Introduction

Little is now about the natural history and impact of irritable bowel syndrome (IBS)-type symptoms on psychological health and quality of life in inflammatory bowel disease (IBD). We aimed to address this in a one-year longitudinal study of secondary care patients.

Aims & Methods

We collected demographic, Rome III IBS-type symptom, psychological, and quality of life data, with questionnaires at 3-month intervals, over 12 months of follow-up in patients with IBD in clinical remission at baseline. We assessed the natural history of Rome III IBS-type symptoms over the 12 months of the study and compared psychological and quality of life data between those reporting Rome III IBS-type symptoms at each of the points of follow-up with those not reporting such symptoms.

Results

Among 206 patients with IBD in clinical remission at baseline (104 (50.5%) women, mean age 56.9 years (range 18-83 years), 79 (38.3%) Crohn’s disease), 33 (16.0%) reported Rome III IBS-type symptoms at baseline and 72 (35.0%) reported Rome III IBS-type symptoms at one or more time points. Among the 33 patients with Rome III IBS-type symptoms at baseline, symptoms resolved in 6 (18.2%) patients, were present throughout in 6 (18.2%) patients, and fluctuated in the remaining 21 (63.6%) patients. Among the 39 patients with new onset of Rome III IBS-type symptoms after baseline, 24 (65.1%) had symptoms at one point in time only, 10 (25.6%) at two points, four (10.3%) at three points, and one (2.6%) at four points. At each point in time, reporting IBS-type symptoms was associated with significantly higher anxiety, depression, or somatoform symptom-reporting scores, and/or lower quality of life scores.

	Baseline		3 months		6 months		9 months		12 months
	Rome III IBS-type symptoms		Rome III IBS-type symptoms		Rome III IBS-type symptoms		Rome III IBS-type symptoms		Rome III IBS-type symptoms
	Yes (n=33)	No (n=173)	Yes (n=35)	No (n=171)	Yes (n=25)	No (n=181)	Yes (n=33)	No (n=173)	Yes (n=34)	No (n=172)
Mean HADS-A (SD)	7.8 (4.0)*	4.8 (3.7)	7.7 (4.2)*	4.9 (3.9)	8.5 (4.7)*	4.8 (4.0)	7.1 (3.9)†	4.9 (4.2)	6.1 (4.7)	5.1 (4.2)
Mean HADS-D (SD)	5.0 (3.3)*	2.8 (2.9)	5.4 (3.9)*	2.9 (3.0)	5.6 (4.2)	3.4 (3.5)	5.2 (3.6)†	3.2 (3.4)	4.7 (4.1)	3.3 (3.4)
Mean PHQ-12 (SD)	7.0 (3.6)*	3.8 (3.1)	6.5 (3.9)†	4.2 (3.3)	5.6 (2.8)	4.2 (3.6)	5.9 (3.9)	4.0 (3.1)	5.9 (4.1)	4.1 (3.4)
Mean SIBDQ (SD)	49.8 (8.6)*	60.0 (7.9)	50.2 (10.7)*	59.8 (8.3)	48.8 (12.9)*	59.3 (8.8)	49.8 (10.9)*	58.4 (9.8)	52.0 (9.8)†	58.1 (10.1)

Conclusion

In this 12-month follow-up study, one-third of patients with IBD reported presence of Rome III IBS-type symptoms at any point in time. Reporting such symptoms was associated with significant impacts on psychological health and/or quality of life.

Disclosure

none

Introduction

Infection by Leishmania spp. in patients diagnosed with inflammatory bowel disease (IBD) is an uncommon infectious complication. The use of anti-TNF-α is well known risk factor for Leishmania infection (LI), particularly in some endemic areas, but only a few case series have been reported in the literature, mainly in the Mediterranean basin.

Aims & Methods

Aim: To evaluate the main demographic, IBD-disease features and risk factors as well as LI disease characteristic and required treatment among IBD patients who develop LI.
Methods: This is a retrospective, observational, multicenter study conducted in twenty-five Spanish hospitals, promoted by the Young Group of GETECCU, including patients diagnosed with IBD and subsequent diagnosis of LI.

Results

We collected a total of 73 patients, 48 of them were men (65.8%) with a mean age of 48 ± 15.06 years. 92% of patients resided in the Mediterranean basin, an endemic area of Leishmania. Only 1 patient was born outside of Spain. Nineteen percent of patients were smokers and 16.4% had some comorbidities.
Fifty patients had Crohn's disease (CD) (68.5%) with ileocolonic involvement (30.1%) and inflammatory behaviour (45.2%) and 42.9% had perianal disease. 94% of CD patients were on clinical remission at the time of LI diagnosis. In addition, 23 patients had ulcerative colitis (UC) (31.5%), being extensive colitis the most frequent extent (78.3%), and all of them were on clinical remission or had mild disease activity. 69 patients (94.5%) were under immunosuppressive and/or biologic treatment during the 6 months prior to the LI. 6.8% were on immunosuppressants monotherapy, 42.5% in combotherapy and 38.4% under biologic monotherapy. Regarding biological treatment, 97% of patients were under AntiTNF and only 2 patients were under treatment with Ustekinumab.
Regarding the characteristics of LI, 62 patients presented cutaneous involvement (85%), 9 visceral (12%) and the rest presented mucocutaneous involvement.
Symptoms associated to LI were fever (9.6%), abdominal pain (4.1%) and constitutional syndrome (8.2%), moreover 24.7% required hospital admission. Regarding the location of the skin lesions, the most frequent were the upper limbs (35.6%) followed by lower limbs (30.1%).
The treatment used for LI was systemic amphotericin in 60.3% of patients and pentavalent antimonials in 35.4%; the remaining patients were treated with other treatments, including miltefosine. LI solved at one month in 33 patients (45.2%) and at one year in 95.3% of patients, and only 11% of patients had recurrent LI.
Treatment was stopped temporarily in 38.4% of patients and definitively in 27.4%, starting Ustekinumab (36.8%), Vedolizumab (15.8%) and antiTNF (10.6%) and the rest of the patients remained without biological treatment after the LI.

Conclusion

The usage of antiTNF is associated to LI in IBD patients, but LI could also happen under inmunossupresants or ustekinumab therapy. Although cutaneous involvement is the most frequent manifestation, 12% of patients have visceral involvement or LI recurrences. This infectious complication should be considered in IBD patients in endemic areas.

Disclosure

No Conflict of Interest.

Introduction

Acute severe flares occur in 15% of patients with ulcerative colitis (UC). Intravenous corticosteroids induce clinical remission in up to 50-60% of cases. Infliximab (IFX) and cyclosporin (CsA) are the only evidence-based alternatives to colectomy in steroid-refractory acute severe UC (SRASUC), with a similar efficacy. It has been suggested that a more aggressive induction regimen of IFX might decrease the rate of colectomy.

Aims & Methods

To evaluate the short and mid-term outcomes of patients with SRASUC treated with IFX regarding the used induction regimen.
Methods: Retrospective, observational study including adult patients included in the ENEIDA registry supported by GETECCU, treated with IFX (at least two doses) due to SRASUC and available follow-up of at least 3 months or until colectomy or death. Dates and dosing of the first three IFX infusions, dose-escalation or treatment discontinuation, colectomy and date were collected. Induction regimens were grouped as follows: CONVENTIONAL (IFX 5mg/kg at 0, 2 and 6 weeks), ESCALATED (any of the first three infusions >5mg/kg) and ACCELERATED (second infusion administered before 11 days of the first one, or third infusion administered before 21 days of the second one).

Results

A total of 339 patients were included, 59% with extensive UC and 34% previously exposed to thiopurines. At the time of the first IFX infusion, median partial Mayo score was 7 (IQR, 6-8), median Mayo endoscopic subscore 3 (IQR, 2-3) and median C-reactive protein 49 mg/L (IQR, 18-99). IFX was started after a median of 7 days (IQR, 6-8) on iv steroids, with concomitant thiopurines in 51% of the cases. The induction regimen was conventional in 207 patients (61%), escalated in 81 (24%), and accelerated in 99 (29%), although 48 (14%) used escalated and accelerated regimens together. Partial Mayo score, Mayo endoscopic subscore and C-reactive protein levels at the time of the first IFX infusion were not significantly different between those patients following conventional regimen and those who did not; baseline serum albumin levels (29.9±0.7 vs 32.3±0.9 g/L; P=0.002) and prior exposure to thiopurines (38.2% vs 25.9%; P=0.022) were significantly lower in patients who followed escalated or accelerated regimens. One hundred and thirty-three patients (39%) discontinued IFX within the first year due to failure (no response or partial response) in 72 (21%), adverse event in 45 (13%), complete remission in 9 (3%) and patient’s willingness in 5 (2%).
The colectomy rate at 30 days, 90 days and 12 months in the whole series was 6%, 8% and 13%, respectively. Patients who followed a full conventional regimen had significantly lower rates of colectomy at 30 (1.5% vs 12.9%; p<0.0001), 90 days (3.9% vs 15.2%; p<0.0001) and 1 year (9.6% vs 20.9%; p=0.004). In the logistic regression analysis, following a conventional induction regimen was the only protective factor of colectomy at 30 (OR 0.08 95%CI 0.02-0.36) and 90 days (OR 0.19 95%CI 0.07-0.54).
No differences were observed among conventional and intensified induction regimens in terms of steroid reintroduction and IFX discontinuation within the first year.

Conclusion

In clinical practice, accelerated and/or escalated induction regimens of IFX are used in almost half of the patients with SRASUC. Accelerated and escalated induction regimens were associated with significantly higher rates of colectomy at one and three months. Therefore, no benefit of using these modified induction regimens was found on the basis of current clinical practice decision-making criteria.

Disclosure

Eugeni Domènech has served as a speaker, or has received research or education funding or advisory fees from AbbVie, Adacyte Therapeutics, Biogen, Celltrion, Galapagos, Gilead, GoodGut, Imidomics, Janssen, Kern Pharma, MSD, Pfizer, Roche, Samsung, Takeda, Tillots.

Introduction

Inflammatory bowel disease (IBD), a chronic inflammatory disease of the gastrointestinal tract, is caused by various factors, including genetic factors and environmental factors, as well as dysregulated immune responses. LMT503, a novel organic small-molecule compound, has the potential to suppress pro-inflammatory cells and induce anti-inflammatory cells by modulating their cell metabolisms. We evaluated the anti-inflammatory effects of LMT503 in a murine adoptive T cell transfer-induced colitis model.

Aims & Methods

This study was conducted to evaluate the anti-inflammatory effect of LMT503 in the murine chronic colitis model. Naïve CD4⁺CD25^-CD45RB^high CD62L^high T cells that were isolated from wild-type mice by flow cytometry based-method and transferred to Rag1 knock-out mice by intraperitoneal injection to induce murine adoptive T cell transfer-induced colitis. LMT503 was orally administrated (50mg/kg, 100mg/kg) for 2 weeks starting at 5 weeks after naïve T cell transfer. The disease activity index (DAI) was checked daily, and histopathological score, macroscopic injury score, and colon length were evaluated upon sacrifice. Macrophages and T cells from the spleen were analyzed by flow cytometry. Gene expression in colon tissue was measured by qRT-PCR and cytokine profiles in plasma was measured by cytometric bead array. Myeloperoxidase (MPO) activity was measured using the MPO activity kit.

Results

Oral administration of LMT503 ameliorated adoptive T cell transfer-induced colitis in mice. The DAI, histopathological score, and macroscopic injury score were significantly decreased after the administration of LMT503 in a dose-dependent manner. The LMT503-treated group showed significantly increased mucin production in the colon. Th1, Th17 cells, and M1 macrophages in the spleen were suppressed, and M2 macrophages were induced by the administration of LMT503. MPO activity and gene expressions of pro-inflammatory cytokines, such as IL-6, IL-1β, and TNF-α, in colon tissue were suppressed by the administration of LMT503. And the level of inflammatory cytokines, such as IL-2, TNF-α, and IFN-γ, in plasma were significantly suppressed by the administration of LMT503. Especially, LMT503 treatment significantly increased the gene expression of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (Ppargc1a), a master regulator of mitochondrial biogenesis, suggesting that LMT503 modulates cellular metabolism towards an anti-inflammatory metabolism.

Conclusion

Our data suggest that the anti-inflammatory effect of LMT503 ameliorates murine adoptive T cell transfer-induced colitis by modulating cellular metabolism and immune cell modulation. Therefore, LMT503 may be a novel therapeutic drug that opens new avenues for the treatment of IBD.

References

1. Erben U, Loddenkemper C, Doerfel K, et al. A guide to histomorphological evaluation of intestinal inflammation in mouse models. Int J Clin Exp Pathol. 2014;7(8):4557-4576.
2. Ostanin DV, Bao J, Koboziev I, et al. T cell transfer model of chronic colitis: concepts, considerations, and tricks of the trade. Am J Physiol Gastrointest Liver Physiol. 2009;296(2):G135-G146.
3. Ghoreschi K, Jesson MI, Li X, et al. Modulation of innate and adaptive immune responses by tofacitinib (CP-690,550). J Immunol. 2011;186(7):4234-4243.
4. Burke JR, Cheng L, Gillooly KM, et al. Autoimmune pathways in mice and humans are blocked by pharmacological stabilization of the TYK2 pseudokinase domain. Sci Transl Med. 2019;11(502):eaaw1736.
5. Kiesler P, Fuss IJ, Strober W. Experimental Models of Inflammatory Bowel Diseases. Cell Mol Gastroenterol Hepatol. 2015;1(2):154-170.

Introduction

No single pharmacological approach is currently available for the treatment of inflammatory bowel disease (IBD) in active and maintenance stages. As evidence is growing on the immuno-modulatory activities of the G-protein coupled receptor GPR120 and on its role in modulating the pathophysiology of IBD, its potential as a therapeutic target for this disease is worthy of exploration.

Aims & Methods

Herein, we have developed DFL23806, a new GPR120 selective small molecule agonist, and propose it as a potential therapeutic approach for IBD. We employed our in-house proprietary Exscalate platform for molecular docking simulations to define the site and mode of binding of the compound with the receptor and used in vitro studies and in vivo models (murine dextran sodium sulfate (DSS)-induced acute and chronic colitis and 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced chronic colitis models) to characterize the mechanism of action of our molecule and evaluate its therapeutic effects.

Results

DFL23806 is a selective agonist of human and mouse GPR120 that can activate both the G-protein dependent and independent signaling (β-arrestin pathway) of the receptor. DFL23806 has been designed to have high metabolic stability and reach the ileum and colon at optimal concentrations that allow for the activation of GPR120 while, notably, delaying its internalization. This can lead to prolonged periods of signal transduction compared to other commercially available GPR120 agonists and amplification of signaling effects. In vivo, intrarectal treatment with DFL23806 exerted consistent immunomodulatory action in DSS-induced acute colitis in mice. Moreover, oral treatment with DFL23806 significantly inhibited both DSS- and TNBS-induced chronic colonic inflammation and fibrosis by improving the disease activity index, endoscopic score, and reducing body weight loss and colonic tissue damage. Interestingly, DFL23806 treatment also modulated the composition of microbiota, inhibiting the concentration of pathogenic bacteria, and rescued intestinal dysbiosis induced by TNBS.

Conclusion

These results suggest that the stimulation of GPR120 could be an effective strategy for managing colitis, and that DFL23806 has great potential as a therapeutic for the treatment of IBD.

Disclosure

The authors are employees of Dompé farmaceutici s.p.a., Italy. The company has interests in the development of GPR120 selective agonist for the treatment of IBD and metabolic diseases.

Introduction

The precise aetiology of inflammatory bowel disease (IBD) remains unclear with excess intestinal cell death implicated yet vastly understudied. Necroptosis, a recently described lytic cell death pathway, is emerging as a key player in intestinal inflammation in mouse models of colitis (1, 2), however clinical data are sparse. This non-apoptotic regulated cell death can be initiated by tumour necrosis factor (TNF) receptor activation and is executed by a core axis of proteins, including receptor-interacting protein kinase (RIPK) -1 and -3, and mixed lineage domain-like pseudokinase (MLKL) independent of caspases (3). The pathway is usually repressed by cellular inhibitor of apoptosis protein (cIAP) -1 and -2, and cellular FLICE-like inhibitory (cFLIP_L).
This project proposes the first study to comprehensively assess programmed cell death in intestinal tissue of adult patients with IBD using a novel toolbox of affinity reagents (4). By comparing this with non-inflamed control tissue, we have uncovered a new molecular defect in IBD: loss of essential cellular death brakes, even in tissue with apparent mucosal and histologic healing. This novel finding may underpin the vicious cycle of remission and disease relapse and poses a step towards molecular healing through restoration of these brakes.

Aims & Methods

Aims:

1. Assess cell death prevalence in IBD
2. Determine why cell death brakes disappear in intestinal IBD tissue, regardless of inflammatory status
3. Determine whether IBD phenotypes can be uniquely profiled according to cell death signals

Methods: Matched intestinal biopsies are retrieved endoscopically from patients without IBD (healthy controls) and those with IBD. Patients requiring endoscopy as part of standard of care are screened for eligibility: exclusion criteria comprise active malignancy, non-IBD inflammation, infection, use of non-steroidal anti-inflammatory drugs, and polyposis syndromes. Biopsies from participants with IBD are taken from macroscopically non-inflamed, margin and inflamed areas. Control specimen are taken from healthy-appearing bowel. Specimen are collected fresh for investigation of pertinent targets (Table 1). Clinical/endoscopy activity indices, biochemical markers (C-reactive protein, faecal calprotectin) and blinded histologic (Robarts Histopathology Index) scoring are correlated with laboratory data in a multi-parametric manner.

MEDIUM	TECHNIQUE	PURPOSE
Phosphate buffer system + protease + phosphatase inhibitors	Immunoblotting	Protein quantification of 26 cell death-related proteins
10% formalin	Immunohistochemistry	Visualisation of 12 cell death-related markers
Methanol + 5% acetic acid	Immunofluorescence	Optic microscopy of necroptosis hot-spots
RNA later	RNA sequencing	Shotgun transcriptomics of host microbiome, immune and inflammatory infiltrates
Dulbecco's Modified Eagle Medium: Nutrient Mixture F12 (DMEM F12) + Primocin	Organoid development	Gut organoid challenges to identify factors impacting cell death

Results

Intestinal biopsies from 28 healthy controls and 52 patients with IBD: 25 UC; 25 CD; and 2 pouchitis have been collected. Interim analysis demonstrates suppression of cell death inhibitory proteins- cIAP-1, -2 and cFLIP_L even in non-inflamed tissue in patients with IBD, unleashing apoptosis (hallmarked by a statistically significant increase in cleaved caspase-3) and/or necroptosis (hallmarked by statistically significant increases in phosphorylated RIPK-3) in nearby tissue.

Conclusion

For the first time, we demonstrate that cellular death brakes are removed in intestinal tissue in IBD, despite histologic remission. Our findings challenge current dogma that necroptosis occurs in the absence of apoptosis and that necroptosis is universally increased in all forms of IBD. Disinhibition of programmed cell death is likely intrinsic to the inflammatory sequence underlying disease recurrence and progression.

References

1. Günther C, Martini E, Wittkopf al. Caspase-8 regulates TNF-α-induced epithelial necroptosis and terminal ileitis. Nature. 2011 Sep 14;477(7364):335-9
2. Patankar JV, Müller TM, Kantham S et al. E-type prostanoid receptor 4 drives resolution of intestinal inflammation by blocking epithelial necroptosis. Nature Cell Biology. 2021 Jul;23(7):796-807
3. Horne CR, Samson AL, Murphy JM. The web of death: the expanding complexity of necroptotic signaling. Trends in Cell Biology. 2023 Feb;33(2):162-174
4. Samson AL,Fitzgibbon C, Patel KM et al. A toolbox for imaging RIPK1, RIPK3, and MLKL in mouse and human cells. Cell Death & Differentiation. 2021 Jul;28(7):2126-2144

Disclosure

AHA is supported by scholarships from the University of Melbourne/Australian Commonwealth Government, Crohn's and Colitis Australia, Avant Foundation, and a grant from the Gastroenterological Society of Australia and Celltrion Healthcare. ALS has received funding from the National Health and Medical Research Council (Grant 2002965). JMM has received funding from the National Health and Medical Research Council (Grants 1172929, 9000719). ALS and JMM contribute to a project developing necroptosis inhibitors with Anaxis Pharma Pty.

Introduction

Recently, artificial intelligence-based computer-aided detection (CADe) for colonoscopy is garnering significant attention due to its effectiveness in increasing adenoma detection rate (ADR). However, theoretically, CADe system cannot decrease exposure error which polyps obscured by an object. In this regard, computer-aided quality improvement (CAQ) which expects to induce the meticulous mucosal inspection and leading to a reduction of blind spot area. In this study, we developed and evaluated CAQ for colonoscopy.

Aims & Methods

This was a single center, retrospective study from period April 1, 2022 to February 25, 2023. We randomly extracted colonoscopy videos and created 18,922 training images. Quadrant images were made from one image and three endoscopists annotated the following scores; i) appropriateness for mucosal inspection, ii) appropriate distance, and iii) presence of blind area in the field of view (e.g., fold or flexure). We conducted supervised machine learning using annotated images. The CAQ deployed multi-head deep convolutional neural network model which can output multiclass prediction from one image. Consequently, the CAQ system outputs aforementioned score from whole colonoscopy video. To validate its performance, we retrospectively analyzed colonoscopy procedures performed by seven endoscopists using the CAQ. We compared calculated CAQ model scores and expertise of endoscopists.

Results

29 videos were included as validation samples (8 videos were performed by non-expert endoscopists) As a result, there was a significant difference in the proportion of appropriate images during the examination between experts and non-experts (median 56% vs. 49%, p=0.005, Mann–Whitney U test) and there was also a significant difference in the evaluation score of the distance between the colon mucosa and the endoscope (median 4.2 vs. 3.2, p=0.0004, Mann–Whitney U test). In addition, there was a significant difference in the scores evaluating the presence of blind areas in the field of view (median 1.6 vs. 1.2, p=0.0007, Mann-Whitney U test).

Conclusion

In this study, developed CAQ system could quantify the skill of the endoscopists. Such CAQ would be expected to standardize the observation technique of colonoscopy.