Introduction

Sarcopenia is prevalent in patients with inflammatory bowel disease (IBD) and impacts surgical and therapeutic outcomes; thus, effective diagnostic tools are needed to assess muscle mass and function in IBD population. The ileo-psoas muscle (IP) muscle has already been used in the literature for the assessment of sarcopenia, however, as it is a deep muscle and it needs experienced operators for a proper measurement. Therefore, diaphragm muscle (DM) more superficial and easily assessed, was examined to check its correlation with IP.

Aims & Methods

The aim of this work was to evaluated the correlation of positivity SARC-F score with ultrasound (US) measure of the IP and DM.
A total of 50 IBD patients with significant suspected sarcopenia with SARC-F score positive ≥4, were enrolled. IP and DM US were detected in the enrolled patients. The transverse diameter of the right IP was evaluated. We defined "reliable" the measurements of the IP that fulfilled all of the following criteria: all anatomical boundaries could be clearly identified (superior margin of the iliac crest and lumbar vertebrae); the maximum diameter of the psoas between each of the three measurements did not deviate from the other two by more than 5 mm. Moreover, we calculated the US psoas/height ratio as the average of the psoas diameter divided by the patient's height (mm/m). For DM, an extended space between the axillary line and the hemi clavicular line was used, in the diaphragmatic thickness between the hyperechogenic limiting. Diameters during expiration and during inspiration were assessed, then diaphragmatic expansion was evaluated. We calculated the diaphragm/height ratio (mm/m) as well. The correlation between IP and DM ratio was researched by using the Pearson correlation test. Age and sex were taken into consideration as confounders in a linear regression model, using the psoas/height ratio and these confounders as independent variables and the diaphragm index as dependent variable.

Results

The mean of the three US IP measured diameters was 30.37 mm, the psoas/height ratio was 17.92 mm/m. The mean maximum inspiration DM diameter was 20.4 mm (± 5 mm), the mean minimum expiration DM diameter was 10.7 mm (± 35 mm). The mean difference between the two diameters was 9.7 mm (± 3,4 mm). The diaphragm/height ratio was 0.59 mm/m (±0.21 mm/m). A significant correlation was identified between IP and DM ratio, with a Pearson coefficient r = 0.3568 (p-value <0.05). A consistent association was found between the two indices, with diaphragm/height ratio increasing linearly with the psoas/height ratio (OR: 0.018; p-value: 0.008). Multivariate analysis showed that age and sex were not significantly associated with the diaphragm/height ratio (p-value >0.05).

Conclusion

The findings of this study emphasize the potential of muscle US as a reliable diagnostic tool for assessing sarcopenia in IBD patients. IP US is confirmed to correlate with sarcopenia. DM can be used more easily and correlates with IP. This research could take a significant implications for disease management in IBD patients and underscores the importance of further investigations to validate these findings in larger cohorts. This study will continue to expand the cohort under evaluation.

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

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.

Introduction

The appropriateness of lower gastrointestinal (GI) endoscopy in patients with inflammatory bowel disease (IBD) is a key issue in endoscopic practice, especially given limited healthcare resources, the growing demand for endoscopic procedures, and the increasing prevalence of IBD. While numerous studies have examined the appropriateness of endoscopy, particularly upper GI endoscopic procedures, in general gastrointestinal disorders,^{[1, 2]} there is a relative lack of literature specifically addressing the appropriateness of lower GI endoscopy in patients with IBD.^{[3, 4]}

Aims & Methods

This study aimed to evaluate the appropriateness of lower GI endoscopic examinations in patients with IBD at a tertiary referral center. Secondary objectives were identifying reasons for inappropriateness and assessing the presence of clinically significant pathological findings in inappropriate procedures. This was a prospective, observational, monocentric study including all adult patients affected by IBD who underwent lower GI endoscopy at a tertiary referral center between September 2024 and April 2025, with a confirmed IBD diagnosis for at least six months. Data collected included IBD subtype, endoscopic procedure appropriateness based on the 2023 ECCO Guidelines,^[5] and endoscopic/histological findings.

Results

Among 406 endoscopic procedures, 26 were excluded from the analysis due to inappropriate timing resulting from patients lost to follow-up. Therefore, a total of 380 IBD patients were included (mean age 52.9 ± 15.1 years; 57% male). Among them, 135 (35.5%) had Crohn’s disease (CD), 176 (46.3%) ulcerative colitis (UC), 60 (15.8%) ileal pouch, and 9 (2.4%) unclassified IBD (IBD-U). Lower endoscopic procedures included colonoscopy (256, 67.4%), rectosigmoidoscopy (61, 16.1%), pouchoscopy (60, 15.8%), and trans-stomal ileoscopy (3, 0.8%). Overall, 308 procedures (81.1%) were deemed appropriate. Appropriateness was higher in CD (115/135, 85.2%), in UC (147/176, 83.5%) and IBD-U (8/9, 88.9%), and lower in ileal pouch (38/60, 63.3%). Between the different endoscopic procedures, rectosigmoidoscopy showed the highest appropriateness (56/61, 91.8%), followed by colonoscopy (213/256, 83.2%), pouchoscopy (38/60, 63.3%), and trans-stomal ileoscopy (1/3, 33.3%). Among the 72 inappropriate procedures (18.9%), 23 (31.9%) were performed too early, 20 (27.8%) too late, 27 (37.5%) were unwarranted, and 2 (2.8%) were improper endoscopic procedures. Most early procedures were prescribed by physicians (78.3%), while the remaining (21.7%) were requested by patients. Despite being considered inappropriate, 27 of the 72 examinations (37.5%) revealed endoscopic pathological findings, and 17 (23.6%) led to clinically relevant conclusions (based on both endoscopic and histological findings), including 4 cases of dysplasia. It is noteworthy that, among the inappropriate examinations that led to clinically relevant conclusions, almost 60% were performed either too early or were considered unwarranted, while only the remaining 40% were performed too late.

Conclusion

The appropriateness of lower gastrointestinal endoscopy in patients affected by IBD was found to be nearly 80% in a tertiary referral center. Notably, among the examinations classified as inappropriate, roughly 24% revealed clinically relevant findings based on both endoscopic and histological report. A greater spread and awareness among physicians of the latest international guidelines on IBD management could improve the appropriateness of endoscopic procedure prescriptions, while reducing waiting lists and related healthcare costs.

References

1. Tursi A, Palieri AP, Lattarulo V, Elefante A, Gigliobianco A, Spinazzola D, Elisei W, Papa A. How we can improve the appropriateness of ambulatory gastrointestinal endoscopy: the lesson of the COVID-19 outbreak. Eur J Gastroenterol Hepatol. 2023 Oct 1;35(10):1149-1153. doi: 10.1097/MEG.0000000000002626. Epub 2023 Jul 28. PMID: 37665614.
2. Bohara TP, Laudari U, Thapa A, Rupakheti S, Joshi MR. Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding. JNMA J Nepal Med Assoc. 2018 Jan-Feb;56(209):504-509. PMID: 30058633; PMCID: PMC8997324.
3. Manes G, Imbesi V, Ardizzone S, Cassinotti A, Bosani M, Massari A, Porro GB. Appropriateness and diagnostic yield of colonoscopy in the management of patients with ulcerative colitis: a prospective study in an open access endoscopy service. Inflamm Bowel Dis. 2008 Aug;14(8):1133-8. doi: 10.1002/ibd.20434. PMID: 18314901.
4. Manes G, Imbesi V, Ardizzone S, Cassinotti A, Bosani M, Massari A, Bianchi Porro G. Use of colonoscopy in the management of patients with Crohn's disease: appropriateness and diagnostic yield. Dig Liver Dis. 2009 Sep;41(9):653-8. doi: 10.1016/j.dld.2008.10.006. Epub 2008 Nov 25. PMID: 19036651.
5. Gordon H, Biancone L, Fiorino G, et al. ECCO Guidelines on Inflammatory Bowel Disease and Malignancies. J Crohns Colitis. 2023;17(6):827-854. doi:10.1093/ecco-jcc/jjac187

Introduction

The Inflammatory Bowel Disease (IBD) Disk represents a self-administered questionnaire that can facilitate, in real time, assessment of IBD related disability, and IBD-related daily life burden^1,2. Surrogate markers of IBD activity tend to associate with increased disability. Intestinal ultrasound (IUS) is a non-invasive tool that can objectively and accurately define disease activity and complications in IBD patients.

Aims & Methods

The aim of our study was to investigate the correlation between IBD-Disk and IUS in IBD patients. We performed a cross-sectional study that included formally diagnosed IBD patients who underwent IUS and subsequently completed the IBD-Disk questionnaire. Active disease on IUS was defined as bowel wall thickness (BWT) >3 mm at the most affected bowel segment. The overall IBD-Disk score was calculated as the sum of its 10 components, ranging from 0 to 100 (best score: 0, worst score: 100). We explored the correlation between IBD-Disk and its components with IUS. We additionally investigated the correlation of IBD-related daily life burden with IUS. (IBD-Disk total score > 40: high IBD related daily life burden vs IBD-Disk total score ≤ 40: low IBD related daily life burden²).

Results

We included 69 patients (Table 1), who underwent IUS for disease monitoring (56.5%) and symptoms suggestive of disease flare (43.5%). Median IBD-Disk total score in our cohort was 48 (IQR 19-56.5). Median IBD-Disk total score was 52 (IQR 47-58.5) in IUS active vs 16 (IQR 6-23) in IUS inactive patients (p<0.001). The area under the ROC curve of IBD-Disk total score in predicting IUS activity was 0.909 (95% C.I: 0.819-0.99, p<0.001). IBD-Disk score >33 predicted disease activity in IUS with 93.5% sensitivity and 91.3% specificity. We observed a moderate correlation between IBD-Disk score and BWT (ρ=0.554, p<0.001) as well as between IBD-Disk score and C-reactive protein (ρ=0.686, p<0.001). Among the components of the IBD-Disk, 7/10 (abdominal pain, regulating defecation, education/work, sleep, energy, sexual function and interpersonal interactions) manifested a moderate correlation with BWT. IBD-Disk score > 40 was found in 40/46 (87%) of IUS active and 2/23 (8.7%) of IUS inactive patients, while IBD-Disk score ≤ 40 was found in 6/46 (13%) of IUS active and 21/23 (91.3%) of IUS inactive patients respectively (p<0.001). Median BWT was 2.1 mm (IQR 1.6-2.9) in patients with IBD-Disk score ≤ 40 and 6 mm (IQR 4.8-6.8) in patients with IBD-Disk score > 40 (p<0.001).

Conclusion

IBD-Disk displayed a significant correlation with IUS evidence of disease activity in IBD patients. Active disease in IUS was significantly correlated with a high IBD-related daily life burden as expressed by IBD-Disk total score > 40. IBD-Disk could be used in clinical practice to evaluate disease activity and severity in IBD patients.

References

1) S. Ghosh et al. Inflamm Bowel Dis. 2017, 333-340
2) S. Tadbiri et al. Journal Crohns Colitis, 2021, 766–773

Introduction

One of the challenges in the management of inflammatory bowel disease (IBD) is the noninvasive and accurate assessment of disease activity and the prediction of treatment response and prognosis. Colonoscopy is limited due to its invasiveness; therefore, noninvasive methods are of high clinical relevance. Fecal calprotectin (FC), a surrogate marker for neutrophils, is a clinically relevant biomarker that correlates with intestinal inflammatory activity. Bowel ultrasound (B-US) is an established method that can be performed at any time and at low cost.

Aims & Methods

The aim of this study was to evaluate the correlation between B-US and FC in terms of inflammatory activity and disease severity in IBD patients. Patients were selected from a prospective study to compare FC and B-US. A total of 320 patients, including (n=188) with Crohn's disease (CD), (n=114) with ulcerative colitis (UC), and (n=18) control patients were included for further analysis. FC measurements were performed using the ELISA kit. The inflammatory activity was classified according to the FC cut-off (0: <100, 1: 100-200, 2: 200-400, 3: >400 in mg/g). The evaluation in B-US was based on the thickness of the intestinal wall (none: <2.9, mild: 3.0-4.9, moderate to severe: >5).

Results

Based on FC, patients were divided into inflammatory activity (n=211) and remission (n=109) groups. When comparing B-US and FC, there was a significant correlation regarding inflammatory activity (r=0.59, p<0.001). B-US in MC showed a better correlation (r=0.63, p<0.001) than CU (r=0.45, p<0.001) with FC. Patients with unremarkable B-US had a median FC of 57.2 mg/g (95%CI: 41.5-94.1) compared to marked inflammation in B-US median 999 mg/g (95%CI: 751.8-1517). Among patients with pathological FC values (cut-off >100 mg/g), 75.4% had sonographic evidence of inflammatory activity. Localization of inflammation in the rectum was associated with lower diagnostic accuracy. Compared to FC, B-US showed a sensitivity of 75.4%, a specificity of 78.9% and a positive predictive value of 87.4%.

Conclusion

B-US shows good diagnostic accuracy compared to FC in assessing inflammatory activity in IBD patients. Both methods can be considered as complementary non-invasive diagnostic tools in IBD.

Disclosure

Alexander Link: speakers fee: Janssen; consulting fee: Ferring.

Introduction

In the years to follow we anticipate a rise in the prevalence of an aging population of inflammatory bowel disease (IBD) patients and a rise in cancer incidence. We are in urgent need of data to help us manage these patients.
We therefore followed a cohort of patients from a referral oncology hospital with prior and active cancer who received biologic therapy to control their IBD.

Aims & Methods

We first recorded data regarding inflammatory bowel disease characteristics: disease type, disease duration, disease severity, previous surgery or hospitalization and received therapy: type and duration of biologic therapy, prior use of immunosuppressants. We also recorded all available data regarding cancer disease: cancer site, stage, virus related cancer, family history of cancer, smoking status and received therapy (curative surgery, chemotherapy, hormone therapy, radiotherapy, immunotherapy). We monitored outcomes of IBD (steroid free clinical remission, IBD-related surgery or hospitalization) and outcomes of cancer (recurrence free survival, progression free survival, overall survival).
A blinded oncologist was asked to retrospectively evaluate all available data regarding cancer prognosis (stage, histology, response to therapy) and to categorize patients in 3 groups: low, intermediate or high risk to recur or progress.

Results

A total of 30 patients were included, 57 % female, median age 60 years, 60% Crohn's Disease, median disease duration 9.5 years, 26% prior IBD surgery, 33% prior azathioprine use, 36% smokers. They were treated with anti-TNF therapy (n=19) anti-integrin therapy (n=8) and anti-IL 12/23 therapy (n=4). The majority (20%) of patients had a history of hematologic malignancy (lymphomas, myeloproliferative disorders, leukemias), 13% with a virus related cancer and 66% with curative surgery. Patients were classified retrospectively as 63% low risk, 13% intermediate risk and 10% high risk. Four patients ) with active cancer (2 with lung cancer and 2 with myeloproliferative disorders) continue to receive biologic therapy for IBD and oncological therapy with no signs of progression from both diseases. All but 3 patients have remained in steroid free clinical remission: 3 had IBD-related surgery. Median follow up under biologic therapy was 5.5 years: only 2 patients showed cancer recurrence: 1 patient with breast cancer developed bone metastases and finally died, and 1 patient with colon cancer developed bladder cancer and died as well. Both patients were classified as high risk.
In both patients biologic therapy was interrupted and that resulted in administration of high-dose steroids and IBD-related hospitalizations and infections (pneumonia, C Difficile colitis).

Conclusion

In this cohort of cancer patients with IBD treated with biologics and followed up for more than 5 years the risk of cancer recurrence was low and not unexpected in oncology terms.
Biologic therapy was successful in the majority of patients and kept them off surgeries and steroids for their underlying IBD. We need more smart and innovative ways to study this particular clinical scenario in the future.