Introduction

Cytomegalovirus (CMV) infection frequently affects patients with Ulcerative Colitis (UC) and it has been associated with disease relapse and increased severity.

Aims & Methods

Our study aimed to assess clinical and biochemical differences between CMV-positive UC patients with moderate to severe disease relapse and those without CMV infection.
We retrospectively included all patients with UC who were followed for at least one year at the Unit of Gastroenterology of the Azienda Ospedale Università Padova and that were studied for CMV infection at the time of a moderate/severe reactivation (pMayo ≥5 and/or fecal calprotectin ≥ 250 and/or endoscopic Mayo ≥ 2) from May 2019 to October 2023. Patients were considered CMV-positive if CMV antigens were revealed by immunohistochemistry (at least 1 CMV intranuclear inclusion body in routine hematoxylin and eosin-stained sections and/or immunohisto-chemical staining) and/or a positive tissue viral load was detected by qualitative real-time PCR on colonic biopsies. Demographic and clinical features, fecal calprotectin, and previous and ongoing UC therapy were compared between CMV-positive patients and those who tested negative. Finally, the anti-CMV therapy administered was reported. Differences between the two study groups were assessed using the independent-samples t-test, while differences in the categorical analysis were analyzed using the Chi-squared test. A p-value <0.05 was considered significant. STATA 11 was used for statistical analysis.

Results

We retrospectively included 122 UC patients with moderate-to-severe disease (58.2% females, mean age at study 51 ± 17 years, time from diagnosis 11 ± 10 years). 24 patients (19.7%) were positive for CMV infection; no differences in gender, age, and time from diagnosis were observed between CMV-positive and negative patients. Serum quantitative CMV-DNA was tested in 18 patients and > 1000 copies/ml in 4 patients (22.2%) were detected. Approximately half of the patients were treated with immunomodulatory therapy during disease relapse with a similar distribution between CMV-positive and negative patients (p = 0.7). 95.2% of CMV-positive patients had diarrhoea compared to 71.6% of patients without CMV infection (p = 0.02), and abdominal pain was present in 71.4% CMV-positive compared to 42.1% CMV-negative patients (p = 0.015). In contrast, symptoms like fever and bloody diarrhoea had similar rates in the two groups (p=ns). Mean levels of fecal calprotectin were similar between the two groups (p = 0.07). Hospitalization was necessary in 91.7% of CMV-positive patients compared to 30.2% of CMV-negative patients. CMV-positive patients were treated with oral or intravenous steroids and switched to UC biological therapy more frequently than CMV-negative patients (p < 0.05). In parallel, 14/24 CMV-positive patients were treated with Ganciclovir for 3-5 days, and 13/14 were subsequently treated with Valganciclovir for another 2-6 weeks. Ten patients were only treated with oral Valganciclovir.

Conclusion

CMV-positive UC patients required systemic steroid therapy and hospitalization more frequently than non-infected patients, suggesting a more challenging management of the disease. Moreover, symptoms such as abdominal pain and diarrhoea emerged as potential indicators of CMV infection when compared to other clinical presentations.

Introduction

Patients suffering from inflammatory bowel diseases (IBD) manifest an increased risk of developing colitis-associated colon cancer (CAC). Interleukin 22 (IL22) is a cytokine involved in the proliferation and survival of epithelial cells. However, it also correlates with the development of tumoral lesions. IL22 is secreted by different immune cell types, including iNKT cells, tissue resident cells possessing cytotoxic properties in colorectal cancer (CRC). In IBD patients, though, iNKT cells perform both pro-inflammatory or tolerogenic functions in a microbiota-dependent fashion, opening questions on their functional role in CAC development.

Aims & Methods

Immune cell composition and iNKT cell phenotype of inflamed, non-tumor and cancerous tissue lesions of CAC (n=49), IBD (n=20) and sporadic CRC (n=38) patients were analysed in samples obtained from Policlinico Hospital, Milan, and IOV-IRCCS, Padua. High-dimensional single-cell flow cytometry, metagenomics, RNAseq, spatial immunophenotyping and trascriptomic (Cosmx, Nanostring), ex vivo and in vitro experiments were performed to evaluate the phenotype and function of human iNKT cells. Metabolomics was performed to identify microbial-derived molecules involved in iNKT cells activation.Mechanisms were dissected in CAC murine models, either iNKT proficient or deficient.

Results

An increased expression of IL22 and a higher NKT22 infiltration was observed in CAC tissues, as well as an enrichment of Odoribacter, a gram-negative bacteria implicated in tryptophan metabolism. Stimulation of iNKT cells with Odoribacter-derived metabolites induced Ahr-dependent IL22 production by iNKT cells. Metabolomic analyses revealed an increased presence of tryptophan metabolites in the Odoribacter supernatant, promoting NKT22 differentiation both in vitro and in vivo models. Moreover, the administration of Odoribacter Supernatant or of the single purified metabolites were sufficient to increase tumorigenesis in CAC mouse models, but not in iNKT-deficient mice.
Spatial proteomics and trascriptomic analyses of human CAC tissues confirms the microbiota-dependent functional skewing of iNKT cells residing closely to cancer cells.

Conclusion

iNKT cells in CAC patients are the major IL22 producing cells and are induced by the recognition of microbiota-derived metabolites implicated in tryptophan metabolism and Aryl hydrocarbon receptor (AhR) stimulation. NKT22-microbiota interaction in CAC patients plays a potential crucial role in tumor development.

Introduction

This study looks at the profile of Crohn's patients who have been on at least 3 different advanced treatments, such as tumour necrosis factor inhibitors (TNFi), integrin blockers and IL12/23 inhibitors.

Aims & Methods

Objective: The purpose of this study was to evaluate the profile of Crohn’s disease patients who are in the 3^rd or 4^th line of an advanced treatment and to consider whether patients may be likely to switch to a different treatment.
Methodology: In both Q1 and Q3 2023, ~200 gastroenterologists from France, Italy, Germany, Spain, and the UK contributed ~1200 anonymous patient record forms for individuals receiving advanced therapy for Crohn’s Disease. All the forms were collected through the Therapy Watch IBD (UC and Crohn’s) online survey by Research Partnership. The survey has been conducted with similar numbers of gastroenterologists for 3 years at regular intervals. Informed consent from physicians was obtained. Where relevant, statistical comparisons were performed using a pairwise z-test.
In addition, Research Partnership has conducted research with 138 Crohn’s disease patients through their Living With Crohn’s EU5 survey. Quantitative online interviews were conducted with patients who were currently on an advanced treatment for Crohn’s.

Results

Of all the Crohn’s disease patient record forms collected in the Therapy Watch survey in 2023, 104 patients were on their 3^rd or 4^th line of advanced treatment.
The majority of 3^rd or 4^th line patients were on a non TNFi treatment, such as an integrin blocker or an IL12/ IL23 inhibitor. ~20% of patients were on a TNFi.
The patients were a mix of male and female, at 44% and 56% respectively, and with a wide age range (42% under 40, 30% aged 41-50 and 28% aged over 50). 42% had suffered with Crohn’s disease for over 10 years. The majority of patients had an existing co-morbidity, most commonly a CV condition or depression.
At the time of the survey, the current severity of Crohn’s was reported by physicians to be: 32% mild, 50% moderate and 18% severe. Approximately a quarter of them also were reported as having flares that are increasing in frequency.
From our Living With Crohn’s survey, out of 138 Crohn’s patients currently on an advanced therapy*, approximately a quarter stated that their flares had increased in the last 6 months, but they have not requested a different treatment from their physician. The reasons for not requesting a new treatment were mainly: patients feel they can still tolerate the symptoms that they experience and they are scared of potential side effects of a different treatment.
* Living With patients include those in any line of advanced treatment, not only 3^rd or 4^th line.

Conclusion

Our data suggests that the majority of 3^rd and 4^th line Crohn’s patients have moderate or severe disease, and therefore may be candidates for a switch to a new treatment as these become available for Crohn’s. 30% of 3^rd and 4^th line Crohn’s disease patients are classified as mild in severity, and this segment appear to have found a level of efficacy at this stage.
Our patient survey (Living With) has shown that even those patients who suffer increasing frequency of Crohn’s symptoms do not feel confident in switching to a different therapy; there is a level of fear of switching.

Introduction

Crohn’s disease (CD), a variant of inflammatory bowel disease, is a complex, debilitating, chronic and relapsing disorder of the gastrointestinal tract. If poorly controlled, patients are at risk of intestinal obstruction and infection due to the formation of strictures, fistulae and narrowing of the intestinal lumen, often requiring surgical intervention. As the precise aetiology remains unclear, current treatments for CD are limited. An altered composition of native gut microbiota may play a role in CD pathogenesis, with recent faecal microbiota transplantation (FMT) studies revealing variable therapeutic efficacy in CD management. Orally administered Emu Oil, derived from Emu adipose tissue, has demonstrated anti-inflammatory and reparative properties in models of intestinal disease.

Aims & Methods

The current study aimed to determine whether Emu Oil-modulated FMT could reduce disease severity and modulate the gut microbiota in a mouse model of trinitrobenzene sulfonic acid (TNBS)-induced Crohn’s-like colitis. Female ARC(s) mice were assigned to FMT donor (n=5/group) and recipient (n=10/group) groups. Donor mice were orally administered either Water (80μl), Olive Oil (OO) or Emu Oil (160μl) daily (days -7 to 0); fresh faeces were collected (days -1 to 3) and pooled per group. Recipient mice were administered TNBS (3mg; day 0) and donor faecal supernatant (120μl; day 3) intrarectally and euthanised on day 6. Daily bodyweight and disease activity index (DAI), colonoscopically-assessed disease severity, organ weights, intestinal permeability (fluorescein isothiocyanate [FITC]-dextran uptake), histologically-assessed colonic damage (disease severity, crypt depth), intestinal barrier function (mucin-secreting cells), acute inflammation (myeloperoxidase [MPO]) and faecal microbiome (16S rRNA amplicon sequencing) were assessed. p<0.05 was considered statistically significant.

Results

TNBS induced bodyweight loss in all groups, which normalised to day 0 values on the final day of the experimental period. Daily DAI remained elevated throughout the trial in all groups; only Emu Oil FMT normalised DAI on day 6 compared with day 0 (p<0.05). TNBS increased colonoscopically-assessed disease severity scores (p<0.05), with no significant Emu Oil nor OO FMT effect. Emu Oil FMT decreased liver weights and increased small intestinal weights relative to bodyweight, reduced histologically assessed disease severity and increased colonic mucin counts compared with Water and OO FMT (p<0.05). The most abundant genera across all groups were Muribaculaceae, Eisenbergiella and Bacteroides; while alpha and beta diversity, taxonomic profiles, FITC-dextran, crypt depth and MPO activity remained unchanged in all treatment groups (p>0.05).

Conclusion

Emu Oil-modulated FMT improved histologically-assessed indicators of intestinal disease and barrier function, compared with Water FMT and OO FMT. Interestingly, Emu Oil-modulated FMT affected liver and small intestinal organs weights, suggesting a systemic effect in this setting of disease. Importantly, key genera across taxonomic profiles were identified, however, the microbiome and remaining disease indicators were largely unchanged between treatments. Overall, Emu Oil-modulated FMT demonstrates therapeutic potential in CD management. Future studies would benefit from a deeper assessment of the gastrointestinal microbiome through long-read whole genome sequencing to further determine the role of the microbiome in EO FMT efficacy compared with conventional FMT.

Clinical Case Summary

A 13-year-old boy presented with abdominal distention, recurrent hypoglycemia, and self-resolving jaundice. Clinical examination revealed growth retardation and hepatosplenomegaly. Blood work revealed anemia, thrombocytopenia, elevated aspartate and alanine transaminase levels, and raised plasma cholesterol and triglycerides. Ultrasound showed an enlarged liver with surface irregularity, splenomegaly, and a dilated portal vein. Etiological work-up for cirrhosis was positive for hepatitis B (HBV) surface antigen (HbsAg) and antibodies for HBV core and envelope antigens (anti Hbc, antiHbe) but an undetectable HBV DNA level. HBV was considered to be an unlikely cause of cirrhosis due to the young age of the patient, hence further metabolic and genetic work-up was done. Tests for Wilson’s and autoimmune liver disease were negative. Liver biopsy revealed a distorted lobular architecture with nodules, thin septae, and portal fibrosis. Hepatocytes showed marked swelling and pyknotic nuclei, and negative HbsAg immunostaining. Molecular analysis revealed a novel mutation in the exon 3 of the PHKG2 gene (c.98G>T, p.Gly33Val). The patient was diagnosed with cirrhosis due to GSD IXc with inactive chronic hepatitis B. His symptoms resolved with an optimized diet of corn starch, high-protein and vitamin supplementation. The importance of liver transplantation was also discussed with the family.

Introduction

Gastric cancer is the 5^th most common cancer globally(1). Europe's Beating Cancer Plan recognises the urgent need for a gastric cancer screening strategy(2). One promising approach, outlined in the Maastricht VI/Florence consensus report, suggests integrating screening modalities for gastric cancer, such as gastroscopy with colorectal cancer screening (3). This method holds the potential for cost-saving benefits through combined screening efforts (4).

Aims & Methods

We aimed to determine the prevalence of preneoplastic and neoplastic lesions in a high-risk age group, in those who underwent gastroscopy at the time of colonoscopy. Our secondary aims were to determine a)the quality of endoscopy performed and b) the endoscopic burden for pathology that required follow-up.
This was a single-centre review and audit of key performance indicators in a colorectal cancer screening centre. The age group targeted was 50-74, i.e. the target group for colon cancer screening in Europe. We included those undergoing colonoscopy for polyp surveillance or as part of the national colon cancer screening programme. Participants with red flag symptoms (iron deficiency anaemia, weight loss, dysphagia), family history of gastric cancer, established diagnosis of Barrett’s, intestinal metaplasia, dysplasia or who had a gastroscopy in the last 3 years were excluded. The sample size required for a 95% confidence interval with a presumed positivity rate of 5-7% was 101. Descriptive statistics, correlations and associations were examined using Stata software.

Results

101 patients were included; the median age was 59;38% were male. Indications for gastroscopy included abdominal pain (45%), chronic reflux (37%), chronic dyspepsia (7%) and other (9%). All patients had a technically complete gastroscopy (D2 intubation rate 100%, retroflexion 100%), the median procedure length was 7 minutes(range 4-21). 93% of patients had a macroscopic finding at the time of gastroscopy. Findings included gastritis(chronic superficial, chemical)(60%), hiatus hernia (50%), oesophagitis (28%), duodenitis (24%), gastric body polyps (10%), Barrett’s mucosa (8%), benign gastric or duodenal ulceration(9%), Schatzki ring (4%), erosions (4%), intestinal metaplasia (IM)(1%), oesophageal candidiasis (1%) and varices (1%). 59% had biopsies taken from two topographical sites as per MAPS guidelines. On biopsy, Helicobacter pylori infection was found in 15% (15/101), 7% had intestinal metaplasia(IM); no atrophy, dysplasia or cancer was detected. In those with IM who had MAPS biopsies (5/7), all were focal IM. In those with suspected Barrett’s (n=8), 88% had biopsies taken in accordance with the Seattle protocol and the Prague classification was used in 50% of cases. Additional pathology encountered included histological evidence of antral gastritis (56%), body gastritis (53%), reflux oesophagitis (21%), Barrett’s without dysplasia (4%), duodenitis (3%), and eosinophilic oesophagitis (1%). There was no statistical difference in age (p<0.82) or gender (p<0.32)in those with preneoplastic changes on gastroscopy.

Conclusion

11% of individuals within the target age bracket exhibited a pre-neoplastic condition on gastroscopy and/or histology (i.e. gastric intestinal metaplasia, gastric atrophy or Barrett's oesophagus), a further 15% were diagnosed and treated for Helicobacter pylori infection, the leading cause of gastric cancer. Among these cases, 4-7% necessitated subsequent surveillance gastroscopy. Our findings support the role of dual endoscopic screening with quality gastroscopy as a potential strategy for gastric cancer screening.

References

1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-49. doi: 10.3322/caac.21660. Epub 2021 Feb 4.
2. Commission E. Europe's Beating Cancer Plan - Communication from the commission to the European Parliament and the Council. 2021.
3. Malfertheiner P, Megraud F, Rokkas T, Gisbert JP, Liou JM, Schulz C, et al. Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report. Gut. 2022.
4. Libanio D, Antonelli G, Marijnissen F, Spaander MC, Hassan C, Dinis-Ribeiro M, Areia M. Combined gastric and colorectal cancer endoscopic screening may be cost-effective in Europe with the implementation of artificial intelligence: an economic evaluation. Eur J Gastroenterol Hepatol. 2024;36(2):155-61. doi: 10.1097/MEG.0000000000002680. Epub 2023 Nov 15.

Introduction

Arsenic, a potent environmental toxin, has been widely reported to cause significant health problems, including liver damage and disturbances in the metabolic processes. One of the lesser-understood facets of arsenic toxicity is its impact on gut microbiota, the community of microorganisms living in the intestinal tract, which plays a crucial role in host metabolism and overall health. Previous studies have indicated that arsenic exposure can alter the composition of gut microbiota, potentially affecting the host’s metabolism of arsenic and exacerbating its toxic effects. Despite ongoing research, the mechanisms underlying the interaction between arsenic exposure, gut microbiota changes, and arsenic metabolism remain inadequately defined.

Aims & Methods

The primary objective of this study was to elucidate the dynamics of gut microbiota changes under varying levels of arsenic exposure and to understand how these changes affect arsenic metabolism and subsequent liver toxicity. We used C57BL/6 mice as a model system, exposing them to 0, 5, or 10 ppm sodium arsenite (NaAsO2) in their drinking water over a period of six months. We conducted a comprehensive analysis of the gut microbiota, focusing on folic acid (FA)/vitamin B12 (VB12)- and butyrate-synthesizing communities. Additionally, molecular interactions between arsenic and methionine synthase (MTR), an enzyme crucial for FA/VB12 utilization, were assessed using 3D molecular simulations and biochemical assays. The intervention model involved supplementation of FA and VB12 to evaluate their protective effects against arsenic-induced disturbances.

Results

Exposure to NaAsO2 significantly altered gut microbiota, with a notable increase in the abundance of FA/VB12- and butyrate-synthesizing microbiota. This shift was hypothesized to compensate for the disrupted utilization of these nutrients due to arsenic exposure. In higher arsenic exposure levels, however, the microbiota changes were inconsistent, suggesting a potential threshold beyond which the compensatory mechanism may be overwhelmed. Biochemical assays confirmed that arsenic binds to MTR, disrupting its function and further impacting FA/VB12 metabolism. The interaction was substantiated by SEC-UV-DAD and fluorescence-labeled arsenic studies, which demonstrated that arsenic directly interacts with MTR in both non-cellular and cellular systems. Our intervention model using FA and VB12 supplementation showed that it was possible to mitigate the disturbances in gut microbiota, restore MTR levels, enhance arsenic metabolism, and reduce liver injury.

Conclusion

This study provides significant insights into the interaction between arsenic exposure and gut microbiota. We demonstrated that changes in gut microbiota are not merely a consequence of arsenic exposure but are intricately linked to the metabolic processes affected by arsenic, particularly through the disruption of MTR function. The supplementation of FA and VB12 proved effective in blocking these disturbances, suggesting potential therapeutic strategies to combat arsenic toxicity. The findings emphasize the importance of considering gut microbiota in the management and treatment of arseniasis and underscore the complex interplay between environmental toxins, gut microbiota, and host metabolism. Future studies should focus on further delineating the specific pathways and mechanisms by which microbiota influence arsenic metabolism and exploring the potential for microbiota-targeted therapies in arsenic-related diseases.