Introduction

Patients with inflammatory bowel disease (IBD) may present with persisting gastrointestinal symptoms, despite clinical, biochemical and endoscopic remission. Disorders of the gut-brain interaction may coexist, resulting in hypervigilance and visceral hypersensitivity, thus affecting the quality of life of these patients. Failure to identify the origin and assess the reported symptoms may result in unnecessary treatment escalation. The aim of this study is to describe the prevalence of gastrointestinal symptoms and visceral hypersensitivity and the quality of life in patients with IBD in deep remission.

Aims & Methods

We analyzed data from consecutive patients with either Crohn's disease (CD) or ulcerative colitis (UC), who remained under deep remission for at least 6 months. Remission was defined as absence of clinical, biochemical and endoscopic features of active disease. We collected demographics, disease characteristics, symptom severity (via Patient Assessment of gastrointestinal disorders (PAGI-SYM), quality of life (via Patients assessment of gastrointestinal disorders- PAGI-QoL), psychological features including anxiety/depression (Hospital Anxiety and Depression Scale (HADS) and GI-specific anxiety (Visceral Sensitivity Index (VSI).

Results

A total of 69 patients, of whom 50.8% with CD and 49.2% with UC under deep remission (43.2% females, mean age 41.29 +/-14.87) were recruited. All applied questionnaires displayed excellent reliability analysis (Cronbach's alpha was 0.922 for PAGI-SYM, 0.962 for PAGI-QOL, 0.909 for VSI, and 0.848 for HADS respectively). Patients with CD and UC expressed similar gastrointestinal symptoms, as reflected by PAGI-SYM, with the exception of the loss of appetite, where patients with CD experience more severe symptoms than patients with UC (p=0.03). Moreover, the two groups displayed similar outcomes in VSI. Both patients with UC and CD in remission scored normally in HADS, although high on the anxiety score scale (mean anxiety scale 6.25+/- 3.5 and depression scale 4.47 +/- 3.31). However, a total of 36% and 24% of patients score abnormal in anxiety and depression scales respectively.

Conclusion

In this retrospective cohort, we found similar expression of gastrointestinal symptoms, quality of life, visceral hypersensitivity, and anxiety and depression scores in patients with UC and CD in deep remission. However, almost one-third of patients have persisting symptoms, affecting their QoL. A holistic approach is of paramount importance in patients with IBD, targeting both inflammatory and neuro-sensitivity pathways.

Introduction

It has long been hypothesised and increasingly proven that stress (both acute and chronic) can have a significant impact on inflammatory bowel disease (IBD) patient's condition in terms of relapses and worsening disease.1 It is also understood that patients with IBD are at a higher risk of developing depressive disorders than the healthy population. 2 As such ongoing work into the bidirectional gut brain axis and its association with the inflammatory response in the gut is important in understanding how reduction in stress can assist in managing IBD. 3

Aims & Methods

Our study aim was to assess the impact of stress on our IBD patients’ self-reported symptoms, to understand how our IBD patients' managed their stress levels and to assess how their inflammatory bowel disease affects their quality of life.
101 IBD patients attending University Lewisham Hospital completed an anonymous structured paper questionnaire between December 2023 and January 2024. Data was analysed for age, gender, IBD subtype and medications, the impact of stress on their condition, their methods of stress reduction as well as the impact of IBD on their social, work and sexual life.

Results

101 patients completed the survey. 55% were female and the median age was 42 years (IQR 30-58). 45% had ulcerative colitis (UC), 48% had Crohn’s disease (CD) and 8% had IBD-unspecified (IBD-U). 5.6% of patients were not on treatment, 29.7% on mesalazine, 10.9% on azathioprine and 75% were on a biologic therapy.
Of the 101 patients surveyed 76.2% (77/101) felt that stress triggers flares in their condition. 26.7% (27/101) felt that stress directly led to their IBD developing, while 23.8% (24/101) felt it was a contributing factor. 40.6% (41/101)felt that controlling stress was more important than their medications. 62.4% (63/101) employed methods of stress reduction.
The most common methods were: exercise/sports/yoga (41.5%). walking (30.7%), reading (26.7%), socialising (22.8%), alcohol (10.9%) smoking (5.9%) and recreational drugs (3.0%).
32.7% (33/101) felt their condition made them exhausted all of the time. 63.4% (64/101) reported avoiding social events due to their IBD. 48.5% (49/101) reported their condition affected their sex life. 25.6% (26/101) felt their relationship with their partner was affected because of their condition.
Over half of patients surveyed (57.4%, 58/101) felt that their condition affected their mental health, but only 24.8% (25/101) felt they had received sufficient NHS mental health support.
19.8% (20/101) of patients felt their condition had stopped them from getting promoted at work, and 47.5% (48/101) attended work whilst in a disease flare for fear of losing their job. 14.9% (15/101) reported feeling discriminated against because of their condition.

Conclusion

Over three quarters of IBD patients surveyed felt that stress is a significant trigger for flares, however surprisingly over a quarter of IBD patients perceive stress as a direct factor for their disease developing. IBD significantly impacts patients social, work, and sexual life with a significant impact seen on mental health. This survey found that although a good proportion of patients used commonly perceived healthy methods of stress reduction, almost 20% of patients relied on unhealthy methods (smoking, alcohol/recreational drugs). This data presents a clear argument for a holistic approach to IBD patient care and integrating psychological support within an IBD service. Further work should follow on the relationship between patient perceived stress levels and disease outcomes and failed treatments.

References

1) Mikocka-Walus A, Pittet V, Rossel JB, von Känel R; Swiss IBD Cohort Study Group. Symptoms of Depression and Anxiety Are Independently Associated With Clinical Recurrence of Inflammatory Bowel Disease. Clin Gastroenterol Hepatol. 2016 Jun;14(6):829-835
2) Sun Y, Li L, Xie R, Wang B, Jiang K, Cao H. Stress Triggers Flare of Inflammatory Bowel Disease in Children and Adults. Front Pediatr. 2019 Oct 24;7:432.
3) Ge L, Liu S, Li S, Yang J, Hu G, Xu C, Song W. Psychological stress in inflammatory bowel disease: Psychoneuroimmunological insights into bidirectional gut-brain communications. Front Immunol. 2022 Oct 6;13:1016578

Disclosure

Nothi

Introduction

​​​​​As a chronic disease, patients’ perspectives on their disease status and quality of life is an essential part of inflammatory bowel disease (IBD) management¹. Patient-reported outcomes should be the standard of measure for signs and symptoms evaluation².

Aims & Methods

We aimed to evaluate the correlation between patients’ self-assessment of disease activity, activity scores and the physician’s global assessment.
A unicentric cross-sectional study was conducted. The Short Inflammatory Bowel Disease Questionnaire (SIBDQ)³ was administered to consecutively evaluated IBD patients in the outpatient setting. Additionally, a pilot questionnaire addressing perceived disease activity was completed by both patients and their attending physician.
Disease activity was categorized as remission, mild, moderate, or severe. Remission was defined as Harvey Bradshaw Index (HBI) ≤ 4 for Crohn's disease or Mayo Clinic Subscore (MCS) ≤ 2 for ulcerative colitis.
Spearman’s rank correlation coefficient was used to assess correlations between patient-reported disease activity, physician global assessment, disease activity scores, and quality of life.

Results

A total of 105 patients were included (female: 52%; mean age: 44±15 years), of whom 68% had Crohn's disease. 71% percent of patients were receiving advanced therapy (table 1).
A quarter of the patients (27%, n=28) perceived their disease to be in remission, of whom 56% were indeed in deep remission and 19% in endoscopic remission (table 1). A statistically significant positive correlation was observed between patient self-assessment and HBI scores (mean=2.5±6.5 points, r=0.400, p=0.001) and MCS scores (mean=3.4±4.0 points, r=0.574, p<0.001).
Among patients who did not consider themselves in remission, 42% rated the activity of their disease as mild, 23% as moderate, and 9% as severe. The attending physician assessed 26% with mild disease, 22% with moderate disease, and 18% with severe disease (table 1). There was a statistically significant positive correlation between patient and physician assessments (r=0.374; p<0.001).
The mean SIBDQ score was 50.7 ± 12.1 points (table 1), and a statistically significant negative correlation was found between patient self-assessment of disease activity and the SIBDQ (r=-0.417, p<0.001).

Conclusion

These observational data suggest a weak correlation between patient-reported disease activity and the physician’s global assessment. Divergent perceptions of disease activity between patients and physicians may compromise patient-engagement. Furthermore, the moderate correlation observed with overall quality of life supports the importance of alignment patients and physicians to improve the quality of care provided.

References

1 - Fiorino G et al. Quality of Care Standards in Inflammatory Bowel Diseases: a European Crohn's and Colitis Organisation [ECCO] Position Paper. J Crohns Colitis. 2020 Sep 7;14(8):1037-1048. doi: 10.1093/ecco-jcc/jjaa023.
2 - Turner D et al. International Organization for the Study of IBD. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021 Apr;160(5):1570-1583. doi: 10.1053/j.gastro.2020.12.031.
3 - Roseira J et al. Short Inflammatory Bowel Disease Questionnaire: translation and validation to the Portuguese language. Health Qual Life Outcomes. 2021 Feb 18;19(1):59. doi: 10.1186/s12955-021-01698-9.

Introduction

Therapeutic goals in inflammatory bowel diseases (IBD) have undergone considerable change in recent years, with a shift of focus from simply achieving clinical remission. Patient-related outcomes (PROs) have also become increasingly important as adjunctive tools in assessing the efficacy of medical therapy from the patients’ standpoint. Health-related quality of life (HRQoL) questionnaires, correlate well with disease activity and can detect meaningful clinical changes in IBD patients who either suffer a relapse of disease or achieve remission [1,2].

Aims & Methods

We aimed to assess the utility of SIBDQ in the long-term follow-up of IBD patients compared to the conventionally used markers such as clinical indices, CRP levels and endoscopic activity scores. Patients were scheduled for evaluation every 12 months, but additional evaluations were performed as required in case of worsening clinical condition. The main data collected at each study visit included clinical aspects (disease activity, on-going medication, quality of life assessement-The Short Inflammatory Bowel Disease Questionnaire), endoscopic and histological findings.

Results

In a prospective setting, 176 patients were included in the study (65 Crohn’s and 111 UC patients) , with a mean follow-up time of 16 months and 1.3 study visits per patient. Clinical activity was associated with significantly lower SIBDQ (median 4.3 vs 5.7 in those without clinical activity, p<0.001 mann whitney u) and increased inflammatory burden ( median CRP levels 1,99 mg/L vs. 7.2mg/L, p<0.001 mann whitney u). SIBDQ scores were also significantly higher in patients showing mucosal healing compared to those with active ongoing inflammation (5.8 vs 4.9, p<0.001 MWU), while inflammatory burden was also significantly different between patients with and without ongoing mucosal activity (1.6 mg/L vs 4.2 mg/L, p< 0.001 MWU). SIBDQ significantly improved over time, with a median of 4.7, 5.4 and 5.8 at visits 1, 2 and 3 respectively (p<0.001 MWU), which was also consistent with a decrease in the overall inflammatory burden in the cohort (median CRP levels of 4.2, 3.4 and 2.5 mg/L respectively).

Conclusion

Clinical activity is associated with significantly lower quality of life and increased inflammatory burden. QoL scores are significantly higher in patients showing mucosal healing compared to those with active ongoing inflammation.

References

[1] Jowett SL, Seal CJ, Barton JR, Welfare MR. The short inflammatory bowel disease questionnaire is reliable and responsive to clinically important change in ulcerative colitis. Am J Gastroenterol. 2001 Oct;96(10):2921-8.
[2] Irvine EJ^​, Zhou Q, Thompson AK.The Short Inflammatory Bowel Disease Questionnaire: a quality of life instrument for community physicians managing inflammatory bowel disease. CCRPT Investigators. Canadian Crohn's Relapse Prevention Trial. Am J Gastroenterol. 1996 Aug;91(8):1571-8.

Introduction

The management of inflammatory bowel disease (IBD) has traditionally focused on controlling symptoms and reducing or even clearing inflammatory burden. However, the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE)-II statements have expanded the targets to include health-related quality of life (HRQoL) as a long-term outcome. Despite this, the predictive factors for worse HRQoL have yet to be fully completely determined. Alongside psychosocial status, it has been hypothesized that illness perception may also influence HRQoL. Additionally, a bidirectional relationship between sleep quality and IBD has been observed.

Aims & Methods

We thus aim to investigate the potential association between self-reported sleep quality and HRQoL in patients with IBD and to identify other predictors of HRQoL to so that these factors can be integrated into the evaluation of IBD patients. We conducted a prospective single-center cohort study at a tertiary center. From January 2024 to March 2024, patients previously diagnosed with IBD were invited to complete a comprehensive questionnaire assessing HRQoL using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ), self-reported sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and illness perception using the revised version of the Illness Perception Questionnaire. Demographic, clinical (including history of psychopathology), and symptomatology (evaluated using the Harvey Bradshaw Index (HBI) and Partial Mayo Score), as well as analytical parameters (fecal calprotectin), were assessed at the time of questionnaire completion. Clinical remission was defined as HBI<=3 or Partial Mayo Score<=1. Poor HRQoL was defined as SIBDQ<50 and poor sleep quality defined as PSQI>5. Logistic regression was used to performed both univariate and multivariable analysis. Predictors with p<0.1 in the univariate analysis were included in the multivariable analysis.

Results

A total of 272 patients were included, with 53.3% being male. The median age was 48 years (interquartile range [IQR] 38-58). Ulcerative colitis was present in 184 (68%) patients, while the remaining patients had Crohn's disease. A history of psychopathology was noted in 35 (12.9%) patients. The majority of patients were in clinical remission (245 (90.1%) patients). Poor QoL was reported by 87 (32.7%) and poor sleep quality was reported in 185 (70.1%). Univariate analysis revealed a statistically significant association between female gender, Crohn’s disease, absence of clinical remission, self-reported poorer sleep quality, and illness perception (higher scores in four components: timeline cyclical, illness consequences and coherence, and emotional representation of IBD) and worse HRQoL. Multivariable analysis confirmed younger age, absence of clinical remission, worse sleep quality, and illness perception (illness consequences, coherence, and emotional representation of IBD) as independent predictors of poor HRQoL.

Conclusion

HRQoL in IBD is influenced by factors beyond disease activity. Sleep quality emerges as a significant determinant of HRQoL, alongside the patient's illness perception. Therefore, integrating sleep quality assessment into patient clinical evaluation is paramount. Moreover, addressing patients' understanding of their disease, perspective on consequences, and emotional response to the condition is crucial for improving HRQoL.

References

Khan S, Sebastian SA, Parmar MP, et al. Factors influencing the quality of life in inflammatory bowel disease: A comprehensive review. Dis Mon. 2024;70(1S):101672. doi:10.1016/j.disamonth.2023.101672
Knowles SR, Graff LA, Wilding H, Hewitt C, Keefer L, Mikocka-Walus A. Quality of Life in Inflammatory Bowel Disease: A Systematic Review and Meta-analyses-Part I. Inflamm Bowel Dis. 2018;24(4):742-751. doi:10.1093/ibd/izx100
Knowles SR, Keefer L, Wilding H, Hewitt C, Graff LA, Mikocka-Walus A. Quality of Life in Inflammatory Bowel Disease: A Systematic Review and Meta-analyses-Part II. Inflamm Bowel Dis. 2018;24(5):966-976. doi:10.1093/ibd/izy015
Mitropoulou MA, Fradelos EC, Lee KY, et al. Quality of Life in Patients With Inflammatory Bowel Disease: Importance of Psychological Symptoms. Cureus. 2022;14(8):e28502. Published 2022 Aug 28. doi:10.7759/cureus.2850
Qazi T, Farraye FA. Sleep and Inflammatory Bowel Disease: An Important Bi-Directional Relationship. Inflamm Bowel Dis. 2019 Apr 11;25(5):843-852. doi: 10.1093/ibd/izy334. PMID: 30388243.

Disclosure

FP received speaker fees from Abbvie, Falk, Ferring, Janssen, Pfizer, Pharmakern, Takeda and Tillotts.

Introduction

Inflammatory bowel disease (IBD) commonly affects female patients of reproductive age, making the interaction between fertility, pregnancy and IBD an important issue in disease management. The effect of disease activity on the outcome of pregnancy and its impact on neonatal growth is a field of intense research. Close follow-up of pregnant IBD patients by a multidisciplinary team improves maternal and neonatal outcomes.

Aims & Methods

Α national retrospective study of pregnancies in women with IBD between 2010-2020 was carried out in 22 IBD reference centers in Greece. Patient characteristics such as disease profile, type of treatment, and disease activity during gestation were analyzed in correlation to the method of delivery, pregnancy outcomes, as well as breastfeeding and offspring health.

Results

Two-hundred and twenty-three pregnancies in 175 IBD patients were registered in the study. 122 with Crohn’s disease (CD). Median age during diagnosis was 25.6 years (12-44) with median disease duration of 7.4 years (0-23). One-hundred and twenty-nine patients (58%) were recorded during their first pregnancy. Early pregnancy termination was reported by 48 patients (22%). Pregnancy as a result of in vitro fertilization (IVF) occurred in 15 cases (6.7%). At the beginning of gestation 165 patients (74%) were under treatment: 48 with anti-TNF agents (29%), 43 with azathioprine (26%), 101 with 5-aminosalicylic acid formulations (61%) and 12 with steroids (7%). We recorded 49 cases of IBD flares (22%) during pregnancy. Two-thirds of them (n=30) were in remission at the onset of the pregnancy. Almost half of them (n=22) required corticosteroid treatment. Patients with ulcerative colitis (UC) were in greater risk of disease flare during pregnancy (p<0.001). All but 3 pregnancies (99.1%) resulted in uncomplicated delivery. In 147 cases (67.1%) cesarean delivery was performed. Two late fetal deaths (0.9%) were reported, both in patients with continuously active disease since the beginning of pregnancy. After delivery, 75 patients (34%) presented with a disease flare, which was associated with active disease at the beginning of pregnancy (p <0.001).
Table 1. Demographics and characteristics of the cohort

Conclusion

The majority of female, Greek IBD patients, had a favorable pregnancy outcome. Active inflammation during gestation and UC diagnosis were associated with a negative impact on pregnancy outcomes. The results of this study are in favor of the continuation of IBD treatment during pregnancy.
This study was funded by a research grant 2020EOMIFNEmp1 from the Hellenic Group for the Study of IBD (EOMIFNE)

Introduction

The appropriateness of lower gastrointestinal (GI) endoscopy in patients with inflammatory bowel disease (IBD) is a key issue in endoscopic practice, especially given limited healthcare resources, the growing demand for endoscopic procedures, and the increasing prevalence of IBD. While numerous studies have examined the appropriateness of endoscopy, particularly upper GI endoscopic procedures, in general gastrointestinal disorders,^{[1, 2]} there is a relative lack of literature specifically addressing the appropriateness of lower GI endoscopy in patients with IBD.^{[3, 4]}

Aims & Methods

This study aimed to evaluate the appropriateness of lower GI endoscopic examinations in patients with IBD at a tertiary referral center. Secondary objectives were identifying reasons for inappropriateness and assessing the presence of clinically significant pathological findings in inappropriate procedures. This was a prospective, observational, monocentric study including all adult patients affected by IBD who underwent lower GI endoscopy at a tertiary referral center between September 2024 and April 2025, with a confirmed IBD diagnosis for at least six months. Data collected included IBD subtype, endoscopic procedure appropriateness based on the 2023 ECCO Guidelines,^[5] and endoscopic/histological findings.

Results

Among 406 endoscopic procedures, 26 were excluded from the analysis due to inappropriate timing resulting from patients lost to follow-up. Therefore, a total of 380 IBD patients were included (mean age 52.9 ± 15.1 years; 57% male). Among them, 135 (35.5%) had Crohn’s disease (CD), 176 (46.3%) ulcerative colitis (UC), 60 (15.8%) ileal pouch, and 9 (2.4%) unclassified IBD (IBD-U). Lower endoscopic procedures included colonoscopy (256, 67.4%), rectosigmoidoscopy (61, 16.1%), pouchoscopy (60, 15.8%), and trans-stomal ileoscopy (3, 0.8%). Overall, 308 procedures (81.1%) were deemed appropriate. Appropriateness was higher in CD (115/135, 85.2%), in UC (147/176, 83.5%) and IBD-U (8/9, 88.9%), and lower in ileal pouch (38/60, 63.3%). Between the different endoscopic procedures, rectosigmoidoscopy showed the highest appropriateness (56/61, 91.8%), followed by colonoscopy (213/256, 83.2%), pouchoscopy (38/60, 63.3%), and trans-stomal ileoscopy (1/3, 33.3%). Among the 72 inappropriate procedures (18.9%), 23 (31.9%) were performed too early, 20 (27.8%) too late, 27 (37.5%) were unwarranted, and 2 (2.8%) were improper endoscopic procedures. Most early procedures were prescribed by physicians (78.3%), while the remaining (21.7%) were requested by patients. Despite being considered inappropriate, 27 of the 72 examinations (37.5%) revealed endoscopic pathological findings, and 17 (23.6%) led to clinically relevant conclusions (based on both endoscopic and histological findings), including 4 cases of dysplasia. It is noteworthy that, among the inappropriate examinations that led to clinically relevant conclusions, almost 60% were performed either too early or were considered unwarranted, while only the remaining 40% were performed too late.

Conclusion

The appropriateness of lower gastrointestinal endoscopy in patients affected by IBD was found to be nearly 80% in a tertiary referral center. Notably, among the examinations classified as inappropriate, roughly 24% revealed clinically relevant findings based on both endoscopic and histological report. A greater spread and awareness among physicians of the latest international guidelines on IBD management could improve the appropriateness of endoscopic procedure prescriptions, while reducing waiting lists and related healthcare costs.

References

1. Tursi A, Palieri AP, Lattarulo V, Elefante A, Gigliobianco A, Spinazzola D, Elisei W, Papa A. How we can improve the appropriateness of ambulatory gastrointestinal endoscopy: the lesson of the COVID-19 outbreak. Eur J Gastroenterol Hepatol. 2023 Oct 1;35(10):1149-1153. doi: 10.1097/MEG.0000000000002626. Epub 2023 Jul 28. PMID: 37665614.
2. Bohara TP, Laudari U, Thapa A, Rupakheti S, Joshi MR. Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding. JNMA J Nepal Med Assoc. 2018 Jan-Feb;56(209):504-509. PMID: 30058633; PMCID: PMC8997324.
3. Manes G, Imbesi V, Ardizzone S, Cassinotti A, Bosani M, Massari A, Porro GB. Appropriateness and diagnostic yield of colonoscopy in the management of patients with ulcerative colitis: a prospective study in an open access endoscopy service. Inflamm Bowel Dis. 2008 Aug;14(8):1133-8. doi: 10.1002/ibd.20434. PMID: 18314901.
4. Manes G, Imbesi V, Ardizzone S, Cassinotti A, Bosani M, Massari A, Bianchi Porro G. Use of colonoscopy in the management of patients with Crohn's disease: appropriateness and diagnostic yield. Dig Liver Dis. 2009 Sep;41(9):653-8. doi: 10.1016/j.dld.2008.10.006. Epub 2008 Nov 25. PMID: 19036651.
5. Gordon H, Biancone L, Fiorino G, et al. ECCO Guidelines on Inflammatory Bowel Disease and Malignancies. J Crohns Colitis. 2023;17(6):827-854. doi:10.1093/ecco-jcc/jjac187