Introduction

Inflammatory bowel disease(IBD) that includes Ulcerative colitis (UC) and Crohn’s disease (CD) may be associated with considerable changes in body composition, which include alterations in muscle and adipose tissue mass as well as osteopenia and osteoporosis which can have considerable impact on disease course and outcome.

Aims & Methods

Body composition and presence of sarcopenia were assessed in patients with UC and CD and their relationship with disease duration, location and severity was studied. This was a Single-Centre cross-sectional study conducted from January 2022 to June 2023. Body composition analysis was performed using bioelectrical impedance (BIA) method and sarcopenia assessment was done with hand grip strength (HGS) using digital hand dynamometer and skeletal muscle index (SMI) at 3^rd lumbar vertebral(L3) level using computed tomography (CT).

Results

A total of 132 patients (92 UC and 40 CD) were included. Mean age and sex in UC (37.33 ± 12.91 years, 46.7% males) and in CD (39.05 ± 15.05 years, 52.5% males). Mean duration of disease in UC and CD were 5.9 ± 5.28 years and 6.13 ± 4.33 years respectively. In UC group 41.3% patients had pancolitis and 37% had left sided colitis, among CD patients ileal(L1) and colonic disease(L3) was 37.5% each and 55% patients had inflammatory disease behavior. In UC patients 33.7% had active disease and in CD 40 % had active disease. In UC group, mean total body fat percentage was significantly lower with disease duration of 1-5 years compared to those with disease duration > 5 years (23.67 ± 8.52% vs 29.39 ± 7.14%, p=0.003) and mean visceral fat level was lower in those with active disease than in remission (3.26±3.09 vs 6.49±6.77, p=0.013). CD patients did not show any significant change in BMI, total body fat percentage, whole body skeletal muscle percentage with respect to disease duration, location, behavior and severity. In UC group mean dominant HGS and L3-SMI were lower in active disease than remission (22.27 ± 8.72 kg vs 28.57 ± 9.1 kg, p=0.002 and 36.5 ±13 cm²/m² vs 42.74±13.92 cm²/m², p=0.02). Among CD patients no significant change in HGS and L3-SMI were observed. As per European consensus definition, prevalence of probable sarcopenia and sarcopenia in UC and CD were (26% and 9.4%) and (32.5% and 15%) respectively. On comparison between UC and CD, SMI was significantly lower in CD patients(Table1). When BIA method was used to measure low muscle mass, the prevalence of sarcopenia in UC and CD were13.4% and 17.5%. Difference observed with the two methods of measurement of sarcopenia prevalence was not significant.

Table 1- Body composition and sarcopenia variables in UC and CD

Conclusion

Point prevalence of probable sarcopenia and sarcopenia was found to be 26% & 9.4% among UC and 32.5% and 15% patients with CD. CD patients had lower muscle mass as compared to UC patients. BIA showed good diagnostic accuracy compared to CT in assessing muscle mass. Both these methods can be considered complementary diagnostic tools in assessment of sarcopenia among patients with UC or CD.

Introduction

Malnutrition is a common condition of patients with inflammatory bowel disease (IBD) and could be associated with sarcopenia i.e. a reduced muscle mass and strength. Recent data suggest that the prevalence of sarcopenia is, respectively, 52% and 37% in Crohn's disease (CD) and ulcerative colitis (UC). It is well demonstrated that sarcopenic IBD patients have two to three times higher risk of lost of response to biotechnology drugs than non-sarcopenic patients.

Aims & Methods

Consecutive IBD patients accessing the IBD outpatient service were enrolled. Detailed data regarding the characteristics of MC and CU populations, current therapy and disease activity are reported. Each patient was interviewed about the frequency (none, low, high) and the kind (aerobic or anaerobic) of the physical activity they were practicing.
At the enrolment, nutritional assessments were performed by body mass index (BMI) evaluation according with the World Health Organization recommendations, global subjective assessment by the MUST (Malnutrition Universal Screening Tool) index according with the European Society for Clinical Nutrition and Metabolism and the Global Leadership Initiative on Malnutrition [GLIM]. Moreover, the SARC-F questionnaire, recommended by the scientific consensus EWGSOP 2 to identify individuals at risk for sarcopenia was administrated. A SARC-F value ≥ 4 was significant of sarcopenia. Finally, the quality of life was assessed using the inflammatory bowel disease questionnaire (IBDQ). Univariate and multivariate analysis was conducted between BMI, MUST, SARC-F and IBDQ values and patient characteristics (age, current therapy, disease activity and physical activity).

Results

A total of 321 IBD patients (158 CD and 163 UC), 56.07% male, with a mean age of 44.78 years were enrolled. Sixty-seven patients (20.87%) reported a current smoking habit. A mean BMI of 70.37 kg, was calculated. Regarding malnutrition, 199 patients (61.99%) were considered at low risk (MUST=0), 75 subjects (23.36%) at medium risk (MUST=1), 47 (14.64%) at high risk (MUST ≥2). A SARC-F value ≥4 was evaluated in 50 patients (15.58%). A reduction in quality of life, understood as IBDQ < 209, was found in 45 (14.02%) patients. Females and males presented a significantly different prevalence of sarcopenia (chi2: 9.69; p-value: 0.002).
Univariate analysis shows a significant protective role of male sex (OR vs. female sex: 0.33; p-value: 0.018) in the risk of sarcopenia; older subjects had a slightly higher sarcopenic risk (OR: 1.04; p-value <0.001). The risk was associated with corticosteroid therapy (OR 1,03, p-value <0.001), with increasing MUST (OR 1,65, p-value <0.001) and with the IBDQ decreases (OR 2,1; p-value<0.001).
Multivariate analysis confirmed an higher incidence of sarcopenia in female subjects of advanced age with active-stage disease (R²: 0.88, p-value<0.0001), furthermore female patients with active-stage disease who did not engage in physical activity had a greater impairment in quality of life, regardless of age (R²: 0.75, p-value<0.0001). Aerobic and anaerobic physical activity played a protective role in the onset of sarcopenia regardless of sex and age (R²: 0.82, p-value<0.0001).

Conclusion

In our cohort of patients, sarcopenia was present in only 18.94%. Male sex was found to be a protective factor for sarcopenia. Disease status is firmly linked to the risk of sarcopenia. Regular physical activity has been shown to have a protective role for good quality of life and it was related with a lower risk of sarcopenia. This study will continue to expand the cohort taken into account.

Introduction

The role of adipose tissue in IBD is yet to be fully elucidated. Adipose tissue is distributed into two main compartments ; Visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Previous studies suggest that VAT may be a predictor of disease progression particularly in Crohn’s disease (CD)(1). VAT:SAT ratio, and not BMI, has been associated with a structuring CD phenotype, faecal calprotectin and quality of life (2). In previous studies, visceral obesity has been defined as a VAT area of 100cm² as well as VAT:SAT 40% (3-4). We sought to investigate the difference in fat composition of patients with IBD using computed tomography (CT).

Aims & Methods

Patients with IBD were selected randomly from an IBD database in our centre. Age and gender matched controls were selected for comparison.
Using TeraRecon^​ software, we retrospectively analyzed CT results to obtain the following parameters; VAT Area (cm²), SAT Area (cm²), VAT:SAT Ratio (VAT/VAT+SAT - %) and Waist Circumference (WC) (cm). Measurements were taken at the level of the umbilicus (L3). Data was also collected retrospectively from outpatient clinic letters, previous biopsy reports and endoscopy reports. Statistical analysis was preformed using Minitab.

Results

A random sample of 480 patients were identified. 279 of these patients were excluded, leaving 201 patients which were analysed.
The majority of this cohort were female (n=102). The mean age was 43. 122 patients had CD and 79 patients had Ulcerative colitis (UC). At the time of imaging, 95 patients were on biologics with a further 29 patients progressing onto biologics later in their treatment. Visceral obesity (40% VAT:SAT) was found in 31.8% of patients. 46.8% of patients had VAT 100cm². Male gender accounted for 17.27% more VAT:SAT in comparison to female gender (p =0.000). VAT showed a strong correlation with WC (r =0.809).
No significant difference was found in fat composition or WC between a sample of patients with IBD and their controls.
Patients with UC had 5.2% more VAT:SAT compared to patients with CD (p=0.036). Males had a 17.3% higher VAT:SAT (p=0.000). There was no significant differences noted between those on biologics vs. non-biologic treatments. However, those taking thiopurines (6-Mercaptopurine (6-MP)/Azathioprine) had 5.6% lower VAT:SAT compared to those not (p=0.038). Combination therapy (thiopurine + Biologic) had 9.02% more VAT:SAT than those on thiopurine monotherapy (p=0.058).
Binary logistic regression models were used to identify factors associated with markers of disease severity (surgery, multiple surgeries and multiple biologic use). Age was found to be a significant associated factor with multiple surgeries (coeff 0.0641) (p=0.001).

Conclusion

Visceral obesity was found in at least 30% of patients in this IBD cohort. This was in comparison to 44%of the age-gender matched control group.
We report no significant difference in body fat composition or WC in age and gender matched controls and a random sample of patients with IBD. Rising obesity levels in the community may account for this. However, in this cohort, patients with UC had a higher % VAT:SAT compared to those with CD. Regarding treatment, thiopurine monotherapy was associated with lower %VAT:SAT. This may suggest that combination therapy may be required in those with higher %VAT:SAT to treat a more aggressive disease course.
Age is a known risk factor for a more severe disease course in IBD. This was in keeping with our model.
Of note, WC showed a strong correlation with VAT. This may be a more acceptable alternative for monitoring VAT rather than CT imaging.

References

1. Tsai, Y.-W. et al. (2020) “Adipokine-modulated immunological homeostasis shapes the pathophysiology of inflammatory bowel disease,” International Journal of Molecular Sciences, 21(24), p. 9564. Available at:https://doi.org/10.3390/ijms21249564.
2. Bryant, R.V. et al. (2018) “Visceral adipose tissue is associated with stricturing crohn’s disease behavior, fecal calprotectin, and quality of life,” Inflammatory Bowel Diseases, 25(3), pp. 592–600. Available at: https://doi.org/10.1093/ibd/izy278.
3. Kong, M. et al. (2022) “Assessing visceral obesity and abdominal adipose tissue distribution in healthy populations based on computed tomography: A large multicenter cross-sectional study,” Frontiers in Nutrition, 9. Available at: https://doi.org/10.3389/fnut.2022.871697.
4. Matsuzawa, Y. et al. (1995) “Visceral fat accumulation and cardiovascular disease,” Obesity Research, 3(S5). Available at: https://doi.org/10.1002/j.1550-8528.1995.tb00481.x.

Introduction

QuantiFERON-TB is replacing the tuberculin skin test for latent TB screening in IBD patients before starting biologic therapy(1). Indeterminate results may cause delays in treatment initiation and necessitate further evaluation(2).

Aims & Methods

This is a retrospective chart review study conducted at King Fahad Medical City, Riyadh , Saudi Arabia, to investigate factors associated with indeterminate QuantiFERON-TB results in patients with inflammatory bowel disease (IBD).

Results

A total of 300 participants were included, with 53.2% diagnosed with Crohn’s disease (CD) and 46.8% with ulcerative colitis (UC). Indeterminate QuantiFERON-TB results were observed in 4.7% of cases. None of these patients showed positive seroconversion or developed active tuberculosis during the follow-up period up to the study's completion.

Conclusion

Indeterminate QuantiFERON-TB results were significantly associated with factors like geographical region, elevated WBC, hypoalbuminemia, elevated CRP, and steroid use, highlighting the need to consider these variables in latent TB screening for IBD patients. Importantly, none of the patients developed active TB or showed positive seroconversion.

References

1. Cabriada, J. M., et al. (2018). Comparison of QuantiFERON-TB Gold and Tuberculin Skin Test for Screening Latent Tuberculosis in Inflammatory Bowel Disease Patients. Journal of Crohn's and Colitis, 12(7), 862-868.
2. Hradsky, M., et al. (2014). Impact of Indeterminate Results on the Timing of Anti-TNF Therapy in Inflammatory Bowel Disease Patients. Clinical Gastroenterology and Hepatology, 12(6), 1040-1046.

Clinical Case Summary

A 77-year-old man underwent liver transplantation in 2008 due to alcoholic cirrhosis associated with hemochromatosis, and was taking tacrolimus and mycophenolate mofetil since that.
He was admitted in the Emergency Department in February 2023 with right upper quadrant abdominal pain and diarrhea for one week. Abdominal computed tomography(CT) showed ileal thickening. Laboratory tests revealed leukocytosis(19,000 leukocytes/mm3) and elevated C-reactive protein(16 mg/dL). Acute gastroenteritis was assumed and he was discharged on metronidazole with clinical improvement. One month later, he returned to the Emergency Department with abdominal pain for two days. CT revealed concentric wall thickening of the last ileal loop and a probable enteromesenteric fistula. He was admitted for further evaluation. Colonoscopy revealed deep mucosal ulceration of the terminal ileum. After colonoscopy, his abdominal pain worsened, so he repeated the abdominal CT, which showed a new organized collection in the right flank measuring 63 mm and small gas bubbles of pneumoperitoneum in the right upper quadrant. He underwent ileocecal resection with terminal ileostomy, and the histopathological evaluation revealed a neoplasm composed of atypical lymphoid proliferation, with positive immunohistochemistry for CD45, CD20, CD79a, BCL2, and BCL6, compatible with diffuse large B-cell lymphoma. After staging and exclusion of distant disease, the patient was proposed for chemotherapy following reduction of immunosuppression.
The clinical presentation of Inflammatory Bowel Disease can be quite heterogeneous and several pathologies can mimic its clinical, endoscopic, and/or histological findings. This case illustrates the importance of considering the diagnosis of small bowel lymphoma as a differential diagnosis of Crohn's disease, especially in elderly patients with risk factors, such as chronic immunosuppression.

Introduction

A significant proportion of patients with inflammatory bowel disease (IBD) have concomitant rheumatological manifestations. On the other hand, patients with spondyloarthritis (SpA) often report gastrointestinal symptoms, some of them being associated to IBD. However, the exact prevalence of this disorder is still controversial, and the optimal approach to its diagnosis remains unknown.

Aims & Methods

Our main was to determine the prevalence of undiagnosed IBD in patients with axial SpA (radiographic and non-radiographic) and psoriatic arthritis (PA). EISER is a multicenter, nationwide, observational, and cross-sectional study where 13 Spanish hospitals participated. Patients ≥18 years-old diagnosed with PA or SpA according to the CASPAR or ASAS criteria, respectively, were selected. Patients receiving biologics or systemic steroids at baseline or within the previous 30 days were not included. Regarding patients older than 50 years, only those without valid colonoscopy in the previous 3 years were included. Rheumatologist performed a baseline visit and collected demographic, clinical, and treatment data. Fecal calprotectin (FC) was determined by the Quantum Blue rapid test and this was followed by a gastroenterologist consultation. A complete colonoscopy was indicated on all patients with symptoms, FC≥80 µg/g without NSAIDs, or 160 µg/g if they were on NSAIDs. Capsule endoscopy or magnetic resonance enterography were performed in those with no findings on colonoscopy.

Results

A total of 559 patients were included (51% men; mean 52.2 years; mean disease duration of SpA/PA was 12.3 years). The most frequent rheumatological disease was radiographic SpA (37%), followed by peripheral APs (36%). Abnormal FC was observed in 47% and 53% of patients with PA and EspAx (80% radiographic-SpA vs 20% non-radiographic-SpA), respectively. Mean FC levels were higher among radiographic-SpA (395 µg/g) compared to the rest of the groups (306 µg/g for non-radiographic-SpA and 306 µg/g in PA). Overall, 11,5% had gastrointestinal symptoms, with the most common being abdominal pain (16%) and chronic diarrhea (11%). In total, 189 colonoscopies were performed, 40% demonstrating at least one abnormal finding, mostly aphthous ulcers (66%), superficial ulcers (21%) and erythema (14%), and they were mainly located in the terminal ileum (41%). Finally, 23 patients were diagnosed with IBD (4.4%), mostly with radiographic-SpA (83%), followed by peripheral PA (8.7%) and non-radiographic-SpA and axial PA (4.3% each). All patients but two were diagnosed with CD (91.3%), with 1 case of unclassified IBD (4.3%) and 1 with nonspecific ileitis (4.3%).

Conclusion

FC levels in patients with SpA and PA, followed by an appropriate endoscopic and/or radiological diagnostic algorithm, allows the identification of a relevant subgroup of patients with previously undiagnosed IBD

Introduction

Sarcopenia is a progressive disorder characterized by reduced musculoskeletal mass leading to reduced strength and poor physical performance. Nutritional status is critical to therapeutic success in Crohn’s Disease (CD) and Ulcerative Colitis (UC) but it is clear how traditional weight and body mass index (BMI) scores are poorly representative of these.^[1,2] Sarcopenia could better reflect the degree of malnutrition.^[3] In inflammatory bowel disease (IBD) sarcopenia has been associated with refractory to medical treatment, prolonged hospitalization, increased rate of surgery and increased frequency of post-operative complications.^[4–6] Recently the measurement of the psoas muscle (PM) by ultrasound (US) has been proposed as a surrogate of sarcopenia obtaining an high concordance with the reference standard CT scan.^[7]

Aims & Methods

Our preliminary prospective study aims to identify correlations between US measurement of PM in a cohort of 57 patients with IBD and their clinical history and variables. The transverse area of the PM in cm² (US-TPA) and the same divided the square height in cm²/m2 (US-PMI) were measured in the right iliac fossa using a low frequency probe: General Electric Logiq P8 (Boston, USA) for outpatients whereas Esaote MyLab One/Touch (Genova, Italia) for inpatients.

Results

Normal weight patients have significantly higher US-TPA and US-PMI values (p=0.032 and 0.031) than underweight (BM<18.5 kg/m²) or overweight (BMI>25 kg/m²). CD patients have significantly lower US-TPA (p=0.03) than UC patients. Patients with history of fistulizing perianal disease or who have at least two surgeries have significantly lower US-TPA and US-PMI values than the rest of the population (p=0.02). Patients with severe disease activity (Mayo Partial 5 or Harvey-Brashaw Index>8) have lower US-TPA and US-PMI (p = 0.0003 and 0.0004) than those in clinical remission or mild-moderate activity. As well as for patients with disease activity of any degree (Mayo Partial >2 or HBI>5) compared to remission (p= 0.001 and 0.002). With due caution, we have empirically applied the US-PMI cut-offs proposed by Kobayashi^[8] in their cirrhotic cohort of 1.89 cm²/m² for males and 1.81 cm²/m² for females: 13 (23%) of our patients were found to be sarcopenic. Of these, 46% of patients were admitted at the time of inclusion, 50% clinically active and 77% clinically severe. The higher frequency of sarcopenia observed in these groups was statistically significant with OR 5.42 (IC 95% 1.4-21.8) and p=0.017, OR 5.4 (IC 95% 1.4-21.2) and p=0.02 and OR 19.3 (IC 95% 3.2-116) and p=0.0002 respectively. Underweight and overweight subjects (BMI <18.5 kg/m2 or >25 kg/m2) were more frequently sarcopenic according to the same cut-off than normal weighted with OR 3.97 (95% IC 1.08 - 14.53) and p=0.037.

Conclusion

US is a simple and reproducible method of measuring the PM as a surrogate for sarcopenia, an independent nutritional index that could affect therapeutic responses and outcome in IBD. Our study has found a correlation between the so quantified sarcopenia and the disease activity and clearly demonstrates how such a state of malnutrition is linked to both underweight and overweight. The widening of the population will allow us in future to emphasize associations and differences. The impact and predictive role of sarcopenia on IBD outcomes will be investigated. It will be necessary to identify PM US cut-off for IBD, validated and related by nutritional parameters or other quantitative or qualitative methods.

References

1 Bryant R V. et al. Systematic review: body composition in adults with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 38: 213–225.
2 Dhaliwal A, Quinlan JI, Overthrow K, Greig C, Lord JM, Armstrong MJ, Cooper SC. Sarcopenia in Inflammatory Bowel Disease: A Narrative Overview. Nutrients 2021, Vol 13, Page 656 2021; 13: 656.
3 Adams DW et al. Sarcopenia Is Common in Overweight Patients with Inflammatory Bowel Disease and May Predict Need for Surgery. Inflamm Bowel Dis 2017; 23:1182–1186.
4 Sigurdsson GV et al. Altered body composition profiles in young adults with childhood-onset inflammatory bowel disease. 2020; 55: 169–177.
5 Bryant R V. et al.Low muscle mass and sarcopenia: common and predictive of osteopenia in inflammatory bowel disease.Aliment Pharmacol Ther 2015; 41: 895–906.
6 Pedersen M et al. Sarcopenia is a Predictor of Surgical Morbidity in Inflammatory Bowel Disease.Inflamm Bowel Dis 2017; 23: 1867–1872.
7 Takai Y. et al.Ultrasound method for estimating the cross-sectional area of the psoas major muscle. Med Sci Sports Exerc 2011; 43: 2000–2004.
8 Kobayashi K et al. Application of transcutaneous ultrasonography for the diagnosis of muscle mass loss in patients with liver cirrhosis. J Gastroenterol2018; 53: 652–659

Disclosure

Francesco Maria Stalla hosted to congresses: Giuliani s.p.a.