Introduction

Bowel urgency is one of the most bothersome symptoms of ulcerative colitis (UC) and have a great impact on quality of life and psychosocial function. The Urgency Numerical Rating Scale (U-NRS) is desinged to ojectify this subjective symptom. It measures the degree of faecal urgency experienced over the past 24 hours by patients with UC on a scale of 0-10. We assumed that the scale has a large variance, as patients evaluate their own symptoms differently, the urge may be different quality for two patients with the same score.

Aims & Methods

The objective of our study was to investigate the possible components of urgency and refine the assessment of urgency. Patients with UC older than 18 years treated at our departments for at least 3 months and having complaints were enrolled in our study. The patients filled out our non-validated questionnaire with questions about fecal urgency (U-NRS), pain level, speed of urge, incontinence and lifestyle characteristics associated with incontinence. Statistical analysis was performed using STATA 18 program.

Results

263 patients were enrolled, median age was 39.5 years, the mean of disease duration was 11.7±9.2 years. The mean U-NRS score was 3.2±3.2, 32% (84/263) had 0 score and 3% (9/263) has 10 score. 12% of the patients (n=31) felt most difficult to hold mucus, 37% (n=97) stool and 29% (n=76) other secretions. 8% (n=22) had urge with every stool in the last 24 hours, 36% (n=95) had less than half of defecations. The speed of urge defined more the level of urgency than the pain level (R2=0.798 p<0.001, β=0.894 vs R²=0.805, p<0.001, β=0.117). The duration of faeces holding in the last 7 days had significant connection to U-NRS (R²=0.211, p<0.001, β=-0.46). Patients using public restroom at least once during the last week had significantly higher score on U-NRS than other patients (4.6±3.1 vs 2.4±3 p<0.001). 12% (31/263) used diaper. The usage of diapers was also significantly more often in patients with higher U-RNS score (5.2±3.2 vs 2.9±3.1,p<0.0001). Faecal leakage both during the day and night was significiantly higher with higher U-NRS score (p<0.001 for both). Patient reported outcome (PRO2) had a weak correlation with U-NRS (R²=0.14). However if we examine bloody stool, the stool number and difficulty of faecas holding seperately we got a significant and better correlation with urgency (R²=0.43). Patients with moderately severe-severe disease (PRO2 > 5) had a higher chance to have urgency (AUC=0.9). The possibility was higher to have urgency among patients with painful defecation (R²=0.41). The level of urgency, duration of faeces holding and the frequency of faeces holding problems had the strongest correlation with U-NRS (R²=0.83). Patients defined urgency with these parameters according to this result. We created score with them, level of urgency points + half of duration points + frequency, which showed a good model to refine the definition of urgency (R²=0.83).

Conclusion

Bowel urgency affects UC patients' lives and is associated with more severe disability. Bowel urgency is common in UC affecting about two-third of patients and associates with more severe activity of UC. Fecal urgency can characterize with the level of urgency, duration of faeces holding and the frequence of stool more accurately than a single, subjective numeric scale. A new scoring system is needed to more accurately assess patients' complaints in this area and to objectify severity.

Disclosure

The authors have no potential conflict of interest to disclose

Introduction

The European Society of Gastrointestinal Endoscopy (ESGE) recommends colorectal cancer (CRC) screening for individuals at average risk, aged 50-75 years. However, recent trends indicate an increasing incidence of colorectal neoplasms among younger individuals.

Aims & Methods

The primary aim of this cross-sectional study is to record the prevalence of polyps, adenomas, and advanced neoplasia (high-grade dysplasia and CRC) in individuals up to 49 years old, and secondarily to identify predictors of neoplasia and high-grade dysplasia. The data were collected retrospectively through the hospital’s electronic database. All serial colonoscopies, with cecum intubation, from 1/1/2018 until 31/12/2024 were included. Endoscopies in patients with diagnosed familial polyposis syndromes, inflammatory bowel disease and those with poor bowel preparation were excluded. Patients’ demographics, CRC family history and the recorded polyps' size, location, Paris classification, and pathology reports were collected. SPSS 23 (IBM, Armonk, NY, USA) was used for the statistical analysis.

Results

Table. Polyps, adenomas and advanced adenomas by age groups
	<25 (n=36)	25-29 (n=31)	30-34 (n=61)	35-39 (n=76)	40-44 (n=146)	45-49 (n=218)	Total (n=568)	P
Polyps, n (%)	0 (0)	2 (6.5)	6 (9.8)	20 (26.3)	52 (35.6)	86 (39.4)	166 (29.2)	<0.001
Adenoma, n (%)	0 (0)	1 (3.2)	2 (3.3)	9 (11.8)	21 (14.4)	36 (16.5)	68 (12.1)	0.006
Advanced adenoma, n (%)	0 (0)	1 (3.2)	0 (0)	3 (3.9)	4 (2.8)	12 (5.6)	20 (3.5)	0.266

A total of 568 colonoscopies were included, involving 306 male patients (53.8%), with a median age of 42 years (IQR: 36-46). Of these, 71 patients (12.5%) had a family history of CRC. At least one polyp was identified in 166 patients (29.2%), with adenomas observed in 68 patients (12.1%) and advanced neoplasia in 20 patients (3.5%), including 3 patients (0.5%) diagnosed with CRC (Table). Advanced adenomas were more frequently detected in colonoscopies performed due to visible blood in stools (8.5%) and as follow-up after diverticulitis (7.1%). In multivariate analysis, in which age, family history of CRC, and bowel preparation quality were included as variables, the presence of adenomas and advanced adenomas was significantly associated with age (adenoma OR = 1.08; 95% CI: 1.04-1.13 and advanced adenoma OR = 1.08; 95% CI: 1.00-1.18).
In total 271 polyps were identified. Ninety-four were adenomas of which 74 had low-grade dysplasia and 20 high-grade dysplasia or cancer. Sixteen of 177 not-adenomatous polyps were found to be serrated and 2 of those had low-grade dysplasia. “Large” polyps [≥10mm] had a higher probability of being adenomas (71.4%) compared to “small” [5-9mm] (26.2%) and “diminutive” [<5mm] (24.4%), Chi square P<0.001. Regarding the Paris classification Ip and Isp presented a higher probability to be adenomas (87.5% and 86.4% respectively) in contrast to Is and 0-IIa (35.6% and 12.2% respectively), Chi square P<0.001.
The resected adenomas were also categorized according to the type of reported dysplasia to identify predictors of high-grade dysplasia. High-grade dysplasia was present in 42.5% of large polyps compared to 4.5% of small and 6.2% of diminutive (Chi square P<0.001). High-grade dysplasia was also present in a higher frequency in polyps resected from the “left” colon (26.2%) compared to the “right” (10.3%) and in 0-IIa (66.7%) and Ip (38.1%) compared to Isp (21.1%) and Is (12.5%) polyps according to the Paris classification, but not in a statistically significant degree (Chi square P<0.010).

Conclusion

Despite the relatively small sample size of our study, initiation of screening at a younger age should be considered to be lowered, since adenoma and advanced adenoma were identified in 15% and 4.3% of individuals aged 35-49.

Disclosure

GB: Advisor/lecturer for Janssen, Pfizer, Takeda, Abbvie, MSD, Mylan, Genesis Pharma, Adacyte Therapeutics, Amgen, Ferring, Cooper; Funding (Grants/Honoraria): Pfizer, Takeda, Abbvie, Aenorasis; Research/Clinical Trials: Abbvie, Takeda.

Introduction

In Crohn’s disease (CD), an exposure-response relationship is suggested for ustekinumab, with higher serum levels associated with better outcomes. Pharmacokinetic data are scarce, with suggested target maintenance trough level associated with remission at 0.8-1.4 µg/mL. ^{1, 2} The REScUE study (NCT04245215) investigated the effect of two different re-induction regimens with ustekinumab in patients with CD. No significant difference was observed on clinical, endoscopic and biological outcomes.³ Here we present the pharmacokinetic and pharmacodynamics results of the REScUE study.

Aims & Methods

This Belgian multicentre prospective double-blind randomized placebo-controlled trial included adult patients with CD treated with ustekinumab who presented with secondary loss of response to ustekinumab after documented primary response. All patients received a single IV re-induction with ustekinumab (≈6mg/kg) and were then randomized 1:1 to blinded maintenance ustekinumab 90 mg SC Q4W (intervention) or 90 mg SC Q8W (control) for 48 weeks. PK samples were obtained at baseline, week 4-8-12-20-28-36-48.

Results

In total, 108 patients were included: 67% female, median [IQR] age 41 [32-54] year, median disease duration 14 [7-22] years. Prior anti-TNF exposure was reported in 92% of the patients. Baseline ustekinumab trough levels at moment of loss of response were similar in both groups and at the suggested target level of 0.8-1.4 µg/mL ¹: median (IQR) q4 week 1.39 (0.84-2.74) µg/mL and q8 week 1.31 (0.91-2.34) µg/mL (p>0.9). Eight weeks after induction, there was a statistically significant difference in ustekinumab trough levels between both groups 10.8 (8.0-15.9) µg/mL versus 8.2 (4.9-11.1) µg/mL for q4weeks vs q8weeks respectively (p=0.002). After 48 weeks of treatment the statistically significant difference persisted with 6.0 (4.8-9.6) µg/mL versus 2.1 (1.6-2.9) µg/mL (p<0.001). No significant association between baseline/week 8/week 48 ustekinumab trough levels and (steroid free) clinical remisison [PRO2 (AP ≤ 1 AND SF ≤ 3) and FCP <250µg/g and no steroids for 90 days prior to week 48] or endoscopic remission [SES-CD <3 at week 48] was seen. However, there was a significant association between baseline/week 8/week 48 ustekinumab trough levels and biomarker remission [CRP <5 mg/L and FCP <250 µg/g at week 48]; OR (95% CI) 2.98 (1.85, 5.23), 1.12 (1.06, 1.19) and 1.35 (1.13, 1.66) (all p<0.01) respectively. As per quartile analysis of the ustekinumab trough levels at week 48, the lowest quartile (ustekinumab <0.9 µg/mL) had the lowest steroid free clinical remission in each treatment group.

Conclusion

In patients with CD experiencing secondary loss of response to ustekinumab, baseline ustekinumab levels are low. Dose optimization with a single IV re-induction followed by intensified maintenance dosing (90 mg SC q4W) leads to higher ustekinumab levels compared to IV re-induction followed by conventional maintenance dosing (90 mg SC q8W). No association was found between ustekinumab levels and different outcomes except for biomarker remission. This suggests that treatment with ustekinumab should be personalized on a patient level, guided by drug-clearance rather than guided by target trough levels.

References

¹ Adedokun O. et al Gastroenterology 2018;154:1660–1671
² Schreiber S. et al ECCO 2023 Copenhagen; P436
³ Bossuyt P. et al ECCO 2025 Berlin; OP35

Disclosure

PB: Financial support for research: AbbVie, EG. •Lecture fees: AbbVie, AMC ICP, Amgen, Bristol Myers Squibb, Celltrion, Dr Falk Benelux, EG, Galapagos, Globalport, Lilly, Medtalks, Materia Prima, Pentax, Springer Media. •Advisory board: AbbVie, Bristol Meyers Squibb, CIRC, Galapagos, Janssen, Lilly, Pentax, PSI-CRO, Roche, Takeda, Tetrameros.

Clinical Case Summary

This case report describes the clinical history of a 59 years-old female with a delayed diagnosis of primary biliary cholangitis (PBC) and celiac disease (CeD), ultimately requiring orthotopic liver transplantation (OLT). In June 2021 the patient developed weight loss, fatigue, anorexia, diarrhea, and generalized itching. As the patient showed progressive worsening of symptoms, an ultrasound scan was performed in May 2022 revealing hepato-splenomegaly, ascites and cholelithiasis, which required hospitalization. Laboratory tests showed hyperbilirubinemia, elevated liver enzymes with a cholestatic pattern, thrombocytopenia, and anemia; serology was positive for antimitochondrial (AMA) and antinuclear antibodies (ANA) and abdominal MRI confirmed intrahepatic bile duct alterations consistent with PBC. Persistent diarrhea and weight loss despite treatment with ursodeoxycholic acid and cholestyramine, required further evaluation for CeD. High tissue transglutaminase antibody levels and duodenal villous atrophy (3B according to Marsh-Oberhuber Classification) confirmed the diagnosis. A gluten-free diet (GFD) was started with incomplete adherence; the patient’s liver function further deteriorated, leading, in October 2023, to an acute on chronic decompensation with ascites and jaundice (Child-Pugh C13 and MELD 32). She eventually underwent successful OLT via piggyback technique. One year after transplant, the patient showed a significant clinical improvement, resolution of diarrhea and itching associated with better adherence to a GFD, although sarcopenia and nutritional deficiencies persisted. This report underscores the critical need for early diagnosis, screening for other autoimmune diseases, strict dietary adherence, regular follow-up, as well as a multidisciplinary management, in patients with PBC and CeD to prevent severe liver dysfunction and improve outcomes.

Figure 1. Trend of liver function markers (AST, ALT, GGT, ALP), MELD, Child-Pugh since PBC diagnosis

References

1. Kingham JG, Parker DR. The association between primary biliary cirrhosis and coeliac disease: A study of relative prevalences. Gut 1998;42(1)

2. Jena A et al. Liver abnormalities in celiac disease and response to gluten free diet: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2023 Jan;38(1):11-22. doi: 10.1111/jgh.16039.

3. Yang J et al.. Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis. Front Med (Lausanne). 2024 Feb 29;11:1346165. doi: 10.3389/fmed.2024.1346165

4. Al-Toma et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019 Jun;7(5):583-613. doi: 10.1177/2050640619844125.

5. European Association for the Study of the Liver, EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol. 2017 Jul;67(1):145-172. doi: 10.1016/j.jhep.2017.03.022. Epub 2017 Apr 18. PMID: 28427765.

Introduction

Biliary leaks are a well-recognized complication following liver transplantation (LT). Despite advancements in ERCP techniques, there remains variability in treatment success, Considering the peculiarities of this patient group, characterized by specific post-surgical anatomy, variations in endoductal pressure, and immunosuppressive therapy. This study was conducted to identify predictive factors influencing the healing of biliary leaks and the development of post-leak strictures, with the goal of refining management strategies and enhancing patient outcomes.

Aims & Methods

A retrospective analysis was performed on 34 LT patients who developed biliary leaks and were managed with ERCP within 24 hours from diagnosis. Variables included: the type of biliary stricture (anastomotic vs. non-anastomotic), presence of clinical symptoms (pain, fever, jaundice), time interval between multiple ERCPs to reach leak healing, characteristics of the stents (number, diameter in French, and length in cm), and leak parameters (high-grade vs. low-grade, early vs. late leak onset). Statistical analyses included Chi-square and Fisher's exact tests for categorical variables, Student's t-test and Mann-Whitney U test were used for continuous variables. The significance threshold was p<0.05.

Results

Among 34 patients with post-liver transplant biliary leaks, the overall healing rate was 94.1% (32/34). Early leaks (≤4 weeks) had longer healing times than late leaks (>4 weeks) (21.1 vs. 13.0 days). Strictures developed in 54.5% of patients (18/33). All strictures occurred in high-grade leaks: 66.7% in early high-grade and 60.0% in late high-grade groups. No strictures were observed in any low-grade leak, regardless of timing.
Based on cholangiographic appearance, high-grade leaks (visible before full biliary opacification) accounted for all strictures and often required multiple ERCPs. Low-grade leaks (visible only after full opacification) never led to strictures and typically healed after a single procedure. Notably, no strictures occurred in low-grade leaks, regardless of timing, while all strictures developed in patients with high-grade leaks, both early and late.
Shorter healing times were associated with the presence of symptoms, use of 10 Fr vs. 7 Fr stents, and intervals <1 month between ERCPs. In contrast, use of multiple stents, pre-existing NAS, and early high-grade leaks were linked to prolonged healing courses or non-resolution with standard ERCP strategy. The Kehr tube showed no significant impact.

Leak Timing	Leak Output	Stricture Rate (%)
Early (≤ 4 weeks)	High Output	66.7
Early (≤ 4 weeks)	Low Output	0
Late (> 4 weeks)	High Output	50
Late (> 4 weeks)	Low Output	0

Conclusion

Leak grade and timing are key predictors of post-transplant biliary leak healing. High-grade leaks, especially when early, were associated with delayed recovery and the need for multiple ERCPs, while low-grade leaks followed a consistently favorable course. Faster healing was also observed in symptomatic patients, with the use of 10 Fr stents and short ERCP intervals (<1 month). Strictures occurred exclusively in high-grade leaks, further supporting the prognostic relevance of cholangiographic grading. Incorporating leak grade and timing into early ERCP decision-making can accelerate healing, reduce complications, and significantly improve post-transplant outcomes.

References

1. Girotra, M., Soota, K., Klair, J. S., Dang, S. M., Aduli Mohit Girotra, F., Aduli, F., & Endoscopic, A. F. (2015). Endoscopic management of post-liver transplant biliary complications. World Journal of Gastrointestinal Endoscopy, 7(5), 446
2. Moy, B. T., & Birk, J. W. (2019). A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. Journal of Clinical and Translational Hepatology, 7(1), 61–71
3. Lee, H. W., Shah, N. H., & Lee, S. K. (2017). An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clinical Endoscopy, 50(5), 451– 463
4. Sendino, O., Fernández-Simon, A., Law, R., Abu Dayyeh, B., Leise, M., Chavez- Rivera, K., Cordova, H., Colmenero, J., Crespo, G., Rodriguez de Miguel, C., Fondevila, C., Llach, J., Navasa, M., Baron, T., & Cárdenas, A. (2018). Endoscopic management of bile leaks after liver transplantation: An analysis of two high-volume transplant centers. United European Gastroenterology Journal, 6(1), 89–96
5. Oh, D., Lee, S. K., Song, T. J., Park, D. H., Lee, S. S., Seo, D. W., & Kim, M. H. (2015). Endoscopic management of bile leakage after liver transplantation. Gut and Liver, 9(3), 417–423