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Background and Aims No consensus exists on defining intestinal ultrasound response, transmural healing, or transmural remission in inflammatory bowel disease, nor clear guidance for optimal timing of assessment during treatment. This systematic review and expert consensus study aimed to define such recommendations, along with key parameters included in response reporting. Methods Electronic databases were searched from inception to July 26, 2021, using pre-defined terms. Studies were eligible if at least two intestinal ultrasound [IUS] assessments at different time points during treatment were reported, along with an appropriate reference standard. The QUADAS-2 tool was used to examine study-level risk of bias. An international panel of experts [n = 18] rated an initial 196 statements [RAND/UCLA process, scale 1–9]. Two videoconferences were conducted, resulting in additional ratings of 149 and 13 statements, respectively. Results Out of 5826 records, 31 full-text articles, 16 abstracts, and one research letter were included; 83% [40/48] of included studies showed a low concern of applicability, and 96% [46/48] had a high risk of bias. A consensus was reached on 41 statements, with clear definitions of IUS treatment response, transmural healing, transmural remission, timing of assessment, and general considerations when using intestinal ultrasound in inflammatory bowel disease. Conclusions Response criteria and time points of response assessment varied between studies, complicating direct comparison of parameter changes and their relation to treatment outcomes. To ensure a unified approach in routine care and clinical trials, we provide recommendations and definitions for key parameters for intestinal ultrasound response, to incorporate into future prospective studies.

Objectives With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care. Methods Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice. Results The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research. Conclusions These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

INTRODUCTION The evolving epidemiologic patterns of IBD throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD in the 21st century. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century. METHODS We systematically reviewed MedLine and Embase for population-based studies reporting hospitalization rates for IBD, Crohn’s disease (CD), or ulcerative colitis (UC) since 2000. Log-linear models were used to calculate average annual percentage change (AAPC) with associated 95% confidence intervals (CI). Random effects meta-analysis pooled AAPCs stratified by countries in the Western world (i.e. North America, Western Europe, and Oceania) versus newly industrialized countries in Eastern Europe, Asia, Latin America, and Africa. Secondarily, we compared hospitalization rates by primary diagnosis of IBD versus all-cause hospitalizations. QGIS 3.44 was used to create a choropleth map of AAPC and ArcGIS Pro 2.4.1 was used to develop an online, interactive map of global hospitalization trends. RESULTS Data were extracted from 87 studies comprising 42 countries. Overall, hospitalization rates were stable in countries of the Western world for IBD (AAPC=−0.25; 95% CI: −0.90, 0.41, n=22), CD (AAPC=2.76; 95% CI: −0.62, 6.15, n=8), and UC (AAPC=1.44; 95% CI: −1.98, 4.86, n=7) (Table 1). However, heterogeneity between countries was observed, for example, hospitalization rates for CD (−0.02%; 95%CI: −0.52, 0.48) and UC (0.40%; 95%CI: −0.81, 1.63) were stable in the USA, but increasing for CD (2.05%; 95%CI: 1.25, 2.84) and UC (1.69%; 95%CI: 0.99, 2.39) in Portugal (Figure 1). CD and UC hospitalization rates in newly industrialized countries increased in Mexico (CD: 5.21%; 95%CI: 3.07, 7.39; UC: 5.96%; 95%CI: 4.30, 7.64), Chile (CD: 6.03%; 95%CI: 5.21, 6.86; UC: 3.78%; 95%CI: 3.43, 4.13), Bahrain (CD: 12.98%; 95%CI: 7.83, 18.38; UC: 7.27%; 95%CI: 2.12, 12.69), and Hong Kong (CD: 8.67%; 95%CI: 5.81, 11.61; UC: 0.14%; 95%CI: −2.21, 2.53), but significantly decreased in Brazil for CD (−3.22%; 95%CI: −5.24, −1.15) and UC (−3.41; 95%CI: −4.63, −2.18) (Figure 1). Studies that defined hospitalization rates as the primary diagnosis of IBD versus all-cause hospitalizations may explain heterogeneity between countries (Table 1). CONCLUSION Hospitalization rates for IBD are stabilizing in North America, Europe, and Oceania. In contrast, newly industrialized countries in Asia and Latin America have rapidly rising hospitalization rates, contributing to an increasing burden on global healthcare systems. Future studies should explore clinical and methodological factors that explain heterogeneity between country-specific hospitalization rates.

BACKGROUND The management of inflammatory bowel disease (IBD) is associated with considerable healthcare and societal cost. A key driver of direct medical cost, remains surgery. Although the cumulative risks of surgery have been well described in countries of the Western world, surgical risk data from Asia, where IBD is rapidly emerging, is lacking. OBJECTIVES The primary objective was to compare the cumulative risk of surgery at 1-year after a diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) between contemporary adult population-based cohorts from the Western world and Asia. Secondarily, we estimated 5- and 10-year risks of IBD-related surgery. METHODS MEDLINE and EMBASE were searched for population-based studies published on or after January 1, 2000, that reported 1-, 5-, and 10-year risks of IBD-related surgery. Authors were contacted to provide previously unpublished data. Random effects models were performed to analyze temporal and regional risks of surgery for cohorts diagnosed with IBD in the year 1998 and later. RESULTS The initial search yielded 10,358 citations. Of those, 37 studies were used in analyses. For UC, the 1-, 5-, and 10-year risk of surgery were 1.71% (95% confidence intervals [CI]: 1.13, 2.29), 3.77% (95% CI: 2.41, 5.13), and 8.33% (95% CI: 5.03, 11.63), respectively. For CD, the 1-, 5-, and 10-year risk of surgery were 7.17% (95% CI: 5.92, 8.42), 13.63% (95% CI: 11.26, 16.00), and 24.57% (95% CI: 19.21, 29.93), respectively (Table 1; Figure 1). For CD, the 1-year risk of surgery was 7.44% (95% CI: 6.07, 8.80) and 7.22% (95% CI: 2.65, 11.78) for countries in the Western world and countries in Asia, respectively (p= 0.93). The Western 5-year risk of CD surgery (13.52%, 95% CI: 10.85, 16.19) was similar to Asia (15.95%, 95% CI: 5.48, 26.43) (p=0.66). The 1-year risk of surgery for UC was not significantly different between Western world countries (1.87%, 95% CI: 1.27, 2.47) and Asia (0.74%, 95% CI: -0.48, 1.97) (p=0.13). The pooled 5-year risk of surgery was significantly higher in countries of the Western world (4.13%, 95% CI: 2.71, 5.55) as compared to Asia (2.11%, 95% CI: 1.88, 2.33) (p=0.02). Comparison of pooled 10-year risk between countries of the Western world and Asia was not possible as there was only one Asian study published on risk of surgery 10-years after CD and UC diagnosis each. CONCLUSIONS During the 21st century the risk of early surgery 1-year after the diagnosis for CD and UC was similar in countries of the Western world as compared to Asia. Long-term (10-year data) was lacking for Asian countries. Future studies are needed to generate more robust long-term estimates for risks of IBD-surgery in Asia.

Background It is unknown whether cannabis users self-medicating their inflammatory bowel disease (IBD) symptoms are more likely to have comorbid mental health or personality risk factors associated with an increased potential for substance misuse compared with recreational cannabis users. Methods We surveyed individuals with IBD about their cannabis use, their mental health symptoms, and personality risk factors associated with substance misuse. We compared risk factors for substance misuse between individuals using cannabis to manage IBD symptoms and those using cannabis recreationally. Results Of 201 persons with IBD who completed the questionnaire, 108 reported lifetime cannabis use. Of those, a larger proportion of Crohn’s disease patients used cannabis to manage IBD symptoms (53% [34/64] vs 28% [12/43]; P = 0.010). Individuals self-medicating with cannabis were more likely to use cannabis for coping reasons (P = 0.016) and demonstrated higher levels of impulsivity (P = 0.004) and depressive symptoms (P = 0.012) when compared with individuals using cannabis recreationally. Logistic regression revealed that cannabis was 4.1 times (P = 0.05) and 3.7 times (P = 0.05) more likely to be used for IBD symptoms by smokers and individuals with moderate–severe depressive symptoms, respectively. Individuals high in impulsivity were 4.1 times more likely to use cannabis for their IBD symptoms than those low in impulsivity (P = 0.005). Conclusions Persons with IBD self-medicating with cannabis have characteristics associated with increased vulnerability to substance misuse when compared with those using cannabis recreationally. Screening for mental health comorbidities and vulnerability to substance misuse should be undertaken if cannabis is to be used to treat IBD symptoms.

ObjectivesMathematical models are increasingly important in planning for the upcoming chronic hepatitis C (CHC) elimination efforts. Such models require reliable natural history inputs to make accurate predictions on health and economic outcomes. Yet, hepatitis C virus disease progression is known to vary widely in the literature and published inputs are currently outdated. The objectives of this study were to obtain updated estimates of fibrosis progression rates (FPR) in treatment-naïve patients with CHC and to explore sources of heterogeneity.DesignA systematic review was conducted using Ovid-MEDLINE, Ovid-EMBASE and PubMed databases (January 1990 to January 2018) to identify observational studies of hepatic fibrosis in treatment-naïve patients with CHC.OutcomesStage-constant FPRs were estimated for each study given the reported fibrosis scores and duration of infection. Stage-specific FPRs (ie, F0→F1; F1→F2; F2→F3; F3→F4) were estimated using Markov maximum likelihood estimation. Estimates were pooled using random-effects meta-analysis and heterogeneity was evaluated by stratification and random-effects meta-regression.ResultsThe review identified 111 studies involving 131 groups of patients (n=42 693). The pooled stage-constant FPR was 0.094 (95% CI 0.088 to 0.100); stage-specific FPRs were F0→F1: 0.107 (95% CI 0.097 to 0.118); F1→F2: 0.082 (95% CI 0.074 to 0.091); F2→F3: 0.117 (95% CI 0.107 to 0.129); F3→F4: 0.116 (95% CI 0.104 to 0.131). Stratified analysis revealed substantial variation in progression by study population. Meta-regression indicated associations between progression and infection age, duration, source, viral genotype and study population. Findings indicate that FPRs display substantial heterogeneity across study populations and pooled values from more homogenous subpopulations should be considered when estimating prognosis.ConclusionsThis large meta-analysis presents updated prognostic estimates for CHC derived from newer studies using better diagnostic methods and improves estimates for important patient populations in terms of clinical policy (eg, injection drug users, non-clinical populations, liver clinic patients) and should be a valuable resource for patients, clinicians and clinical policymakers.

Genetic and environmental factors are thought to profoundly influence the pathophysiology of Crohn’s disease (CD). Changes in dietary and hygiene patterns affect the interactions between the immune system and environment. The gut microbiome is responsible for mediating host immune response with significant dysbiosis observed in individuals with CD. Diet therapy using exclusive enteral nutrition (EEN) has been studied as primary therapy for the management of CD. EEN may cultivate the presence of beneficial microbiota, improve bile acid metabolism, and decrease the number of dietary microparticles possibly influencing disease and immune activity. In this review, we will address the current evidence on EEN in the management of adult and pediatric CD. In adults, EEN appears to be moderately beneficial for the induction of remission of CD; however, its use is understudied and underutilized. Stronger evidence is in place to support the use of EEN in pediatric CD with the added benefit of nutrition support and steroid-sparing therapy during the growth phase. Overall, EEN is an established therapy in inducing CD remission in the pediatric population while its role as primary therapy of adult Crohn’s disease remains to be defined.

BACKGROUND: The presence and severity of symptoms in IBD correlate poorly with the degree of inflammatory activity, especially in Crohn’s disease (CD). Psychological factors, including perceived stress and mood disruption are associated with symptom activity. This relationship is bidirectional with increased symptoms predicting later increased perceived stress and vice versa. It is unclear whether the association between high perceived stress and active symptoms is weighted more towards high perceived stress being associated with symptomatic activity in individuals and no concurrent active inflammation than it would be in persons with increased symptoms and evidence of intestinal inflammation. AIMS: To evaluate whether perceived stress is associated with increased symptoms in non-inflammatory versus inflammatory IBD flares. METHODS: We recruited 487 persons from the University of Manitoba IBD registry to assess the relationship between intestinal inflammation, symptomatic disease activity, and psychologic factors. Disease activity was assessed using the Harvey Bradshaw Index (HBI) for CD and the Powell Tuck Index (PTI) for UC. Perceived stress was measured using the Cohen Perceived Stress (CPSS) scale with high scores defined as ≥ 20. A fecal calprotectin (FCAL) level >250ug/g was the cut point for active inflammation. An inflammatory flare was defined as a FCAL > 250ug/g and disease index >4. A non-inflammatory flare was defined as FCAL ≤250 and disease activity index >4. Completed surveys and stool samples were submitted at baseline, 3 months and 6 months. RESULTS: For CD (n=265), 31 (11.7%) were in an inflammatory flare at baseline while 55 (20.8%) were in a non-inflammatory flare. For UC (n=222) 32 (14.4%) were in an inflammatory flare while 39 (17.6%) were in a non-inflammatory flare. There was no significant difference in the likelihood of having a high CPSS score between those with inflammatory vs non-inflammatory flares either at baseline or at 6 months(Table 1). There were no differences in the scores on individual items in the CPSS score between persons in inflammatory flares versus those in non-inflammatory flares. CONCLUSIONS: Increased perceived stress is equally associated with increased symptoms with persons with IBD regardless of the presence of inflammatory activity. FUNDING AGENCIES: None

1551Background: Hepatitis C virus (HCV) is a risk factor for development of hepatocellular carcinoma (HCC). Patients (pt) with HCV can achieve a sustained virologic response (SVR; undetectable HCV ...