Introduction

In the recent years, the therapeutic options for inflammatory bowel disease (IBD) have expanded. Multiple Janus kinase (JAK) inhibitors have been licensed: First Tofacitinib (TOFA) for Ulcerative Colitis (UC), followed, most recently, by Filgotinib (FIL) in UC and Upadacitinib (UPA) in UC and Crohn’s Disease (CD).

Aims & Methods

The aim of the study was to explore the real-world effectiveness and safety of UPA in a multicenter Belgium refractory cohort of patients with moderate-to-severe CD.
This is an observational, national, retrospective multicenter study including all patients with active CD initiating UPA between September 2022 and January 2024 from 16 Belgian centers. Clinical remission and response were defined using the two-component patient reported outcome. Endoscopic response was defined as a decrease in baseline Simple Endoscopic Score (SES-CD) with ≥ 50%. Endoscopic remission was defined as SES-CD ≤ 4 or disappearance of baseline ulcers. Effectiveness endpoints were evaluated at week 12, 24 and 52, while CD-related hospitalization, surgery and safety were assessed throughout follow-up.

Results

Of the 66 patients who started UPA, 52 patients were analysed (6 excluded for ostomy and 8 for not having yet reached 24 weeks of follow-up) with a median follow-up of 21 weeks (IQR: 4-24). Patients were predominately female (54%), median age at baseline was 37 years old (IQR: 19-62) and median disease duration was 13 years (IQR: 0-29). 12% of the patients had ileal CD, 12% colonic CD, 76% ileocolonic CD with 17% concomitant upper gastrointestinal CD and 42% concomitant perianal disease. The majority of the patients (87%) was exposed to ≥ 3 biologics and 54% had previously undergone a CD-related surgery.
At week 24, 58% and 44% of overall eligible patients achieved steroid-free clinical response and remission, respectively. Endoscopic data were available in 17 out of the 52 patients of whom 65% and 47% reached endoscopic response and remission respectively within the first 24 weeks. Sixteen out of eighteen patients that used concomitant steroids at baseline were able to stop it by week 24.
Overall, 21 patients (40%) discontinued their treatment during follow-up with a median exposure duration of 16 weeks (IQR: 4-24): 11 due to primary non response, 3 due to secondary loss of response, 7 due to adverse event (AE). Among these 21 patients, 4 patients underwent CD-related surgery (2 intestinal resections and 2 diverting ostomies) after a median duration of 15 weeks (IQR: 11-24), while the others switched to another medical therapy. In total, 21%% (11/52) patients required hospitalization within 24 weeks.
Twenty-seven AEs were reported in 19 (37%) patients, with 7 leading to treatment discontinuation (2 allergic skin rash, 1 severe acne, 1 folliculitis, 1 lip oedema, 1 severe stomatitis and 1 loss of appetite). The most common reported AEs were herpes simplex reactivation, respiratory tract infection, cutaneous reactions and acne. No herpes zoster infection, thrombotic or cardiovascular event were reported.

Conclusion

In this real-world cohort of highly refractory CD patients, UPA effectively induced steroid-free clinical remission and endoscopic remission by week 24 and was relatively well tolerated with respect to adverse events.

Disclosure

Dr Anneline Cremer has received lecture and advisory board fees from Galapagos, Abbvie, Janssen (2009-2014); lecture fees from Celltrion (2019-2024), Pfizer (2018-2023); advisory board fees from Takeda (2018-2023).
Dr Denis Franchimont has received lecture and/or advisory board fees from Abbvie, AstraZeneca, Dr. Falk Pharma, Ferring, Janssen, Mundipharma, MSD, Pfizer, Takeda, Amgen and research grants from Abbvie, Janssen, Takeda, Celltrion and Amgen (2019-2024).

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.

Introduction

In the United Kingdom (UK), the Royal College of Obstetricians and Gynaecology (RCOG) recommend that women who have sustained an obstetric anal sphincter injury (OASI) should undergo anorectal physiology testing (ARPT) to inform mode of delivery (MOD), where services are available [1]. ARPT is comprised of endoanal ultrasound (EAUS) which is considered the gold standard for assessing anal sphincter integrity [2,3], and high-resolution anorectal manometry (HR-ARM) for assessing motor and sensory function. However access to such services in the UK are limited, with 12.5% and 3.8% of women offered EAUS and ARM studies, respectively [2,4].

Aims & Methods

The prospective service evaluation assessed the impact of OASIs on anal sphincter anatomy and function, and reviewed the value of ARPT in MOD decision making.
Patients referred for MOD decision making underwent EAUS with the BK medical 3000 system with a 3D anorectal transducer (20R3' 6–16 MHz 360°) and HR-ARM with the Laborie water-perfused system. HR-ARM was performed in accordance with a limited version of the international anorectal physiology working group standardized testing protocol [5], and subsequently analysed in accordance with the London Classification of Anorectal Disorders [5]. Following discussion at a multi-disciplinary team meeting, patients were counselled with the ARPT results by their obstetrician in line with published guidance [6]. Postal feedback surveys were sent post-partum to assess patient experience and the impact of ARPT results on their delivery.

Results

24 pregnant patients with a previous OASI attended for ARPT during a 15 month period. Abnormalities which would encourage counselling for a C-section were identified in 12 patients. 7/12 patients had an external anal sphincter (EAS) defect >30°, 4 of which also had disruption to the internal anal sphincter (IAS). All 7 patients had normal anal contractility on HR-ARM. 1/7 patients had a hypotensive anal canal, disrupted IAS and reported faecal incontinence despite a normal stool consistency. 5/12 patients had anal hypocontractility on HR-ARM; 4 of whom had faecal urgency.
13 patients reported bowel symptoms, with the majority reporting faecal urgency (n=10) and 1 patient reporting Irritable Bowel Syndrome. Of the 13 symptomatic patients, EAUS identified significant defects in 15%, and HR-ARM identified abnormal tone or contractility in 31%. No symptomatic patients were identified to have a major or minor disorder of rectal sensation. 2 urgency patients reported loose stool.
6/18 (33%) patients completed feedback surveys after their delivery. All patients reported that counselling with ARPT results influenced their MOD decision, with 20% changing their intended MOD following ARPT. All patients were satisfied with their MOD choice.

Conclusion

HR-ARM identified 5 patients for C-section counselling, in addition to 7 patients identified by EAUS. There appeared to be poor agreement between EAUS defects and impaired manometric function. EAUS and HR-ARM identified significant anal sphincter impairment in 15% and 31% of symptomatic patients, respectively. This suggests that EAUS may lack sensitivity for identifying symptomatic cohorts, and that HR-ARM abnormality may be a more sensitive indicator of symptomology. This highlights the need to increase HR-ARM provision in perineal services.
Whilst the RCOG recommends counselling with the option of a C-section in all of the patients in this cohort [1], these findings suggest HR-ARM in addition to EAUS may offer a more individualised and collaborative approach to MOD delivery decision making.

References

1. The Management of Third-and Fourth-Degree Perineal Tears Green-top Guideline No. 29. 2015. Available from: https://www.rcog.org.uk/media/5jeb5hzu/gtg-29.pdf. Accessed 24/04/2025.
2. Badri H, et al. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI) . Int Urogynecol J. 2023;34:399–404.
3. Santoro GA, et al. State of the art: an integrated approach to pelvic floor ultrasonography. Ultrasound Obstet Gynecol. 2011;37(4):381–96.
4. Ismail SIMF. The management of obstetric anal sphincter injuries (OASIS): A national postal questionnaire survey in hospitals in the UK. J Obstet Gynaecol. 2015;35(3):229–34.
5. Carrington EV, et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterology and motility. 2020;32(1): e13679.
6. Jordan PA, et al. Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. International Urogynaecology Journal. 2018;29(11):579-1588.

Introduction

Active inflammatory bowel disease in pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes. Understanding patterns of disease activity may inform strategies for improving outcomes.

Aims & Methods

A retrospective cohort study was conducted of pregnancies managed through an IBD–antenatal clinic between August 2020 and January 2025. Patients were stratified into 2 groups based on disease activity during pregnancy. Active disease was defined using the Physician Global Assessment, symptoms, and biomarkers (CRP and/or FCP). Disease flare was defined by an increase in symptoms and/or biomarkers from their baseline. Disease activity was assessed pre-conception (within 6 months before pregnancy) during pregnancy and post-partum (up to 6 months post birth).

Results

Of 209 pregnancies (Table 1), 76.3% (n=158) were in remission and 23.7% (n=49) had active disease pre-conception. Among those with active disease, 81.6% (n=40) remained active into pregnancy, while 18.4% (n=9) achieved remission. Of those in remission at pre-conception, 73.4% (n=116) stayed in remission during pregnancy, and 24.7% (n=39) flared. 2 patients with no pre-conception data were active in pregnancy.
Of 125 patients in remission during pregnancy, 73.6% (n=92) stayed in remission post-partum and 12.0% (n=15) flared. Among 81 patients with active disease in pregnancy, 39.5% (n=32) remained active, and 53.0% (n=43) achieved remission post-partum.
Patients in remission through pregnancy had a higher mean BMI (24.5 vs 23.0 kg/m², p=0.027), were more likely to be of white ethnicity compared to minority ethnic groups (61.0% vs 38.4% p=0.0026), have a diagnosis of Crohn’s disease (58.6% vs 37.0%, p=0.0088), and be nulliparous (51.2% vs 35.0%, p=0.0414).
At conception, approximately 30% of patients in both groups were not receiving any treatment. During pregnancy, this proportion fell to 8.6% in the active group, reflecting therapy escalation. Use of biologics increased from 22.2% to 38.2% in the active group and remained stable at 36.0% in the remission group. Corticosteroid use was exclusive to the active disease cohort (6.2% at conception; 23.5% during pregnancy).
Active disease in pregnancy was associated with higher rates of adverse outcomes: gestational diabetes (12.3% vs 8.0%, p=0.001), fetal growth restriction (4.9% vs 0%, p=0.044), and low birth weight (<2500g: 14.6% vs 2.4%, p=0.015). While rates of small for gestational age infants were higher in the active group (9.9% vs 4.0%), this was not statistically significant.
Emergency c-sections were more common in the active group (29.9% vs 15.0%, p=0.03), while elective c-sections were more frequent in the remission group (27.5% vs 13.4%, p = 0.03). Women in remission more often had an intact perineum (63.6% vs 54.7%), while episiotomy was more frequent in those with active disease (18.8% vs 11.7%); both did not reach statistical significance.

Conclusion

This study underscores the impact of active IBD on maternal and neonatal outcomes.
Nearly 1 in 4 women in remission at preconception flared during pregnancy. This highlights the need for effective pre-conception counselling, access to disease monitoring tools, multidisciplinary management and timely treatment optimisation to sustain remission during pregnancy.

Disclosure

No disclosures