bluuebunny/crossref_metadata_2025 huggingface dataset:
P178 Variation in assessment of outcomes for inflammatory bowel disease in routine clinical practice: a mixed-methods study
Authors: Razanskaite V , Williamson P , Young B , Bodger K
Published: January 2020

Background

A number of global initiatives have sought to standardise the assessment of outcomes for inflammatory bowel disease (IBD), both for clinical trials (Core Outcome Sets1) and routine practice (ICHOM2). Our aim was to explore variability in the assessment and recording of clinical IBD outcomes during routine practice in England, evaluating the range of individual outcomes elicited and the extent of objective quantification of symptoms.

Methods

We performed ethnographic observations of 102 IBD clinic consultations conducted by 24 IBD clinicians (10 consultants, 10 IBD nurses and 4 trainees) in six acute hospitals in the North West region of England. We analysed 909 retrospective clinic records from outpatient IBD clinic visits recorded for observed patients in routine electronic patient records (EPRs). Audio-recordings of observed consultations and clinic records were analysed for pre-defined IBD outcomes, including those items required for Crohn’s Disease Activity Index (CDAI), Harvey–Bradshaw Index (HBI), Mayo Clinic Score (MCS) and Simple Clinical Colitis Activity Index (SCCAI). In addition, we performed 24 semi-structured interviews with IBD clinicians to explore the barriers and facilitators to capturing structured IBD outcomes in EPRs.

Results

The most commonly elicited and recorded outcomes were general well-being (95% consultations [C] and 61% clinic records [R]), stool frequency [SF] (87% C, 68% R), abdominal pain [AP] (79% C, 46% R), blood in stool [BS] (71% C, 57% R) and loose stool (64% C, 51% R). Clinical disease activity indices (HBI and SCCAI) were collected in only 15 (14.7%) observed consultations and recorded in 51 (5.6%) clinic letters. There was marked variation in the quantification of individual symptom items of MCS, SCCAI, CDAI and HBI in analysed consultations and records. Both PRO2 Crohn’s disease outcomes [AP and SF] were collected in 29/50 (58%) observed consultations and recorded in 169/484 (35%) records. Both PRO2 ulcerative colitis outcomes [SF and BS] were collected in 42/52 (81%) consultations and 253/425 (60%) records. Selected outcomes were recorded significantly more frequently by IBD nurses compared with doctors. Clinicians reported a range of IT barriers and issues with psychometric properties of currently available clinical disease activity indices in practice.

Conclusion

There is significant variability in the breadth, depth and quantification of IBD clinical outcomes during routine clinical assessments. Although most domains of clinical disease activity indices were elicited in consultations, formal scoring and assessment over fixed time periods was rare. There is an urgent need for practical alternatives to clinician reported disease activity indices in routine care.
P184 Temporary defunctioning ileostomy in therapy refractory Crohn’s colitis: A viable alternative to immediate colorectal resection?
Authors: van der Holst A M , Otten T , van Renterghem A R P K M , Dijkstra G , van Loo E S , van Praag E M , Buskens C J , Stassen L P S
Published: January 2020

Background

The faecal stream is one of many factors influencing the pathogenesis of Crohn’s disease. Previous research demonstrated some Crohn’s patients benefit from temporary faecal diversion. This study aims to determine the role of temporary faecal diversion by means of a defunctioning ileostomy in treating patients with therapy refractory Crohn’s colitis.

Methods

Data were retrieved by retrospectively assessing patient records. All patients receiving a temporary ileostomy for therapy refractory Crohn’s colitis from three Dutch hospitals between 2010 and 2018 were included. Patients with previous colorectal resection or malignancy were excluded. Stoma reversal, permanent stoma and extension of colorectal resection at follow-up were determined as primary outcomes.

Results

Thirty-six patients received a temporary defunctioning ileostomy for therapy refractory Crohn’s colitis. Stoma reversal was attempted in 20 (56%) patients after a mean period of 1 year of which nine underwent additional resection during stoma reversal. After a mean follow-up of 4.2 years, resection was performed in 29 (81%) patients of which 14 (39%) had reduced resection in comparison with the necessary resection at the time of faecal diversion. Among the 14 (39%) patients with restored continuity, three patients remained with full preservation of the colon. Moreover, the presence of proctitis was associated with low stoma reversal rates (p = .007).

Conclusion

Temporary faecal diversion is associated with reduced resection and reduced risk of permanent ileostomy; therefore, it may be a decent alternative for immediate colorectal resection for patients with isolated Crohn’s colitis. Unfortunately, temporary defunctioning ileostomy is not a viable alternative for resection in Crohn’s patients suffering from proctitis.
P186 Prevalence and management of anaemia in Greek patients with inflammatory bowel disease: a multicentre real-life cohort study
Authors: Karmiris K , Fotinogiannopoulou K , Velegraki M , Koureta E , Axiaris G , Kateri C , Kokkotis G , Kapizioni C , Markopoulos P , Katsoula A , Gklavas A , Papaconstantinou I , Giouleme O , Tsironi E , Michalopoulos G , Bamias G , Papadopoulos V , Kapsoritakis A , Zampeli E , Michopoulos S , Karatzas P , Papatheodoridis G , Theodoropoulou A , Koutroubakis I E
Published: January 2020

Background

Anaemia is a common extra intestinal manifestation of inflammatory bowel disease (IBD) that plays an important role in patients’ quality of life. The aim of our study was to evaluate the prevalence of anaemia and its current management in referral IBD centres in Greece.

Methods

We performed a retrospective analysis of demographic, clinical, laboratory and IBD-related treatment data as well as data concerning the type of anaemia and its treatment in IBD patients registered in 10 Greek tertiary referral centres. Consecutive patients (the last seen) having at least two follow-up visits with available to retrieve relevant laboratory results were included. Anaemia was defined by the World Health Organization criteria. Patients with co-morbidities related to anaemia were excluded.

Results

A total of 751 IBD patients have been registered so far and their demographic and clinical characteristics are presented in Table 1. The point prevalence of anaemia at inclusion was 26.8 % (201 patients), whereas the overall prevalence of history of anaemia was 38.7% (291 patients). The prevalence of anaemia was numerically higher in CD (41.1 %, n = 186) than in ulcerative colitis (35.2 %, n = 105) but the difference was not statistically significant (p = 0.13). Persistent anaemia (anaemia in all measurements) was found in 40 (13.7%) and recurrent anemia in 102 (35.1%) patients, whereas 54 (18.5 %) had a history of anaemia before IBD diagnosis. IBD patients with anaemia at entry had higher activity (HBI, SCCAI and CRP) and lower quality of life (SIBDQ) scores than patients without anaemia (for all comparisons p < 0.05). Among the 291 patients with anaemia iron supplementation was administered in 239 (82.3%); oral iron in 52 (17.9%) and iv iron in 205 (70.4%). Vitamin B12 and folate were administered in 54 and 107 patients, respectively.

Conclusion

The point prevalence of anaemia in Greek IBD patients is 26.8%. Almost half of the patients with anaemia present recurrent or persistent anaemia. The presence of anaemia is associated with active disease and lower quality of life. The vast majority of patients received iron supplementation mainly in the form of iv iron.
P190 Systematic review: Gastrointestinal ultrasound scoring indices for inflammatory bowel disease
Authors: Goodsall T , Nguyen T , Ma C , Jairath V , Bryant R
Published: January 2020

Background

The management of inflammatory bowel disease (IBD) requires frequent monitoring and assessment of disease activity. Endoscopic assessment with biopsy remains the gold standard for disease activity. Gastrointestinal ultrasound (GIUS) is a non-invasive, accessible and affordable test used to assess and monitor IBD and has been shown to be similar to MRI for detecting disease. The aim of this study was to systematically review the literature to identify scoring indices used for GIUS measurement of disease activity in IBD and to appraise their operating characteristics.

Methods

A systematic search of Embase, Medline, Pubmed, Cochrane Central and Clinical Trials.gov from inception to July 2019 was conducted according to PRISMA guidelines. Included were all study types reporting GIUS indices used for grading activity of severity of IBD in comparison to an objective reference standard. Studies using an exclusive clinical reference standard were excluded. All study types and abstracts were considered. Study quality was assessed using the QUADAS tool.

Results

27 eligible studies were identified investigating 1647 patients. Disease phenotype was Crohn’s disease (CD) (n = 13), ulcerative colitis (UC) (n = 10) and IBD (n = 4). The most common reference standard was colonoscopy (n = 23), histology (n = 2), and imaging (n = 2). Bowel wall thickness was an index parameter in 26 studies. The most frequent cut off was 3mm (n = 10), 4mm (n = 9), 5mm (n = 1), and not specified (n = 6). There was no noticeable difference in magnitude of cut off when stratified by disease phenotype. Colour Doppler was an index parameter in 16 studies and was based on the Limburg score (n = 7), binary (n = 7) or categorical (n = 2). Bowel wall stratification was an index parameter in 15 studies and was more frequently used in UC (70%) and IBD (75%) indices than in CD indices (38%). Other index parameters included bowel wall compressibility, presence of complications such as abscess or fistula, bowel wall echogenicity, mesenteric inflammatory, lymphadenopathy, contrast enhancement, ulceration, peristalsis, strictures, absence of haustra coli, and tissue sonoelastography. Twenty-three studies were identified as at risk of bias. Overall concordance was substantial to excellent and accuracy was good to excellent. Two studies demonstrated substantial inter-observer agreement. No studies reported intra-observer agreement.

Conclusion

The identified GIUS scoring indices demonstrate applicability to both CD and UC with good accuracy and concordance. Current evidence does not adequately address concerns about the intra- and inter-observer variability of GIUS. There is a need for robust validation of an evidence-based GIUS index before more widespread use in IBD as a surrogate for colonoscopy and in clinical trials.
P195 Cost-effectiveness of a 17-gene classifier to guide initial treatment choice in Crohn’s disease in the UK
Authors: Buchanan V , Griffin S , Lee J , Mckinney E , Kinnon P , HILLS K
Published: January 2020

Background

PredictSURE IBD™ is a CE-marked whole blood-based biomarker test that predicts long-term clinical outcomes in inflammatory bowel disease (Crohn’s disease, CD and ulcerative colitis, UC). PredictSURE IBD™ uses a 17-gene qPCR-based classifier to stratify patients into two prognostic subgroups, high and low risk. High-risk patients experience significantly more aggressive disease than low-risk patients, with the need for earlier and more frequent treatment escalation over time. Early stratification could enable personalised treatment strategies, such as ‘top-down’ use of biologics in high-risk patients. Our objective was to examine the cost-effectiveness of PredictSURE IBD™ in guiding the use of early biologic therapy in newly diagnosed CD patients in the UK.

Methods

A decision tree leading into a Markov state-transition model was constructed in MS Excel to compare two treatment approaches: (1) standard of care therapy following established UK clinical guidelines, consisting of sequences of immunomodulator followed by biologic upon relapse (‘step-up’ treatment), (2) targeted therapy guided by PredictSURE IBD™, whereby patients identified as high-risk receive sequences of anti-TNF biologic treatment followed by other biologic classes upon relapse (‘top-down’ treatment), Figure 1. Parameters were informed by patient data from PredictSURE IBD™ clinical studies and the literature.

Results

Top-down treatment guided by PredictSURE IBD™ resulted in an incremental cost-effectiveness ratio (ICER) of £7,179 per quality-adjusted life-year (QALY), with £1,852 incremental costs and 0.258 incremental QALYs vs. standard of care generated over a 15-year time horizon. Additional costs relating to earlier biologic use were offset by reductions in the costs of flares, hospitalisations and surgery. Incremental QALYs were driven by increased time spent in remission and improved quality of life from reduced flares and surgery. The model was most sensitive to the time horizon, rates of mucosal healing on top-down vs. step-up therapy, the costs of hospitalisation and the costs and quality of life in the severe disease health state.

Conclusion

Modelling shows that upfront use of biologic guided by PredictSURE IBD™ could substantially improve clinical outcomes for high-risk patients by increasing remission rates and reducing flares, surgery and treatment escalations. The ICER for PredictSURE IBD™ was well below the £20–£30k/QALY threshold used by the UK National Institute for Health and Care Excellence (NICE). Top-down treatment guided by PredictSURE IBD™ would not only represent a treatment paradigm shift for CD patients but would also be a highly cost-effective use of resources in the UK National Health Service.
P200 Risk of progression of preclinical ulcerative colitis
Authors: Rodríguez-Lago I , Merino O , Azagra I , Maiz A , Zapata E , Higuera R , Montalvo I , Fernández-Calderón M , Arreba P , Carrascosa J , Iriarte A , Muñoz-Navas M , Cabriada J L , Barreiro-de Acosta M
Published: January 2020

Background

The diagnosis of ulcerative colitis (UC) is usually established after the development of symptoms, but preclinical disease may be present even years before the final diagnosis. Around 25% of UC patients may show a proximal extension of the disease. The primary aim of the study was to define the main characteristics and the risk of progression of preclinical UC.

Methods

We performed a multicentric, retrospective study of all patients included in the colorectal cancer screening programme in 11 centres between 2009–2014. All subjects were initially assessed with a faecal occult blood test (OC-Sensor, Eiken Chemical Co., Tokyo, Japan) and, if this test was positive (cut-off 20 μg Hgb/g), a colonoscopy was performed. All patients were asymptomatic and had an incidental diagnosis of UC confirmed by histology during a screening colonoscopy. The main outcomes were the risk of developing symptomatic disease and proximal disease extension. A chi-square test was performed in order to assess the risk factors of proximal extension and symptomatic disease.

Results

During this period we performed 31 005 colonoscopies after 498 227 FIT. We included 79 patients with a new diagnosis of UC (age 58 years [IQR, 52–63], 37% non-smokers]). At baseline, disease extension was E1 in 32%, E2 in 33% and E3 in 35%. After a median follow-up of 29 months (IQR, 17–41), 76% received some treatment, and no patient showed proximal disease extension. In 45% (33% E3 and 12% E2) we observed a reduction of the disease extension. Among those subjects who were asymptomatic at diagnosis, 32% developed symptomatic disease after a median of 7.5 months (IQR, 1–14). Disease extent at diagnosis did not influence the risk of symptomatic disease during follow-up (p = 0.85). Those patients with left-sided or extensive UC were more frequently treated with mesalazine, systemic steroids or thiopurines, compared with those with proctitis (p = 0.001, 0.023 and 0.047, respectively).

Conclusion

Approximately one-third of patients with preclinical UC develop symptomatic disease, but there is no risk of proximal disease extension after 2 years of follow-up.
P203 FIT and FC as a surrogate non-invasive marker for mucosal healing in inflammatory bowel disease
Authors: ISMAIL M S , Murphy G , Kelly C , O’Riordan F , Semenov S , Sihag S , Breslin N , Anthony O , Ryan B , McNamara D
Published: January 2020

Background

Mucosal healing (MH) is one of the goals of IBD therapy. Currently, the only way to assess MH is by colonoscopy. Faecal calprotectin (FC) and faecal immunochemical test (FIT) which detect colonic inflammation and bleeding might be useful adjuncts.

Aim

To assess FIT and FC as surrogate markers of MH.

Methods

Following ethical approval, patients undergoing routine colonoscopy were prospectively recruited. Demographics and colonoscopy findings were documented. A FIT and FC were collected prior to colonoscopy. FIT and FC were processed in our laboratory and reported as µg/g of stool. MH was defined no visible activity on colonoscopy.

Results

Of 105 colonoscopies, FC and FIT results were available in 99 and 88 patients. Mean age 48.8, 52% (55) males, 34% (36) UC, 60% (63) Crohn’s, 0.05% (6) IBDU. In all, MH occurred in 12%, (n = 12). In MH, the mean FIT and FC were 1142 and 353, while in active cases were 750 and 819. Only FC was significantly lower in MH cases (353 vs. 819, p = 0.05). Using standard cut-offs of >50; sensitivity, specificity, PPV and NPV for MH for FIT was poor; 59%, 33%, 89%, 9% and for FC was better at 74%, 73%, 91%, 44%. The overall correlation between the biomarkers was weak r = 0.2, p < 0.01. FC ROC analysis gave a specificity and sensitivity of 75% and 67% for a cut-off of <64µg/g, AUC = 0.65.

Conclusion

MH was uncommon (12%) reflecting our clinical practice. FIT was a poor predictor of MH. FC might be a useful marker albeit ongoing research is needed to set an appropriate cut-off.
P206 Demographic data and therapy before proctocolectomy with ileal pouch-anal anastomosis are associated with long-term pouch outcomes: A report from the epi-IIRN
Authors: Ollech J , Harel S , Yadgar K , Asayag N , Cahan A , Lederman N , Matz E , Balicer R , Feldman B , Brufman I , Haklai Z , Turner D , Dotan I
Published: January 2020

Background

Up to 25% of patients with ulcerative colitis (UC) may undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis may occur in 50–70% of patients, and ~30% may develop chronic pouchitis (CP) or Crohn’s-like disease of the pouch (CLDP). We aimed to identify predictors for the development of CP or CLDP during a long follow-up period.

Methods

Patients followed prospectively at the pouch clinic at Rabin Medical Center, were cross-referenced with data from the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45 074). All patients had at least one year of follow-up since ileal continuity (i.e., ileostomy closure after pouch formation). CP was defined as an active flare of pouchitis for >4 weeks and being treated with antibiotics or anti-inflammatory therapy, or >4 episodes of acute pouchitis/year. CLDP was defined as having one or more of the following: pouch-related fistula (>1 year after ileostomy closure), inflammation of the afferent limb, or fibrostenotic disease of the pouch. For the analysis, the cohort was further categorised into favourable pouch outcomes (sustained normal pouch, acute pouchitis) vs. unfavourable pouch outcomes (CP, CLDP or pouch failure). Logistic regression included gender, age, previous therapies, disease duration before pouch surgery, surgical technique and number of previous non-IBD related abdominal operations.

Results

We included 182 patients (55% females; median age at IPAA: 32 years (IQR 23–45); median disease duration until pouch surgery 6 years (3–11); two-staged surgery 69%). The median follow up time was 14 years (IQR 7–22). Before surgery, 37% of patients had been exposed to immunomodulators (either thiopurines or methotrexate), 24% were exposed to anti-TNF therapy and 5% were previously treated with vedolizumab. An unfavourable pouch phenotype was noted in 48% of patients. On multivariate logistic regression, anti-TNF therapy and older age at pouch surgery were associated with decreased odds of an unfavourable pouch outcome (OR 0.3 95% CI 0.11–0.69, p = 0.007 and OR 0.96 95% CI 0.93–0.98, p = 0.005, respectively).

Conclusion

Therapy of UC with an anti-TNF and older age were associated with a favourable pouch outcome. These may be surrogates for patients with longer follow up as well as indication for IPAA. Such factors should be taken into consideration in clinical decision making.
P208 Correlation between physician and patient disease assessments in ulcerative colitis: 2-year UK data from the ICONIC study
Authors: Bhala N , Hart A , Watts D , Lewis S , Ghosh S , van Haaren S , Hansell C , Ahmad T
Published: January 2020

Background

ICONIC is the largest prospective multi-country (n = 33) observational study assessing burden in adult ulcerative colitis (UC) patients under routine care. Both patient and physician assessments of disease severity, activity and life impact were captured 6 monthly up to 2 years. This local subanalysis evaluates baseline (BL) characteristics and the extent of agreement between patients and physicians in measures of disease activity in UK patients.

Methods

Adults with early UC (diagnosed ≤36 months) were enrolled irrespective of disease severity or treatment. Patient self-assessments include disease severity, Pictorial Representation of Illness and Self-Measure (PRISM, a tool assessing perception of disease-associated suffering; lower scores indicate greater disease burden), Patient Health Questionnaire-9 (PHQ-9), Short inflammatory bowel disease Questionnaire (SIBDQ) and patient-modified Simple Clinical Colitis Activity Index (P-SCCAI). Physician assessments include clinical parameters, PRISM, SCCAI. Correlation between PRISM and SIBDQ, PHQ-9 and SCCAI were evaluated by Spearman correlation. BL characteristics are based on observed data.

Results

BL characteristics of 63 UK patients in ICONIC are shown in Table 1. From BL to 2-years, patient/physician PRISM was moderately/strongly correlated with SIBDQ, PHQ-9, P-SCCAI or SCCAI (Table 2). For 62 patients with self and physician assessments, the level of agreement on disease severity at BL (concordant pairs) was: mild 66.7%, moderate 27.8%, severe 45.5%, in remission 50.0%. The mean ± SD P-SCCAI and physician SCCAI values at 2 years were 2.6 ± 2.6 and 1.5 ± 1.5, respectively; the measures were strongly correlated (Table 2). For patient/physician PRISM assessments at 2 years, scores were 5.2 ± 2.6 and 5.2 ± 2.1, respectively, and were moderately/strongly correlated (Table 2).

Conclusion

Results from this subanalysis of ICONIC demonstrate persistently high UC disease burden over 2-years, despite treatment. EIMs were common and therefore awareness of potential EIM impact is essential. PRISM, used for the first time in UC, was moderately correlated with disease-specific measures (SIBDQ/SCCAI) and a general depression assessment (PHQ-9). Alignment between patients and physicians on disease activity/severity varied according to the instrument used but was greatest for SCCAI.
P211 Positivity of stool sampling for enteric pathogens during inflammatory bowel disease flares in paediatric patients and its impact on disease outcomes
Authors: Melnik P , Matar M , Shamir R , Assa A
Published: January 2020

Background

Enteric infections due to Clostridium difficile toxin (CDT) is more common in patients with inflammatory bowel disease (IBD). We aimed to assess the frequency and outcomes of CDT and non-CDT enteric infections in symptomatic paediatric patients with IBD.

Methods

Patients’ records were retrospectively searched for disease flares in which stool samples were collected. Each patient with a positive sample was matched with a patient with IBD flares and negative sample in order to analyse 1-year outcomes following sampling.

Results

A total of 618 paediatric patients with IBD (Crohn’s disease, n = 439, 71%, mean age at diagnosis 12.99 ± 3.4, females, n = 264, 42.7%) had 1204 stool samples during the study period (2001–2018). Of these, 43 (3.6%) were positive for bacteria, and 32 (74.4%) of which positive for Campylobacter jejuni. Of 463 samples for CDT, 31 (6.7%) were positive while parasitic infection was rare, 11/765 (1.4%). Overall, 19 positive C. jejuni cases and 19 positive CDT cases with matching controls were examined. During 12 months of follow-up, the mean number of disease flares and ER visits was higher among patients with positive CDT (1.5 ± 1.4 vs. 0.5 ± 0.9, p = 0.019, 1.3 ± 1.5 vs. 0.4 ± 0.8, p = 0.05, respectively) with a numeric increase of surgical interventions (3 vs. 0). There were no significant differences in disease outcomes between patients with C. jejuni infections and matched controls.

Conclusion

Clostridium difficile and Campylobacter jejuni are the most common enteric infections among paediatric patients with IBD but only clostridial infection results in a more severe disease course within 12 months of infection.
P212 Deep learning video analysis for a fully automated per-frame grading of ulcerative colitis
Authors: GUTIERREZ BECKER B , Gamez Serna C , Thalhammer A , Oh Y , Drawnel F , Arcadu F , Prunotto M
Published: January 2020

Background

Several approaches have been proposed to use deep learning to automatically assess the severity of ulcerative colitis (UC) in terms of Mayo Clinic Endoscopic Subscore (MCES) from colonoscopy videos. These previous methods have been trained and evaluated on high-quality individual frames, carefully hand-picked by an expert gastroenterologist and without rigorous central endoscopy reading as an anchor. We investigate the use of a fully automated, end-to-end approach which takes as input raw endoscopic videos and returns the MCES values for individual colon sections.

Methods

Our method consisted of two stages: (1) a Quality Control Network (QCN) which took as input a raw endoscopic video and removed from the analysis frames with poor image quality and (2) a Severity Scoring Network (SSN) which took the high-quality frames extracted using the QCN and returned a severity score for each individual frame. To obtain an aggregate severity score for a full video or a colon section, the individual predictions were aggregated by averaging all individual predictions. Both the QCN and the SSN are convolutional neural networks (Resnet50) trained in a weakly supervised manner. The QCN was trained by providing the network examples of good quality vs. bad quality video segments and the SSN was trained by giving pairs of video segments extracted for a given colon subsection (rectum, sigmoid, descending colon) and its corresponding MCES. Manual annotations of quality were performed by non-experts while annotations for colon subsection and MCES were performed by expert gastroenterologists as part of the Hickory (NCT02100696) and Laurel (NCT02165215) clinical studies.

Results

We evaluated our method retrospectively in 104 sigmoidoscopy videos obtained from Hickory and Laurel. We measured the agreement between the per-section MCES generated as part of the studies and the MCES obtained by automatic grading. Evaluation was done in a binary setting, where grading was constrained to determining whether a colon section has an MCES above a certain threshold. We achieved an Area Under the receiving operating characteristic Curve (AUC) of 0.76 +−0.08 for the detection of MCES >1 and an AUC of 0.81 +−0.06 for MCES >3 after performing 5-fold cross-validation.

Conclusion

We have demonstrated that the use of deep learning for a fully automated assessment of the severity of ulcerative colitis in colonoscopy videos is feasible. Our approach achieves high accuracy even when training is performed using weak labels and a limited number of examples and paves the way towards a fully automated assessment of the severity of ulcerative colitis in full colonoscopy videos.
P217 The role of 7-alfa-hydroxy-4-cholesten-3-one (C4) as a biomarker for bile acid malabsorption in inflammatory bowel disease and microscopic colitis
Authors: Lyutakov I , Lozanov V , Sugareva P , Nakov R , Valkov H , Dimov A , Vladimirov B , Penchev P
Published: January 2020

Background

Bile acid diarrhoea (BAD) is a condition when excessive bile acids (BAs) enter the colon due to bile acid malabsorption (BAM). Impaired metabolism of BAs and BAM interaction are involved in the pathophysiology of microscopic colitis (MC) and inflammatory bowel disease (IBD), especially in Crohn’s disease (CD). Plasma levels of 7-alfa-hydroxy-4-cholesten-3-one (C4) is a new biomarker of BA synthesis. Little is known about the mechanisms of BAs dysregulation and levels of C4 in patients with IBD, irritable bowel syndrome (IBS-D) and microscopic colitis (MC).

Methods

The aim was to evaluate the diagnostic accuracy of plasma levels of C4 for finding BAM in patients with IBD, IBS-D and MC. We enrolled 109 adult patients with chronic diarrhoea and 11 healthy controls who underwent standard laboratory tests, colonoscopy, serum C4 and faecal calprotectin (FC). Patients were split into six groups: 30 patients with active IBD, 21 patients with IBD in remission reporting a high number of bowel movements per day, 21 patients with IBD after surgery (ileal resection), 23 patients with IBS- D, 14 patients with MC and 11 healthy subjects (controls). Fasting serum C4 were measured by high-performance liquid chromatography (HPLC) analysis and FC by the quantitative immunochromatographic method.

Results

Based on cut-off levels of C4 (above 48.4 ng/ml) diagnosis of BAM was confirmed in 66 of 109 patients (60.5%) and excluded in 43 patients (39.4%) compare to healthy controls. Median levels of C4 in patients with IBD active were 53.1 ng/ml, IBD remission was 52.2 ng/ml, IBD after surgery was 85.7 ng/ml, IBS-D were 7.5 ng/ml, MC was 69.3 ng/ml and healthy controls were with 3.7 ng/ml. A cut-off concentration of C4 of 48.4 ng/ml or higher identified patients with MC and IBD with diarrhoea attributable to BAM with an AUROC 0.89 and sensitivity 79.8%, specificity 90.9%, positive predictive value (PPV) of 96.1% and negative predictive value (NPV) of 88.6% compared with healthy controls (p < 0.001). IBD patients in remission (FC < 100 µg/g) with up to 4 bowel movements daily was n = 16 (76.2%) and concentration of C4 above 48.4 ng/ml were found in n = 13 (61%) of the patients.

Conclusion

BAM in IBD and MC is a common and very under-diagnosed condition. Serum C4 could be used for screening biomarker for BAM in patients with IBD, IBD after surgery (ileal resection) and MC. We found that serum concentrations of C4 above 48.4 ng/ml identify patients with diarrhoea likely attributable to BAM with high diagnostic accuracy and IBD patients in remission with found bile acid diarrhoea can benefit from additional treatment with bile acid binders. Further bigger studies are needed to establish the efficacy of serum C4 in patients with suspected BAM in IBD and MC.
P222 Extraintestinal manifestations in paediatric-onset inflammatory bowel disease depending on disease location and activity
Authors: Grzybowska-Chlebowczyk U E , Buczyńska A , Niewiem M , Flak-Wancerz A , Kałużna-Czyż M , Więcek S
Published: January 2020

Background

Inflammatory bowel disease (IBD) and its major forms, i.e. Crohn’s disease (CD) and ulcerative colitis (UC), have systemic implications, which, as suggested by Vavricka et al., can be divided into extraintestinal manifestations (EIM) directly related to immune mechanisms and non-immune extraintestinal complications resulting from malabsorption. Extraintestinal manifestations may develop prior to or after IBD diagnosis. The aim of the study was to determine the prevalence and types of extraintestinal manifestations (EIMs) in paediatric-onset inflammatory bowel diseases (IBD), i.e., Crohn’s disease (CD) and ulcerative colitis (UC), depending on disease activity and location, and to determine whether the presence of EIM is associated with a distinctive clinical course of IBD.

Methods

The medical records of 336 children with IBD with or without EIMs were retrospectively analysed, especially regarding the following characteristics: age at diagnosis, clinical symptoms, nutritional status, the Paris Classification, and IBD activity. The diagnosis was made based on the revised Porto criteria. The medical histories of patients and data obtained in physical examinations were analysed, especially the following: (a) anthropometric measurements for nutritional status assessment based on percentile charts of the OLAF study, (b) disease activity using the PCDAI and the PUCAI, disease location and type according to the Paris classification.

Results

The study population of 336 children comprised 175 patients with UC and 161 patients with CD. EIMs were diagnosed in 65 patients (19%). The most frequent immune-related EIM in UC patients was primary sclerosing cholangitis (PSC); the collective proportion of PSC and PSC/autoimmune hepatitis (AIH) was 13,7% of UC patients. Arthropathy was the most prevalent EIM in the subpopulation of CD participants (8,6%). Pancolitis was a risk factor for EIMs in the UC and especially for PSC and AIH/PSC. We also analysed the population for correlation in presented symptoms pattern in patients EIM(+) vs. EIM(-) as well as differences in age and sex distribution and IBD activity, location and behaviour.

Conclusion

EIMs are a significant issue in the population of children with IBD; they developed in 19% of our patients. Determination of the prevalence of these manifestations and related risk factors might raise awareness of the problem and facilitate diagnosis and therapy.
P226 Assessing the effectiveness of the nurse navigator role in an inflammatory bowel disease medical home: A retrospective cohort study
Authors: Heisler C G , Gawdat K , Nazer N , Stewart M , Currie B , Phalen-Kelly K , Jones J
Published: January 2020

Background

Patients living with chronic illnesses require long-term and often repeated interactions with the healthcare system. inflammatory bowel disease (IBD) is an incurable, chronic gastrointestinal disease which frequently flares and remits. The nurse navigator (NN) serves as the point of first contact for IBD connecting patients with their multidisciplinary care team in order to facilitate and expedite assessment, treatment and navigation through the healthcare system with the goal of improving disease-related outcomes while reducing healthcare system burden. The aim of this study was to assess the impact of implementation of an IBD NN role within a multidisciplinary IBD Medical home on access to care, disease-related outcomes, patient satisfaction with care, and healthcare resource use.

Methods

This was a retrospective cohort study comparing an IBD patient population that had access to a 24/7 NN-led helpline to a reference population who did not have access to such a service. Data between August 2017 and October 2019 were extracted from patient charts. Distribution of the number of flares and time to clinical assessment between the NN exposed cohort and a non-NN exposed cohort are planned using multivariate analysis. This is a preliminary description of the NN-exposed cohort only.

Results

Preliminary results identified a total of 643 patients in the NN-exposed cohort. The majority of our NN-exposed population were female (64.3%). The mean age was 46.42 ± 16.86 years. Sixty-five per cent of patients had CD, 33% UC and 2% IBDU. Of the 729 calls extracted, care coordination (39%) was the most frequent indication for calls followed by flare (25%), and medication education (16%). Patients made the majority (52.8%) of calls compared with NN initiated calls (47.2%). The mean number of calls per patient was 2.64 ± 2.51 (range 1–18) during the study period. Time to clinic assessment post flare call was on average 10.22 ± 8.51 days.

Conclusion

These results are descriptive of the NN-exposed cohort. Data comparing outcomes amongst the NN-exposed cohort to the non-exposed cohort will be presented at ECCO.
P227 Defining faecal calprotectin thresholds to predict endoscopic and histological healing in ulcerative colitis (UC) by using advanced optical enhancement techniques
Authors: Cannatelli R , Zardo D , Nardone O , Bazarova A , Shivaji U , Smith S C L , Ghosh S , Iacucci M
Published: January 2020

Background

Faecal calprotectin (FC) is the most common surrogate marker of mucosal healing (MH) in UC. A number of endoscopic and histologic scoring systems in UC have been developed for defining MH. We report the optimum FC thresholds for defining MH using all the assessment methods.

Methods

In a prospective study we collected all clinical, endoscopic and histologic data and FC from 76 UC patients (mean age 44.2y, 50.0% male) who attended endoscopy unit for colitis assessment or surveillance. Endoscopic scores were determined by the same endoscopist (MI) and included Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS) and PICaSSO (Paddington International virtual ChromoendoScopy ScOre). Histological activity was scored by the Robarts Histology Index (RHI) and Nancy Index by the same pathologist (DZ). Faecal calprotectin was assayed using Buhlmann faecal turbo test, particle enhanced turbidimetric immunoassay. ROC curves were performed to evaluate sensitivity, specificity and accuracy of the optimum cut-off of FC to predict endoscopic and histological healing.

Results

The best cut-off for FC to predict endoscopic healing calculated as Picasso≤3 was 161 μg/g with Area Under ROC curve (AUROC) of 85.3% (95% CI 76.2, 94.4). Sensitivity, specificity and accuracy were 87.9% (95% CI 57.6, 100), 76.7% (95% CI 53.5, 90.7) and 81.6% (95% CI 68.4, 89.5), respectively. While, the best threshold of FC to predict UCEIS≤1 was 148 μg/g with AUROC of 89.2 (95% CI 81.9, 96.5). Sensitivity was 93.5% (95% CI 50.5, 100), specificity 82.2% (95% CI 53.3, 91.1) and accuracy 86.8% (95% CI 69.7, 92.1). The best threshold for FC to predict MES equal to 0, was 112 μg/g, with AUROC of 89.6 μg/g, (95% CI 82.5, 96.7). Sensitivity, specificity and accuracy were 89.7%ww (95% CI 39.2, 100), 85.1% (95% CI 55.3, 93.6) and 86.9% (95% CI 68.4, 92.1), respectively. The best value of FC to predict histological healing with RHI≤3 was 112μg/g with AUROC of 88.0% (95% CI 80.6, 95.4). Sensitivity, specificity and accuracy were 88.5% (95% CI 53.8, 100), 80.0% (95% CI 62.0, 90.0) and 82.9% (95% CI 72.5, 89.5), respectively.

When used Nancy≤1 FC cut-off to predict healing was 172 μg/g with AUROC of 87.1% (95% CI 78.6, 95.6). Sensitivity was 96.4% (95% CI 60.7, 100), specificity 72.9% (54.2, 85.4) and accuracy 81.6% (69.7, 89.5).

Conclusion

Advanced enhancement technologies can accurately define the level of FC to predict endoscopic and histological healing in UC. The optimum FC threshold for MH by PICaSSO and by Nancy was similar (161 and 172 μg/g respectively), while the FC threshold for mucosal healing by MES and by RHI was 112 μg/g. The FC threshold for determining MH in clinical practice should be lower than at least 200 μg/g.
P229 PillCamCrohn’sCapsule: the use of a panenteric capsule endoscopy in a Portuguese centre
Authors: Gomes C , Sousa M , Ponte A , Pinho R , Rodrigues A , Rocha Silva J C , Afecto E , Carvalho J
Published: January 2020

Background

Crohn’s disease (CD) is a complex chronic inflammatory gastrointestinal condition with variable age of onset, disease location and behaviour. PillCamCrohn’sCapsule (PCC) was recently introduced as a new system composed of a two-headed capsule which allows an extensive coverage of the gastrointestinal (GI) tract. This panenteric capsule endoscopy plays an important role in the diagnosis and monitoring of CD patients and has the potential to reduce multiple procedures in CD, consequently increasing patients’ satisfaction. However, its role in clinical practice remains undefined due to limited data. A recent study in children demonstrated its importance ina treat-to-target approach and a randomised trial is currently under-recruiting in order to evaluate the likelihood of panenteric mucosal healing in CD patients treated with Vedolizumab. The authors present an analysis of the application of this system.

Methods

A cross-sectional analysis of SBC from patients with suspected or established CD was performed. Data were collected retrospectively. Patients performed 2L of polyethylene glycol (PEG) prior to PCC ingestion. After PCC ingestion, patients underwent sequentially: 2 boosters of sodium phosphate (NaP). The authors assessed: indication of PCC, bowel preparation, completeness (when the capsule was naturally excreted), Lewis and CECDAI scores and complications. Diagnosis confirmation and changes in stage disease were also evaluated.

Results

Eighteen patients (median age 43 years, 55.6% female, established CD in 83.3%) were included in the analysis. Indications were suspected CD (16.7%), definition of disease activity and extension (27.8%) and assessment of treatment response (44.4%). All procedures were complete and had an adequate bowel cleansing (Brotzqualitative excellent n = 1, Good n = 15, fair n = 2; Brotz quantitative median 9.5). 72.2% patients presented inflammatory lesions. In established CD median Lewis was 900 and CECDAI 8.5. PCCcorroborated the diagnosis in 1 of 3 patients with suspected CD and changed the staging of the disease in known CD in 13.3% (L1 to L3 n = 1 and B1 to B2 n = 1). No complications were reported including capsule retentions.

Conclusion

This preliminary study showed that PCC is an effective and safe tool to use in suspected or established CD patients. In our study, this method was more frequently used for assessment of treatment response. PCC could be of great advantage in our clinical practice since it provides a complete examination of mucosal healing of the gastrointestinal tract in a single procedure, helping physicians in disease management.
P236 Evaluation of histological inflammation by a novel image enhanced endoscopy technique, dual red imaging, in patients with ulcerative colitis: Preliminary study
Authors: FUJIMOTO K , Watanabe K , Hori K , Kaku K , Kinoshita N , Koshiba R , Kojima K , Sato T , Kawai M , Kamikozuru K , Yokoyama Y , Miyazaki T , Hida N , Nakamura S
Published: January 2020

Background

Endoscopic remission is the ideal treatment goal for patients with ulcerative colitis (UC) in clinical practice. However, several recent investigations tried to evaluate histological healing as a more optimal treatment goal. The assessment of histological healing, however, is usually inconvenient and time-consuming because of the requirement of a biopsy and pathological assessment. Dual red imaging (DRI; Olympus Corporation, Japan) is a novel image enhanced endoscopy technique that can visualise the inflammation, including that in the surface crypt, and vessel findings of the brownish surface or green-coloured deeper layer of the mucosa in contrast to narrow band imaging. We preliminarily evaluated the utility of DRI in the assessment of histological healing in UC as a practical approach.

Methods

We enrolled UC patients who provided consent from May 2018 to September 2019 in our hospital, and performed colonoscopy in the entire colon with white-light imaging and DRI, and then endoscopic pictures and biopsy samples were obtained. Central pathological assessment of histological inflammation based on the Nancy index with individual items was performed for each biopsy sample. We also assessed the clinical background, UC activity according to the Mayo score, white-light endoscopic activity according to the Mayo endoscopic subscore (MES), and DRI findings using a 5-point scale.

Results

We evaluated a total of 90 sets of DRI and pathological findings from 47 UC patients (20 females; median age, 42 [20–84] years; 25 with pancolitis, 17 left-sided colitis, 3 proctitis, and 2 others; median duration of disease, 83 [1–379] months; median Mayo score, 2 [0–11]). Participants were treated with 5-aminosalicylates (38 oral; 7 topical), steroid (4 systemic; 6 topical), immunomodulator (7), anti-TNF agents (5), tofacitinib (3), and tacrolimus (8). Both the MES (r = 0.70) and DRI scale (r = 0.65) correlated well with the Nancy index. Among individual pathological items with respect to inflammation, ulceration (r = 0.69), chronic inflammatory infiltrate (r = 0.66), neutrophils in the lamina propria (r = 0.65), and serrated architectural abnormalities (r = 0.60) correlated well with the Nancy index in contrast to other pathological items. DRI seemed to facilitate the visualisation of histological inflammation in deeper layers of the mucosa compared with white-light imaging or narrow-band imaging.

Conclusion

The novel DRI technique has potential in the evaluation of histological inflammation without the requirement of a biopsy in patients with UC as a practical approach. A further prospective multicenter study in this regard is needed.
P239 Elderly-onset inflammatory bowel disease is associated with higher risks of infections, cancers and hospitalisation: Results from a territory-wide Hong Kong IBD registry
Authors: Mak J W Y , Ho L T C , Wong K , Cheng T Y , Yip T C F , Leung W K , Li M , Lo F H , Ng K M , Sze S F , Leung C M , Tsang S W C , Shan E H S , Chan K H , Lam B C Y , Hui A J , Chow W H , Ng S C
Published: January 2020

Background

Incidence of elderly-onset inflammatory bowel disease (IBD), defined as age ≥ 60 at diagnosis, is increasing rapidly worldwide. We aimed to compare the clinical characteristics and natural history of elderly onset IBD patients to non-elderly onset IBD patients.

Methods

Patients with a confirmed diagnosis of IBD from 1981 to 2016 were identified from a territory-wide Hong Kong IBD registry involving 13 hospitals. Demographics, comorbidities, clinical features and outcomes of elderly-onset IBD patients were compared with non-elderly onset IBD patients.

Results

Total 2413 patients were identified, of whom 270 (11.2%) had elderly-onset IBD during 21805 person-years follow-up. Median follow-up duration was 111 months (Interquartile range [IQR]: 68–165 months). The ratio of ulcerative colitis (UC): Crohn’s disease (CD) was higher in elderly-onset IBD than non-elderly onset IBD patients. (3.82:1 vs. 1.39:1; p < 0.001). Elderly-onset Crohn’s disease (CD) had less perianal involvement (5.4% vs. 25.4%; p < .001) but more stricturing phenotype (32.1% vs. 20.5%; p = 0.04) than non-elderly onset. There was no difference in the rate of cumulative use of biologics (p = 0.49), but significantly lower use of immunosuppressants in elderly-onset IBD patients (p = 0.001). Cumulative risk of IBD-related surgeries was similar (p = 0.89). Elderly-onset IBD was associated with higher risks of cytomegalovirus colitis (Odds ratio [OR]: 3.07; 95% Confidence Interval (CI) 1.92–4.89; p < 0.001); herpes zoster infections (OR: 2.42; 95% CI: 1.22–4.80; p = 0.12) and all cancer development (Hazard ratio: 2.97; 95% CI: 1.84–4.79; p < 0.001). Elderly-onset IBD was also associated with increased number of overall hospitalisation (OR: 1.14; 95% CI 1.09–1.20; p < 0.001), increased number of infections-related hospitalisation (OR: 1.87; 95% CI 1.47–2.38; p < 0.001) and longer hospitalisation (OR: 1.004; 95% CI: 1.001- 1.007; p = 0.007) compared with non-elderly onset IBD.

Conclusion

Elderly-onset IBD has less perianal CD. However, they have significantly more comorbidities and are associated with increased risk of infections, cancer development and increased and prolonged hospitalisations. Specific therapeutic strategies are needed in this special group of patients.