Introduction

The diagnosis of Crohn’s Disease (CD) is based on a combination of clinical symptoms, laboratory tests, endoscopy and imaging data. Imaging technique use, including ultrasonography, computed tomography (CT) and magnetic resonance enterography (MRE), have been increasing in recent years. Transabdominal ultrasound is non-invasive, does not use ionizing radiation and is easily accepted by patients. In particular, in Small Intestine Contrast Ultrasonography (SICUS) the ingestion of a macrogol solution as oral contrast medium may optimize image quality and increase sensitivity and diagnostic accuracy in detecting lesions of the small intestine.

Aims & Methods

We aimed to evaluate diagnostic performance of SICUS for CD. A literature search was performed and updated in February 2023. We selected only studies in which SICUS was compared to a technique allowing the assessment of whole gastrointestinal tract such as MRE, CT scan or surgical evaluation. The end-point was to estimate the pooled weighted sensitivity, specificity, likelihood ratio for positive and negative test (PLR and NLR, respectively) and diagnostic odd ratio (DOR) of SICUS. Summary receiver operating characteristic curves (SROC) were drawn and pooled areas under the curve (AUC) were calculated. A random effect model was followed in all analyses. We assessed heterogeneity using the χ² test and, if statistically significant, the I² statistic was computed. The data were expressed as proportions/percentages, and 95% confidence intervals (CI) were calculated. The MetaDisc software version 1.4 was used.

Results

Five studies were included in the analysis. Overall, 325 patients with CD were recruited. SICUS showed a pooled sensitivity for diagnosis of 95% (95% CI 89-99%) a specificity of 77% (95% CI 60-90%), and the AUC of SROC curve was 0.94. Presence of strictures was examined in 94 patients within all studies. SICUS demonstrated a pooled sensitivity of 78% (95% CI 63-88%) and a specificity of 96% (95% CI 85-99%), with AUC = 0.93. For abscesses, SICUS demonstrated a pooled sensitivity of 100% (95% CI 59-100%) and a specificity of 90% (95% CI 74-98%). Fistulae were evaluated in 55 patients overall across three studies. SICUS showed a pooled sensitivity of 77% (95% CI 46-95%) and a specificity of 92% (95% CI 75-99%). Three studies investigated the presence of pre-stenotic luminal dilation in 61 patients. We found a pooled sensitivity of 100% (95% CI 80-100%) a specificity of 80% (95% CI 65-90%) and the AUC of SROC curve was 0.91.

Conclusion

SICUS has excellent diagnostic performance compared to gold standard, despite some situations (stenosis and fistulae) show suboptimal diagnostic effectiveness.

Introduction

Data are needed to inform therapeutic positioning of advanced therapies, including biological drugs, small molecule agents, and stem cells for fistulizing Crohn’s disease (CD).

Aims & Methods

We aimed to assess the comparative efficacy of these advanced therapies in patients with fistulizing CD. We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials between inception and March 21st, 2023. The co-primary outcomes were induction of fistula remission, defined as closure of all draining fistulas at week 6-14 and week 44-54. Network meta-analysis was conducted under the Bayesian framework.

Results

We identified a total of 1,275 citations, of which 21 randomized clinical trials comprising 1,452 patients were eligible and included in the analysis. Based on the probability of achieving fistula remission within the induction period (week 6-14), infliximab 5 mg/kg monotherapy or in combination with ciprofloxacin ranked highest but was not statistically superior to other advanced therapies. Further, upadacitinib 45 mg once daily, infliximab 10 mg/kg, and ustekinumab 6 mg/kg were similarly superior to placebo, while adipose-derived stem cells Cx401, bone marrow-derived mesenchymal stem cells, vedolizumab 300 mg, and adalimumab 80/40 mg were not superior to placebo. Based on the probability of inducing long-term fistula remission during the maintenance period (week 44-56), upadacitinib 30 mg or 15 mg ranked highest although not superior to placebo; of note, both doses of upadacitinib did achieve statistical significance in terms of superiority to placebo for fistula remission at week 52 in the original trial. In contrast, adalimumab 80/40 mg, infliximab 5 mg/kg and adipose-derived stem cells Cx601 were superior to placebo but no differences between the active interventions were demonstrated.
Table 1: League plot for the comparison of advanced therapies in patients with fistulizing Crohn’s disease for maintenance of fistula remission at weeks 44-56. The values in each cell represent the relative treatment effect (relative risk and 95% credible intervals) of the column-defining treatment compared to the row-defining treatment. A double asterisk indicates statistical significance.

	Upadacitinib 30 mg	Upadacitinib 15 mg	Adalimumab 80/40 mg	Vedolizumab 300 mg	Infliximab 5 mg/kg	Ustekinumab 6 mg/kg	ASCs Cx601	Adalimumab 160/80 mg	Placebo
Upadacitinib 30 mg		0.85 (0.27-3.11)	0.33 (0.01-2.89)	0.31 (0.01-3.51)	0.25 (0.01-1.98)	0.23 (0.01-2.07)	0.20 (0.01-1.51)	0.18 (0.01-1.88)	0.14 (0.00-1.02)
Upadacitinib 15 mg	1.18 (0.32-3.75)		0.38 (0.01-3.01)	0.36 (0.01-3.75)	0.30 (0.01-2.05)	0.28 (0.01-2.16)	0.24 (0.01-1.57)	0.21 (0.01-1.98)	0.17 (0.01-1.06)
Adalimumab 80/40 mg	3.06 (0.35-97.11)	2.60 (0.33-82.27)		0.93 (0.24-4.63)	0.78 (0.29-1.85)	0.71 (0.24-2.23)	0.62 (0.25-1.34)	0.55 (0.14-2.25)	**0.43 (0.18-0.88)**
Vedolizumab 300 mg	3.28 (0.28-113.23)	2.80 (0.27-95.01)	1.08 (0.22-4.20)		0.84 (0.18-2.68)	0.77 (0.16-3.04)	0.67 (0.15-1.98)	0.59 (0.10-2.94)	0.47 (0.11-1.32)
Infliximab 5 mg/kg	3.96 (0.51-124.21)	3.36 (0.49-103.92)	1.29 (0.54-3.44)	1.19 (0.37-5.44)		0.91 (0.40-2.55)	0.80 (0.45-1.40)	0.71 (0.22-2.60)	**0.55 (0.34-0.89)**
Ustekinumab 6 mg/kg	4.28 (0.48-135.38)	3.63 (0.46-114.35)	1.40 (0.45-4.18)	1.30 (0.33-6.34)	1.10 (0.39-2.49)		0.88 (0.33-1.79)	0.77 (0.33-1.77)	0.61 (0.24-1.16)
ASCs Cx601	4.95 (0.66-152.08)	4.20 (0.64-127.86)	1.61 (0.74-4.02)	1.49 (0.50-6.54)	1.25 (0.71-2.24)	1.14 (0.56-3.00)		0.89 (0.29-3.10)	**0.70 (0.51-0.93)**
Adalimumab 160/80 mg	5.63 (0.53-192.41)	4.79 (0.51-159.41)	1.82 (0.45-7.16)	1.69 (0.34-9.95)	1.40 (0.38-4.59)	1.29 (0.56-2.99)	1.12 (0.32-3.44)		0.78 (0.23-2.28)
Placebo	7.12 (0.98-217.65)	6.02 (0.95-182.46)	**2.32 (1.14-5.55)**	2.15 (0.76-9.19)	**1.80 (1.13-2.97)**	1.63 (0.86-4.14)	**1.44 (1.08-1.96)**	1.29 (0.44-4.32)

Conclusion

We found no apparent differences in efficacy between currently available advanced therapies for fistulizing CD. The study supports the role of infliximab 5 mg/kg, upadacitinib 45 mg, ustekinumab 6 mg/kg, and adipose-derived stem cells in the clinical management of fistulizing CD. The current study informs the positioning of advanced therapies; however, clinical decisions need to be individualized.

Disclosure

M.A.: None
D.N.R.: None
F.B.: Personal fees from Tillotts Pharma, outside the submitted work.
J.B.: reports grants and personal fees from AbbVie, grants and personal fees from Janssen-Cilag, personal fees from Celgene, grants and personal fees from MSD, personal fees from Pfizer, grants and personal fees from Takeda, grants and personal fees from Tillotts Pharma, personal fees from Samsung Bioepis, grants, and personal fees from Bristol Myers Squibb, grants from Novo Nordisk, personal fees from Pharmacosmos, personal fees from Ferring, personal fees from Galapagos, outside the submitted work.
J.B.S.: has received research grants from Takeda, Janssen and is national coordinator of studies from AbbVie, Arena Pharmaceuticals, Ely Lilly, and Boehringer Ingelheim. None of these pertain to the research submitted here.

Introduction

Data are needed to clarify the positioning of biological therapies and small molecules for early resolution of moderately to severely active luminal Crohn’s disease (CD). We aimed to compare early response for advanced CD therapies in a systematic review with network meta-analysis.

Aims & Methods

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials between inception and Sep 10, 2022. The co-primary outcomes were the induction of clinical response, defined as ≥70-point reduction in Crohn’s Disease Activity Index (CDAI-70 response) from baseline, and clinical remission, defined as CDAI ≤150 at week 2. Network meta-analysis was conducted under the Bayesian framework (PROSPERO ID: CRD42022368509).

Results

Of 16,242 and 19,281 studies from databases and congress proceedings, respectively, a total of 61 studies, comprising 17,436 patients, were included in this study. Infliximab 5 mg/kg combined with azathioprine or monotherapy ranked highest for induction of clinical response at week 2 and was significantly superior to adalimumab 160/80 mg, adalimumab 80/40 mg, certolizumab 400 mg, risankizumab 1200 mg, and risankizumab 600 mg. Accordingly, infliximab 5 mg/kg ranked highest for induction of clinical remission at week 2. Findings were consistent throughout week 6 in the overall population and bio-naïve patients. Upadacitinib 45 mg QD ranked highest at week 2 but was not significantly superior to biologics for the induction of CDAI-100 response; of note, no data on CDAI-100 response for infliximab 5 mg/kg were found. Comparison of agents for bio-exposed patients was first possible at week 4; herein, adalimumab 160/80 mg and ustekinumab 6 mg/kg ranked highest for induction of both clinical response and clinical remission in the absence of data on infliximab 5 mg/kg. Finally, Vedolizumab 300 mg, guselkumab 200/600/1200 mg, mirikizumab 200/600/1000 mg, and filgotinib 200 mg reached significant differences from placebo at weeks 4, 8, 8, and 10, respectively, in either CDAI scores or 2-item patient-reported outcome (PRO-2) scores.


Table 1: League plot for the comparison of biologics and small molecule drugs for the induction of a CDAI-70 response at week 2 in patients with moderately to severely active luminal Crohn’s disease. The values in each cell represent the relative treatment effect (relative risk and 95% credible intervals) of the column-defining treatment compared to the row-defining treatment. A double asterisk indicates statistical significance.

	Infliximab 5 mg/kg + azathioprine	Infliximab 5 mg/kg	Adalimumab 80/40 mg	Adalimumab 160/80 mg	Certolizumab 400 mg	Risankizumab 1200 mg	Risankizumab 600 mg	Upadacitinib 24 mg BID	Placebo
Infliximab 5 mg/kg + azathioprine		0.88 (0.74-1.05)	**0.41 (014-0.94)**	**0.34 (0.12-0.75)**	**0.31 (0.11-0.68)**	**0.29 (0.10-0.64)**	**0.29 (0.10-0.64)**	**0.25 (0.08-0.70)**	**0.22 (0.08-0.47)**
Infliximab 5 mg/kg	1.13 (0.95-1.36)		0.46 (0.16-1.04)	**0.39 (0.14-0.83)**	**0.35 (0.13-0.76)**	**0.33 (0.12-0.71)**	**0.33 (0.12-0.70)**	**0.28 (0.09-0.78)**	**0.25 (0.09-0.52)**
Adalimumab 80/40 mg	**2.47 (1.07-7.10)**	2.17 (0.96-6.13)		0.84 (0.62-1.13)	0.75 (0.50-1.13)	0.71 (0.48-1.05)	0.71 (0.48-1.05)	0.62 (0.30-1.31)	**0.54 (0.39-0.75)**
Adalimumab 160/80 mg	**2.93 (1.33-8.24)**	**2.59 (1.20-7.12)**	1.20 (0.88-1.61)		0.90 (0.65-1.24)	0.85 (0.62-1.16)	0.84 (0.62-1.15)	0.74 (0.37-1.50)	**0.65 (0.51-0.81)**
Certolizumab 400 mg	**3.26 (1.47-9.19)**	**2.88 (1.32-7.96)**	1.33 (0.88-1.99)	1.11 (0.80-1.54)		0.94 (0.69-1.30)	0.94 (0.68-1.29)	0.82 (0.41-1.68)	**0.72 (0.57-0.91)**
Risankizumab 1200 mg	**3.46 (1.57-9.66)**	**3.05 (1.41-8.36)**	1.41 (0.95-2.08)	1.18 (0.87-1.60)	1.06 (0.77-1.46)		0.99 (0.84-1.18)	0.87 (0.44-1.77)	**0.76 (0.61-0.94)**
Risankizumab 600 mg	**3.48 (1.57-9.70)**	**3.07 (1.42-8.41)**	1.42 (0.96-2.09)	1.18 (0.87-1.61)	1.06 (0.77-1.47)	1.01 (0.85-1.19)		0.88 (0.44-1.78)	**0.77 (0.62-0.94)**
Upadacitinib 24 mg BID	4.02 (1.44-13.32)**	**3.54 (1.28-11.56)**	1.62 (0.76-3.36)	1.35 (0.66-2.70)	1.22 (0.60-2.43)	1.15 (0.57-2.28)	1.14 (0.56-2.28)		0.87 (0.45-1.68)
Placebo	**4.54 (2.12-12.40)**	**4.01 (1.92-10.72)**	**1.85 (1.33-2.57)**	**1.55 (1-24-1.94)**	**1.39 (1.10-1.77)**	**1.31 (1.06-1.63)**	**1.31 (1.06-1.62)**	1.14 (0.60-2.24)

Conclusion

We found infliximab 5 mg/kg, combined with azathioprine or alone, to be consistently superior to all other agents and associated with the most rapid onset of effect, particularly among bio-naïve patients. This network meta-analysis has implications for rational individualized therapeutic decision-making in patients with CD.

Disclosure

M.A., J.G., and O.H.N.: None
C.S.: reports research grants from Takeda, paid speaker by MSD, Tillotts.
A.P.: reports research grants and personal fees from Janssen, Takeda, and MSD, personal fees from Bristol Myers Squibb. National coordinator of studies from AbbVie, Boehringer Ingelheim, and Bristol Myers Squibb. None of these pertain to the research submitted here.
J.B.: reports grants and personal fees from AbbVie, grants and personal fees from Janssen-Cilag, personal fees from Celgene, grants and personal fees from MSD, personal fees from Pfizer, grants and personal fees from Takeda, grants and personal fees from Tillots Pharma, personal fees from Samsung Bioepis, grants, and personal fees from Bristol Myers Squibb, grants from Novo Nordisk, personal fees from Pharmacosmos, personal fees from Ferring, personal fees from Galapagos, outside the submitted work.
J.B.S.: has received research grants from Takeda, Janssen and is national coordinator of studies from AbbVie, Arena Pharmaceuticals, Ely Lilly, and Boehringer Ingelheim. None of these pertain to the research submitted here.

Introduction

Crohn’s disease (CD) is characterized by recurrent flares of intestinal inflammation that can affect any segment of the digestive tract. Frequently, transmural inflammation can lead to serious intraabdominal complications that may eventually require surgical intervention. Surgery in CD is not curative and almost 25% of patients will need multiple interventions. The mesentery might be involved in CD pathogenesis by modulating local hormonal and immunologic processes, which is why surgical techniques involving the mesentery have recently drawn attention. Certain studies reported that removing the mesentery during intestinal resection might improve the postoperative outcome, but the results are controversial.

Aims & Methods

Our main aim was to evaluate the effectiveness of performing extended mesenteric excision (EME) in preventing postoperative CD recurrence (POR) compared with limited mesenteric excision (LME). Second, we investigated the role of EME on overall postoperative complications, as compared to LME. We conducted our study according to a pre-registered protocol in PROSPERO (CRD42022371789). Studies that reported short- and long-term outcomes of CD patients who underwent intestinal resection with EME compared with LME were considered eligible. A systematic search was performed in five databases (Pubmed, Embase, Cochrane, Scopus, Web of Science) from inception until 9th November 2022. Pooled odds ratios (ORs) with a 95% confidence interval (CI) were calculated using the random-effects model. The risk of bias was assessed with the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. We evaluated the certainty of evidence according to the recommendations proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.

Results

During the systematic search, 7201 records were retrieved. After the duplicate removal and selection process, we included six papers that reported data from five studies. The meta-analysis was performed with data pooled from three retrospective cohort studies, of which two included patients with ileocolic resections and one with colorectal resections. These studies analyzed 516 patients, of which 304 underwent EME and 212 LME. Our results showed a non-significant lower rate of surgical recurrence in the EME group compared with LME (OR 0.3; 95% CI: 0.02-3.73). Regarding overall postoperative complications, performing EME was also associated with non-significant lower odds (OR 0.78; 95% CI: 0.33-1.82). The certainty of the evidence for the meta-analysis outcomes was very low and low, respectively. Concerns were raised by the moderate level of bias and, more importantly, by the inconsistency and imprecision of the results.

Conclusion

Our meta-analysis indicated a trend towards lower rates of POR in patients who underwent intestinal resections with EME compared with LME. However, results are to be interpreted cautiously due to the statistical non-significance and the low quality of evidence. Considering overall postoperative complication rates, performing intestinal resections with EME appears to be a safe procedure compared with LME. Results from ongoing randomized controlled trials and further high-quality studies are needed to determine the role of mesentery resections in CD surgery.

Introduction

The Montreal classification reflects the varying phenotypes of Crohn’s including location and behaviour, however the majority of trials to date, despite including Montreal classification in baseline characteristics, do not report treatment efficacy by disease location. Ileal disease is associated with a higher risk of progression to stricturing and penetrating complications.

Aims & Methods

To perform a systematic review summarising the evidence for different biologic and advanced therapies available for small bowel Crohn’s disease in adult patients.
Systematic search of MEDLINE and EMBASE was conducted. Articles were then screened, duplicates removed. Inclusion criteria included trials with efficacy outcomes stratified via disease location. Primary outcome was drug efficacy, measured via endoscopic response, healing, clinical remission or improvement of MRI severity scores.

Results

A total of 868 publications were screened and assessed for eligibility following database screening and removal of duplicates. 12 studies were included with 746 patients, with a total median follow up of 52 weeks(range 14-165). All studies were included in qualitative analysis; Infliximab (6 trials n=404) Adalimumab (4 trials n=204), Vedolizumab (2 trials n=50), Ustekinumab (1 trial n=28), Filgotinib (1 trial n=60).
Of the 6 infliximab studies (n=404), 3 reported on endoscopic response (ER) and 2 endoscopic healing (EH) via double balloon enteroscopy, 2 reported on clinical outcomes only and 1 reported on improvements in MRI outcomes, as detailed in the below table. Median follow up was 52 weeks.

First author	Year	N	Design	Drug	Outcome	Follow up
Huang	2025	110 64 28 18	R	IFX UST VEDO	EH 29.6% (19/64) ER 42.2% (27/64) UH 35.9% (23/64) EH 10.7%(3/28) ER 28.6% (8/28) UH 17.9% (5/28) EH 5.5% (1/18) ER 11.1% (2/18) UH 11.1% (2/18)	52 weeks
Wei	2024	111	R	IFX	ER 42.3% (47/111) MH 29.7% (33/111)	32 months
Han	2021	91	R	IFX	DR(CR+MH) 47.2% (42/91)	14 weeks
Chen	2021	79	R	IFX	CR 46.8% (37/79)	38 months
Zorzi	2012	44 34 (I) 28 (M)	O	IFX – Induction (I) Maintenance(M)	CR 74% (20/28)	54 weeks
Van Assche	2013	15	P	IFX	MRI improvement 40% (6/15)	26 weeks

IFX=Infliximab, ADA=Adalimumab, VEDO=Vedolizumab,
EH= Endoscopic healing(defined as a modified SES-CD <3 or 0 if jejunal/proximal ileum), ER=Endoscopic Response(defined as a reduction of SES-CD by more than 50% at both segmental and complete level), UH=Ulcer Healing (defined as no inflammation, ulcers or erosions), MH=mucosal healing(SES-CD=0), DR=Deep Remission, CR=Clinical Remission

There were 4 trials for adalimumab (n=204), 2 trial outcomes reported on EH(53.3%) and ER on capsule (42%). Two trials focused on clinical response rates; 64-66%[iii][iv]. Median follow up was 52 weeks (range 24-154).
Ustekinumab data (n=28) was available from Huang et al who reported EH in 10.7%(3/28), ER in 28.6% (8/28) and UH rates of 17.9% (5/28).
Two retrospective studies reported on Vedolizumab outcomes(n=50); reporting on EH 5.5% (1/18), ER 11.1% (2/18), UH 11.1% (2/18) [v] and another study (n=36) reported on CT and MRI outcomes for ileal Crohn’s reporting a 22% (7/32) imaging response based on EMBARK scoring[vi]. Both studies had 52 week follow up.
One RCT involving two doses of Filgotinib reported rates of clinical remission (based on CDAI<150 at week 24) of 25% in both groups[vii] and secondary outcomes of MRI remission (based on MaRIAseg<7) in 6.3%(2/32) of 100mg arm and 8%(2/25) of the 200mg arm.

Conclusion

Robust retrospective data exists for small bowel mucosal healing with anti-TNF therapy. Data is lacking for vedolizumab, ustekinemab and newer smaller molecule therapies. Dedicated clinical trials are needed to specifically investigate the effectiveness of therapies in isolated ileal Crohn’s disease patients to optimise their management.

References

[i] ‘Mucosal Healing and Clinical Efficacy of Adalimumab in Small Intestinal Crohn’s Disease (SIMCHA Study): Final Results From a Prospective, Open-Label, Single-Arm Study’, The Turkish Journal of Gastroenterology 34, no. 6 (9 June 2023): 603–10, https://doi.org/10.5152/tjg.2023.22527.
[ii] Barry Hall et al., ‘A Prospective 52week Mucosal Healing Assessment of Small Bowel Crohn’s Disease as Detected by Capsule Endoscopy’, Journal of Crohn’s and Colitis 8, no. 12 (December 2014): 1601–9, https://doi.org/10.1016/j.crohns.2014.09.005.
[iii] Yoram Bouhnik et al., ‘Efficacy of Adalimumab in Patients with Crohn’s Disease and Symptomatic Small Bowel Stricture: A Multicentre, Prospective, Observational Cohort (CREOLE) Study’, https://doi.org/10.1136/gutjnl-2016-312581.
[iv] F. Zorzi et al., ‘Efficacy and Safety of Infliximab and Adalimumab in C Rohn’s Disease: A Single Centre Study’, https://doi.org/10.1111/j.1365-2036.2012.05100.x.
[v] Zi-Cheng Huang et al., ‘Effectiveness of Biologics for Endoscopic Healing in Patients with Isolated Proximal Small Bowel Crohn’s Disease’, https://doi.org/10.3748/wjg.v31.i7.98448.
[vi] Lukasz Kwapisz et al., ‘CT or MR Enterography to Assess Response During Vedolizumab Therapy for Small Bowel Crohn’s Disease’, https://doi.org/10.1093/crocol/otac003.
[vii] Geert R. D’Haens et al., ‘Filgotinib for the Treatment of Small Bowel Crohn’s Disease: The DIVERGENCE 1 Trial’, https://doi.org/10.1053/j.gastro.2023.03.234.

Introduction

The disease course of ileal and ileocolonic Crohn’s disease (CD) is highly heterogeneous, and continuous objective measures of disease activity are needed. Intestinal Ultrasound (IUS) is a non-invasive modality assessing disease activity in IBD. The International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) is an index for grading CD activity. However, importance of the ultrasonic findings in the terminal ileum (TI) at diagnosis and the responsiveness of ultrasonic findings to different treatments is still limited. We thus aimed to investigate the IUS characteristics of the TI at diagnosis and changes in IUS parameters in response to treatment 3 months after inclusion.

Aims & Methods

Patients with new-onset IBD are recruited in the ongoing multicentre prospective inception cohort study, the IBD Prognosis Study. IUS is performed at diagnosis and after three months (3M). IBUS-SAS (0-100) is scored for the TI and incorporates the bowel wall thickness (BWT), bowel wall stratification (BWS), colour Doppler signal (CDS), and inflammatory fat (I-FAT). Only patients with ileal and ileocolonic CD who had an available IBUS-SAS of the TI at diagnosis were included. Patient without subsequent assessment at 3M were excluded (except resected patients). Transmural remission was defined as IBUS-SAS < 12 (corresponding to BWT < 3 mm and no signs of inflammation). If the operator assessed the TI as complete transmural remission at 3M without providing numeric BWT values, the IBUS-SAS was set to 8. Patients treated with corticosteroids for > 72 hours or with any IBD treatment > two weeks prior to baseline IUS were excluded from analysis.

Results

Baseline IBUS-SAS at TI was available in 46 CD patients (ileal: 21, ileocolonic: 25). According to the Montreal classification, 31 patients had B1 (non-stricturing, non-penetrating disease), 9 patients had B2 (stricturing disease), and 6 patients had B3 (penetrating disease).
Among all patients, the mean IBUS-SAS was 60.7 at diagnosis vs. 33.7 at 3M (p<0.001). Mean baseline BWT decreased from 5.8 to 4.6 (p=0.011) at 3M. The other IBUS-SAS parameters also had significant reductions (p=0.021, p=0.001, and p<0.001 for BWS, CDS, and I-FAT, respectively). After three months, 12/39 (30.8%) of non-resected patients were in transmural remission.
Changes in IBUS-SAS between diagnosis and 3M stratified by initiated treatment are presented in Figure 1 (​https://ibb.co/mBcVF9b​​​). In total, 6 (13.0%) patients started only systemic steroids with a mean IBUS-SAS reduction of 20.6 (p=0.025), 5 (10.9%) patients started systemic steroids + biological therapy with a mean reduction in IBUS-SAS of 37.6 (p=0.022), 11 (23.9%) patients started on systemic steroids + immunomodulator with a mean reduction in IBUS-SAS of 35.6 (p<0.001), 4 (8.7%) patients started on immunomodulator + biological therapy with a mean reduction in IBUS-SAS of 24.8 (p=0.271), and 9 (19.6%) patients were started on budesonide with a mean reduction in IBUS-SAS of 9.4 (p=0.287). Finally, 4 (8.7%) patients did not commence on any treatment and these patients increased their IBUS-SAS by 6.75 (p=0.536), and 7 (15.2%) patients were resected as primary treatment with 1, 2, and 4 having the B1, B2, and B3 Montreal classification, respectively. Baseline IBUS-SAS was significantly higher for patients undergoing resection than patients without resection, (87.9 vs. 55.8, P<0.001).

Conclusion

IUS performed at diagnosis and after three months can effectively identify patients achieving ultrasonic response and / or transmural healing to multiple drug classes. All four IBUS-SAS activity parameters demonstrated responsiveness to treatment and patients without treatment increased their IBUS-SAS non-significantly. Transmural remission was achieved in up to 30 % of non-resected patients within 3M.

Introduction

Capsule retention is the main adverse event of SBCE. Current guidelines support the use of conservative/medical treatment for asymptomatic patients. However, the appropriate duration of conservative and medical therapy, the optimal regimens, and the timing to perform DAE/surgery in asymptomatic patients is still largely undefined.

Aims & Methods

Through a systematic search of multiple electronic databases until November 2023, studies including CD patients undergoing capsule endoscopy (CE) were identified. Capsule retention was defined according to ICCE criteria.

Results

We included 42 studies, totaling 196 capsule retentions in CD patients. Of these, 50 underwent anti-inflammatory therapy, consisting of corticosteroids (n= 34); corticosteroids + antibiotics (n=1), and corticosteroids + infliximab (n= 15). Steroids allowed for spontaneous passage in 44% (n=22): 3 out of 16 asymptomatic patients; 3 out of 5 symptomatic without complete small bowel
occlusion (SBO); 2 in 3 with complete SBO. Combination with infliximab solved the retention in further 6 out of 15 patients. Mean time to resolution was 6,9 days (R 15h-21d), which was reported in 6 patients. Steroid administration route was reported in 2 patients (intravenous) and dosage in 3 patients: 100mg for 3 days, 1.2 mg/kg/day for 17 days, 0.5 mg/kg/day for 17 days, the latter being unsuccessful. Conservative treatment only or after failed medical therapy was used in 19 asymptomatic patients, with spontaneous passage in 6. One study reports retention of a capsule for 8.5 years. Of patients undergoing medical treatment 3 underwent urgent and 15 programed surgeries.

Conclusion

Evidence was of low quality. Treatment duration, regimen and time to spontaneous passage was underreported. We were unable to find predictors of the need to perform DAE/surgery in asymptomatic patients. As capsule retentions are increasingly rarer, the available evidence is unlikely to change.