crohn’s Disease (CD) on active therapy. Unlike SES-CD, MM-SES-CD accounts for the number of segments affected and the different prognostic weight of individual SES-CD parameters according to disease location. Nevertheless, there is scarce information regarding its relationship with laboratorial parameters, namely C-reactive protein (CRP) and fecal calprotectin (FC). We aimed to analyze the association between MM-SES-CD and these laboratorial parameters. Methods Retrospective cohort-study including all ileocolonoscopies performed in adult CD patients between January 2020 and October 2022 with CRP (mg/dL) and FC (ug/g) collected within one month. Patients with previous intestinal surgery or inadequate bowel preparation were excluded. MM-SES-CD, ranging from 0 to 130.5, was calculated and different severity categories were defined as follows: remission ( Results A total of 272 ileocolonoscopies from 218 CD patients were included, most females (54.1%) with a mean age of 41 years old. Most patients were A2 (72.8%), L1 (51.1%) and B1 (73.9%), according to Montreal classification. Median MM-SES-CD, CRP and FC was 12.0, 2.9 and 222.0, respectively. Despite MM-SES-CD values correlated weakly with CRP (r=0.376, P Conclusion To the best of our knowledge, this is the first study reporting an association between CRP and FC and increasing degrees of disease activity assessed by MM-SES-CD. A CRP

Background Anti-tumour necrosis factor-α (anti-TNF-α) therapy is an effective treatment for Crohn’s disease (CD). However, treatment failure is common. Our aim was to identify predictors of anti-TNF-α therapy failure. Methods Retrospective single-center study including anti-TNF-α naïve patients with CD, who started on intravenous infliximab, between January 2019 and December 2021. Biochemical parameters included erythrocyte sedimentation rate(ESR), c-reactive protein(CRP), faecal calprotectin, infliximab serum concentrations and antibodies to infliximab(ATI). Anti-TNF-α therapy failure was defined as ATI development at 6 or 12 months, absence of clinical response at 6 months, absence of clinical remission or objective response at 12 months. Clinical response was defined as reduction in Harvey-Bradshaw index(HBI) of≥3points comparing with initial value or HBI Results Totally 53 CD patients were included, 49.1%treated with combination of anti-TNF-α and immunomodulatory therapy. Anti-TNF-α therapy failure occurred in 21 patients(39.6%). At 6 months, ATI development occurred in 6 patients(11.3%) and absence of clinical response in 9(17.0%). At 12 months, absence of clinical remission was seen in 13.6% of patients and absence of objective response in 27.0%. At 6 months, ATI development was significantly higher in patients with lower infliximab serum concentrations at week 14 (with ATI 5.9±3.2 vs without 14.3±7.7, p Conclusion Infliximab serum concentration after induction is the most important factor in ATI development, influencing treatment response, regardless of the combination with immunomodulatory therapy. Higher initial value of ESR can also predict the development of ATI.

Background Bowel wall thickness (BWT) is an accurate ultrasonographic parameter to assess disease activity in Crohn’s disease (CD). The IBUS-SAS score includes BWT, doppler sign, loss of stratification and inflammatory fat (i-fat) and allows a reproducible assessment of inflammation in CD using intestinal ultrasound (IUS). Our aim: to assess clinical, laboratorial and ultrasonographic predictors of mucosal healing (MH) at 1 year of infliximab (IFX) therapy. Methods Prospective multicentric cohort study including patients with active CD starting IFX. Harvey-Bradshaw index, C-reactive protein (CRP), fecal calprotectin (FC) and IUS were performed at week 0, 14, 30 and 54. IUS remission was defined as BWT normalization (≤3mm) in the most affected segment. Ileocolonoscopy was performed at W0 and W54. MH was defined as SES-CD Results We included 28 patients with CD (61% male; mean age of 34±12y). Clinical, laboratory and sonographic parameters are shown in Table 1. At week 54, 89% were in clinical remission, 79% had normalization of CRP and FC, 50% had IUS remission and 39% had MH. MH at W54 was associated with lower BWT at W14 (3.7 vs 5.2mm, p=0.049), lower Limberg score at W14 (1 vs 2, p=0.006), lower levels of i-fat at W14 (18 vs 72%, p=0.006) and lower IBUS-SAS score at W0, W14 and W30 (47 vs 71, p=0.002; 26 vs 58, p=0.001; 25 vs 50 p=0.046). We found a fair to good correlation between SES-CD W54 and BWT at W14 (r=0.45, p=0.015), Limberg score at W14 (r=0.4, p=0.037), IBUS-SAS at W0 and W14 (r=0.49, p=0.008; r=0.58, p=0.001). The area under the curve of IBUS-SAS for MH was 0.86 at W0 and W14 and 0.69 at W30. Best IBUS-SAS cut-off value was 27.6 at W14. Conclusion Lower values of BWT, Limberg score and i-fat after induction (W14) were associated with MH at 1 year of therapy. IBUS-SAS score at W14 had the highest AUC to predict MH at 1 year. Early IUS monitoring can be a helpful tool to predict response to therapy in CD patients at 1 year.

Background Capsule endoscopy is a valuable tool in the diagnosis and monitoring of Crohn’s disease (CD). Recently, a new panenteric capsule (pan-CE), PillCam Crohn’s (Medtronic, USA) was approved. A novel quantitative score of inflammation for PillCam Crohn’s, the Eliakim score, has emerged. However, the optimal index for panenteric monitoring disease activity is far from being completely defined. We aimed to evaluate the correlation and accuracy between the pan-CE Eliakim and capsule endoscopy Crohn’s disease activity index (CECDAIic) scores and inflammatory parameters. Methods Retrospective study, including a cohort of consecutive patients with suspected or established CD that underwent Pan-CE PillCam Crohn’s over 4 years. The Eliakim and CECDAIic scores were calculated. Spearman correlation (rs) was used to access the correlation between the scores and inflammatory biomarkers. Results Thirty-two patients were included, 71.9% females, with mean age of 35±13 years, 59.4% with suspected CD. The median Eliakim and CECDAIic scores were 5.5 (0–13) and 6.5 (0–15.5), respectively. The diagnosis of CD was established in 31.6% of patients with suspected CD. We found a very good correlation between Eliakim and CECDAIic scores (rs=0.87; p Conclusion The Eliakim and CECDAIic scores have a strong correlation in assessing panenteric CD activity, and a moderate correlation with inflammatory biomarkers. The application of Eliakim ≥3.5 and CECDAIic score ≥5.5 as the cutoff values for the presence of significant inflammatory activity in patients undergoing pan-CE for suspected CD may be useful to establish the diagnosis.

Background Colonoscopy is of utmost importance in the management of inflammatory bowel disease (IBD) and is a critical tool for diagnostic and therapeutic decision-making. The quality of bowel preparation is important for the efficacy of colonoscopy and inadequate bowel preparation (IBP) is associated with increased costs and inconvenience. Most studies on IBP have not specifically evaluated the impact of concomitant conditions, such as IBD, on the quality of bowel preparation. We aimed to identify disease and non-disease related factors for IBP in patients with IBD submitted to colonoscopy. Methods Retrospective cohort-study which included adult IBD patients submitted to colonoscopy between 2016–2021. Patients’ demographic, comorbidities, clinical, biochemical, and colonoscopy data were recorded. IBP was defined as a final Boston Bowel Preparation Scale (BBPS) ≤5 or ≤1 in at least one segment. A univariable analysis tested the association between covariables and the outcome (IBP) in general and considering Crohn’s disease (CD) and ulcerative colitis (UC) patients separately. Statistically significant variables were included in multivariable logistic binary regression. Results Of 309 patients, 52.4% were female with a mean age of 43.7±13.7 years. Fifty one percent (n=158) had UC and 48.9% (n=151) had CD. Twenty-seven percent of the patients (n=82) had IBP which was not significantly different between UC and CD patients (40vs42, p=0.699, respectively). The presence of diabetes mellitus (adjusted OR 13.9 [95% CI 1.388–139.624], p Conclusion This study demonstrates that the presence of diabetes mellitus and antidepressant use are predictors of inadequate bowel preparation for colonoscopy in patients with inflammatory bowel disease. Disease-related factors seem to have no influence in the quality of bowel preparation suggesting that a specific approach is unnecessary in these patients.

Background The severe acute respiratory syndrome coronavirus, 2 (SARS-COV-2) infection may lead to the development of the novel coronavirus disease, 2019 (COVID-19). Currently, little to no data is available regarding safety and efficacy of SARS-COV-2 vaccination in Inflammatory Bowel Disease (IBD) patients, which may present differences between subgroups, as these patients may exhibit impaired innate and adaptive immune system responses. Lower immunological response could, in this specific population, require an additional booster injection. Methods We conducted a prospective study including adult patients with Crohn’s disease (CD) and Ulcerative Colitis (UC) who have undergone complete vaccination against SARS-COV-2 infection with BioNTech® vaccine. Patients with previous SARS-COV-2 infection were excluded. Medical data regarding age, sex, IBD classification and current medication for IBD were collected. A control group with healthy individuals matched for age and sex was also analyzed. Blood samples were collected, 30 days after complete vaccination to quantify IgG antibody titers for SARS-COV-2 in both groups (IBD and non-IBD). Results Our final sample included, 81 IBD and, 32 non-IBD patients, 55 (48.7%) of them females, with a mean age of, 40.2±13.0 years. From the IBD patients, 58(71.6%) had CD and, 23(28.4%) had UC. IBD patients had significantly lower anti-SARS-COV-2 IgG levels when compared to the control group (8950±9366 vs, 14834±11679 AU/mL; p=0.003). Regarding IBD medication, significant lower levels of SARS-COV-2 IgG antibodies when compared to control patients were found in patients under thiopurines (9074±9779 AU/mL; p=0.011); methotrexate (1987±2568 AU/mL; p=0.002); infliximab (7208±7276 AU/mL; p=0.001); and corticosteroids (1065±933 AU/mL; p=0.001). Additionally, patients under combined therapy (infliximab plus thiopurines) presented with significantly lower antibodies titers when compared to patients treated with thiopurines in monotherapy (8130±11048 vs, 10563±5680 AU/mL; p=0.039). No significant differences were found in IBD patients under salicylates (10195±7371 AU/mL; p=0.226); adalimumab (15644±21467 AU/mL; p=0.336); vedolizumab (10464±9087 AU/mL; p=0.286) and ustekinumab (11366±10016 AU/mL; p=0.390). Conclusion IBD patients presented with significantly lower anti-SARS-COV-2 IgG levels, 1 month after complete vaccination against SARS-COV-2 infection compared to healthy controls. Thiopurines, methotrexate, infliximab and corticosteroid treatment were associated with significantly lower antibodies levels. These findings may express the benefit of an additional booster injection in this population.

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.

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 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 Objective goals are needed to guide patient management and assess treatment efficacy in patients with Crohn’s disease (CD). Bowel ultrasound (US) is a widely available, non-invasive and inexpensive technique increasingly being used in these patients. The use of bowel wall thickness (BWT) has been proved to be an accurate measure for assessing disease activity and response to therapy. Recent studies show a rapid improvement of BWT after 3-month of therapy. Our aim was to evaluate BWT variation after induction therapy with infliximab (IFX) in CD patients and correlate BWT with clinical and laboratory parameters. Methods Prospective cohort multicentre study including patients with active CD starting IFX therapy. Clinical disease activity was assessed using the Harvey–Bradshaw index (HBI). C-reactive protein (CRP) and faecal calprotectin (FC) were measured both at week 0 and after induction therapy (week 14), and infliximab trough levels (ITL) were measured at week 14. Bowel ultrasound was performed at week 0 and 14, BWT from the worst segment was selected for analysis. Abnormal BWT was defined has higher than 3mm in any bowel segment. Results We included 10 patients with CD (80% males; median age 29 (21–64) years). According to Montreal classification, most patients were A2 (7/10), had ileocolonic disease (L1 20%; L2 20%; L3 60%) and an inflammatory phenotype (B1 60%; B2 20% and B3 20%). Most patients were anti-TNF therapy naive (80%), and combination therapy was used in 80%. Before IFX (week 0) median HBI was 2 (IQR 1.75–5.25), CRP 1.10 mg/dl (IQR 0.65–3.50) and FC 802 μg/g (IQR 324–1336). The terminal ileum was the most affected segment identified by the USA (5/10), followed by ascending colon (2/10) descending colon (2/10) and sigmoid colon (1/10). Median BWT was 4.6 mm (IQR 3.6–6.4). After induction therapy (week 14), all patients were in clinical remission (HBI 3 μg/ml. Median BWT at week 14 was higher in patients with ITL < 3 μg/ml (6.25 vs. 2.98 mm, p = 0.048). Conclusion The majority of our patients showed a US response (reduction in BWT) after 14 weeks of infliximab, suggesting that reduction in BWT could be an early marker of response to therapy. US evaluation after induction therapy can be a helpful tool to monitor disease activity and guide patient management in CD patients in our daily practice.

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.

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.

patients in remission and 86% in active condition reporting fatigue. However patients report that their complaints of fatigue are often not addressed in clinical consultations. To date there are no studies exploring this topic from the clinician’s perspective. This study aimed to gain an understanding of healthcare practitioners’ (HCPs) perception of IBD fatigue as experienced by people with IBD, and to identify the range of methods that HCPs use to assess and manage fatigue. Methods: Descriptive phenomenology was carried out to achieve the aims of the study. Purposive sampling was used to identify a range of professionals (gastroenterologists, IBD nurses, general practitioners, dietitians, psychologists and pharmacists). In-depth semi-structured interviews were conducted with 20 HCPs who work with people with IBD between June and December 2012. Interviews were audio recorded and transcribed verbatim. Colazzi’s seven step framework was used to analyse data. The study was approved by the local university ethics committee. Results: Three main themes and several sub-themes were identified. The main themes were: the phenomenon of fatigue as perceived by HCPs; the impact of fatigue on patients’ lives as perceived by HCPs; and the methods used by HCPs to deal with fatigue. Fatigue was identified as an important, but difficult and often frustrating, symptom to understand. The study participants perceived fatigue as ‘such a complicated and complex thing’. HCPs reported that fatigue impacts on the emotional, private and public aspects of patients’ functioning, however there were very few methods suggested on how to assess and manage the fatigue in a systematic way. Many expressed a desire for better education and a frustration at not being able to help patients more. There was consensus that managing fatigue should be a multi-disciplinary effort, but with little idea of clearly defined roles. Conclusions: Despite fatigue being one of the symptoms most frequently reported by IBD patients, it remains poorly understood by HCPs, who find fatigue challenging and frustrating. There is a need for a systematic and structured assessment and management of this distressing symptom and HCPs should communicate with each other about care for each individual patient. There is a need for an assessment framework and for intervention strategies to be tested. It is essential for multidisciplinary team members to be involved in planning and managing coordinated care of patients reporting fatigue in IBD.