Clinical cases with contrast-enhanced ultrasound and elastography in Crohn's Disease strictures

Compared to the general population, patients with inflammatory bowel disease (IBD) have an increased risk of developing colorectal cancer. Chronic inflammation is believed to promote the development of neoplasia. Adenocarcinoma complicating UC and CD develops from a precursor lesion, dysplasia. Dysplasia complicating IBD is very variable macroscopically and histologically and is often multifocal. Besides conventional dysplasia in patients with IBD, nonconventional dysplasia are described. Three recent publications allow us to better define these new nonconventional types of dysplasia, from a clinical, morphological and molecular point of view, as well as nonconventional mucosal lesions in patients with IBD. Crohn’s disease (CD) is associated with an increased risk of small bowel adenocarcinoma (SBA). Research papers dedicated to small bowel adenocarcinoma (SBA) in patients with Crohn’s disease (CD) are scarce. (Yet, several advances have been accomplished in epidemiology, natural history and characteristics of SBA, in patients with CD). Several recent publications help us to better understand this entity.

Educational Objectives:
1. To review the type of transducers used in intestinal ultrasound (IUS).
2. To review probe orientation and scan planes in IUS.
3. To have an overview of the normal bowel wall in ultrasound and possible mural and extramural findings.
4. To review how to distinguish between small bowel and colon.
5. To emphasise the anatomical landmarks to search for in IUS.
6. To review intestinal ultrasound technique and how to look for each bowel segment.

The talk will show important ultrasound differential diagnosis in IBD 

Educational objectives:
To understand what´s new on the use of IUS in CD regarding the following aspects:
- outcome studies
- activity and fibrosis score
- perineal ultrasound

Educational Objectives:
1. To review the settings in ulcerative colitis (UC) where intestinal ultrasound (IUS) can be used.
2. To review the role of IUS in the management of patients suspected to have UC.
3. To emphasise the important role of IUS as a tool to assess disease activity, severity and extension in UC.
4. To emphasise the important role of IUS as a monitoring tool to assess response to therapy in UC.
5. To have an overview of the existing IUS scores in UC and their applicability.
6. To review potential complications in UC and the role of IUS in predicting surgery.
7. To have an overview of the burning and open questions regarding IUS in UC in 2021.

Educational objectives:
1. Learn about the mechanisms of action of JAK inhibitors such as tofacitinib 
2. Understand the clinical and endoscopic efficacy of tofacitinib in UC and more selective JAKs
3. Discuss the safety profile of tofacitinib and newer JAK inhibitors

1. To understand different treatment options for perianal fistulas beyond TNF-antibodies
2. To have an overview over optimal treatment strategies in patients with perianal fistulas

1. To understand the chronicity of IBD and the need for continuous remission of symptoms
2. To review the drugs available to treat IBD, their indications, their limitations, their optimal use and their potential adverse reactions
3. To emphasise the concept of two goals of therapy which are the achievement of remission (induction therapy) and the prevention of disease flares (maintenance therapy)
4. To have an overview on the new drugs under development

Numerous small molecules and biologics are being tested in phase 1-3 trials. Regarding JAK inihibitors, we still do not know whether JAK selectivity is associated with an improved risk-benefit profile, especially regading zoster risk. TYK2, gut selective or not, look promising and also showed very encouraging results in psoriasis.  Other small molecules targeting integrins or PDE4 may be approbed in a near future. Regarding biologics and beyond biosimilars, many compounds are being developed such as Abivax. One question remains after 2 decades of biologics development : who will beat infliximab? Combination of biologics and bispecific antibodies might tackle this issue. Pending these molecules, many head to head trials are ongoing.

Educational objectives:
1. To understand the mechanism of action of Methotrexate
2. To review its efficacy and appropriate use (mono-, combitherapy)
3. To learn the appropriate management of Methotrexate and its potential adverse events in daily practice
4. To have an overview on other alternative indications

Educational objectives:
1. To provide an overview of different models of IBD.
2. To discuss the choice and appropriateness of different IBD models for different research questions.

To understand the effect of various groups of IBD medications on histology and review the evidence of histological healing 
To review some practical points in relation to microscopic assessment of post surgical changes in diverted rectum & ileo-anal pouch histology

Educational Objectives:

1. Reminder: why nutrition in IBD?
2. How to best deliver nutritional care in IBD: MDT
3. Seeing this through the lens of an adult IBD dietitian
4. Lessons learned from treating adults/elderly with IBD
5. Psychological challenged with nutritional therapy
6. MDT from both our points of view
7. D-ECCO – who we are and what’s in it for you?
    

Summary:

As PIBD specialists we are all aware of the importance and potential of nutritional therapy in IBD, but how is this best delivered?

This presentation, by a dietitian and physician, who are members of the Dietitians of ECCO (D-ECCO) committee, will include our views and experience with managing nutrition in IBD, through a multidisciplinary team. We will mention how to advocate and setup a successful team and highlight some specific settings where an MDT is especially critical, such as peri-surgical care. Lessons learned from treating the elderly IBD population, and the interesting parallels to paediatrics, will be discussed. Finally, we will explain why and how you should get your team involved in D-ECCO activities.

Patients with Inflammatory Bowel Disease (IBD) often experience the problematic and burdensome symptom of fatigue, both during periods of relapse and remission. The optimal management of fatigue in IBD is uncertain, however there is evidence suggesting that physical activity is likely to be a beneficial way of managing the symptom. The aim of this study is to explore the relationship between fatigue and objective measurements of both physical activity metrics and varying intensities of physical activity for individuals with IBD.

A multi-centred, European, cross-sectional, correlational study was employed. A consecutive sample of 187 patients with Crohn’s disease (59%) or ulcerative colitis (41%) were recruited from six IBD centres in the Republic of Ireland (42%), United Kingdom (40%) and Denmark (18%). Fatigue was measured using the IBD-Fatigue (IBD-F) scale, including both the level of fatigue (IBD-F, Section 1) and impact of fatigue (IBD-F, Section 2). Physical activity was objectively measured using scientifically validated triaxial accelerometers (ActiGraph wGT3X-BT) during seven consecutive days.

A moderate level of fatigue (IBD-F Section 1 Md (IQR) = 10 (6 – 13)), predominantly intermittent in nature (72%) was reported by participants (57.4% female; 59% Crohn’s disease; 43% active disease). Participants self-reported sleeping an average of 8.7 hours over the seven nights. During the week, the intensity of activity was predominantly sedentary (Md 5 days, 22 hours, 20 minutes) or light (Md 19 hours, 35 minutes). The median moderate-to-vigorous intensity of physical activity per day was 32.2 minutes and step count over the week was 47052 steps. There was no evidence of a unique linear or non-linear relationship between each of the objective measurements of physical activity with IBD-related fatigue. This lack of evidence extended separately to patients in remission and to patients with active disease. These findings are in the context of a statistically significant moderately-strong relationship between disease activity (measured using both HBI and SCCAI) and level of fatigue for both patients of Crohn’s disease (r_s = .327, p = .001, n = 96) and ulcerative colitis (r_s = .353, p = .003, n = 71).

This large multi-centred study shows no association between objective measurements of physical activity and IBD-fatigue. These findings suggest that engaging or not engaging in physical activity has no differential impact on self-assessment of fatigue.

Subcutaneous (SC) formulations were recently approved for CT-P13 and vedolizumab (VED). No insights in the willingness of patients with Inflammatory Bowel Disease (IBD) to switch from intravenous (IV) to SC maintenance therapy with CT-P13 and VED are available. The aims of this study were (1) to evaluate the percentage of patients with IBD in favour of switching to SC formulations, (2) to define the factors influencing this decision, and (3) to explore the role of the IBD nurse in the process of switching.

This was a monocentric study in patients with IBD on maintenance IV CT-P13 or VED. All patients attending the infusion unit were invited to complete a survey exploring the willingness to switch to SC formulations. Prior to completing the survey, patients were informed on the new SC formulations and the accompanying care pathway. The survey was performed prior to the market introduction of SC CT-P13 and VED. Demographics, patient reported outcomes, willingness to switch and reason for IV vs. SC preferences were captured.

In total, 183 (91%) patients completed the survey (m/f: 84/99; CD/UC/IBD-U: 120/57/6; median age 45 IQR 34-59; remission CD/UC: 67%/75%). The majority of patients preferred switching to SC (56% yes, 12% no, 32% doubt). The main driver to switch was an anticipated decrease in hospital visits (90%); the main reason to continue IV was fear of change (61%). Patients doubting to switch had a lower stool frequency compared with patients making a definite decision (p=0.012). Factors significantly associated with the willingness to switch in the univariate analysis were younger age (p<0.0001), experience with SC therapy (p=0.03), full time work occupancy (p=0.001), younger age at start IV therapy (p=0.001), shorter disease duration (p=0.012), and compliance level (p<0.0001). Multivariate analysis retained younger age as the only independent factor. For patients doubting to switch, an electronic alert (71%), an information brochure (69%), and a personal teaching moment (60%) were recognised as valuable support. An information package should cover patient-focused efficacy and safety data of SC therapy, therapeutic options in case of disease worsening, and practical concerns including information about administrative issues and travelling.

This is the first study exploring the willingness to switch from IV to SC maintenance therapy with CT-P13 and VED in patients with IBD. The majority prefers to switch to a SC formulation, with willingness to switch being most likely in younger patients. Further studies are required to investigate the impact of nurse led interventions on the willingness to switch, patient satisfaction, and treatment compliance.

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, several patients contacted members of the IBD team with coronavirus disease 2019 (COVID-19) related questions. Some patients intended to cancel scheduled IBD clinic outpatient visits or endoscopic examinations and/or stop or postpone their medication. We surveyed the need for information by IBD patients during the SARS-CoV-2 pandemic and the role of the IBD team in this regard.

We performed an anonymous survey at the IBD department of our tertiary referral center. The questionnaire contained 15 closed questions, including on basic demographic data, medication use, testing for COVID-19, information sources, and intention to stop or postpone medication or follow-up. The questionnaire was available to all adult patients attending the IBD outpatient clinic and infusion unit from July 1^st until October 30^th 2020. All questionnaires were collected before the second COVID-19 wave. Patients on subcutaneous medication that did not attend the IBD clinic during these months were contacted via e-mail.

We collected 965 questionnaires. The majority of patients (44.3%) was 18-40 years old. There were more patients with Crohn’s disease (66%) than ulcerative colitis (32%) and IBD unclassified (2%). Demographics and medication use are presented in table 1. A third of the patients (31.7%) was tested for SARS-CoV-2, of whom 8.3% tested positive. Twenty-six percent of patients considered they had higher need for information about COVID-19 than the general population. News websites were a source of information about COVID-19 for 52.5% of patients, followed by hospital websites (43.8%), direct contact with the IBD physician (24.6%), direct contact with the IBD nurse (23.1%), and state sponsored websites (20.9%). In fact, 35.9% of patients contacted the IBD nurse since the start of the pandemic. The majority of patients reported they were satisfied by the information (80.5%) and/or reassured (85%) by the IBD nurse. Ten percent of patients had considered to stop IBD medication due to the pandemic, and 80% of these refrained to do so following the advice of the IBD nurses. Finally, 12.5% of the patients expressed true fear of hospital visits due to the pandemic, which was associated with female gender and higher need for information.

Treatment cessation and anxiety could be avoided by direct interaction with the IBD nurses and in particular with the IBD nurse as first point of contact for the patient. Patients with IBD may profit from an optimized information platform with scientifically correct information addressing the concerns of this specific population.