Introduction

The current international guidelines on the management of dysplasia in Inflammatory Bowel Disease (IBD) recommend proctocolectomy (PC) in cases of endoscopically unresectable dysplasia, multifocal dysplasia and colorectal cancer (CRC), and to consider it in cases of Low Grade (LGD) or Indeterminate dysplasia (IND). However, population-based studies have demonstrated that segmental colectomies (SC) are occurring in 40-70% of patients with IBD-associated CRC. Data on their outcomes is scarce, with only a handful of published articles, as evidenced by a recent systematic review.

Aims & Methods

Our aim is to contribute to this limited body of evidence from English IBD centres. Data of all adult IBD patients undergoing colorectal resections in 2004-2019 for dysplasia and CRC were collected from three centres. Primary outcome was oncological and secondary outcome was post-operative. Descriptive statistics were applied to compare outcome between SC (including subtotal colectomy) and proctocolectomy (PC).

Results

Of 131 patients identified, 45 underwent SC, and 86 PC. No statistically significant difference between SC and PC were identified for: gender, age at IBD diagnosis and subsequent surgery, comorbidity status (including Primary Sclerosing Cholangitis), indication for surgery (CRC vs dysplasia), and IBD subtype (CD vs UC) (p>0.05). Patients undergoing PC had more extensive and active colitis than those undergoing SC, as well as earlier stage and multifocal cancer. Median follow up time was 86 months (range 0 – 204), and 90 months (range 17 – 211), respectively. Unexpected cancer was found in 41/131 (31%), with no significant difference between SC and PC cohorts (28% vs 33%, p=0.581), however only 9/131 (7%) was at a site different to the original neoplasia. Metachronous cancer was found in 1/45 (2%) on completion proctectomy at 125 months post-index extended right hemicolectomy in a patient having completion for High Grade Dysplasia (HGD, SC cohort). Completion surgery occurred in 11/45 (25%) of SC, and only 4/11 were for a neoplastic indication (2/11 LGD, and 2/11 HGD). No significant difference in Overall Survival was observed between SC and PC groups (81% vs 94% at 5 years (p=0.376)).

Conclusion

This study failed to identify oncological advantages to proctocolectomy in patients with IBD neoplasia undergoing resection. Although there is potential for type II error with this small cohort, the findings are consistent with those of the published literature and recent systematic review. This study highlights the need for larger prospective studies.

References

Birch, R.J. et al. (2022) ‘Inflammatory Bowel Disease-Associated Colorectal Cancer Epidemiology and Outcomes: An English Population-Based Study’, The American journal of gastroenterology, 117(11), pp. 1858–1870. Available at: https://doi.org/10.14309/AJG.0000000000001941.
Bogach, J. et al. (2021) ‘Extent of Surgical Resection in Inflammatory Bowel Disease Associated Colorectal Cancer: a Population-Based Study’, Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, 25(10), pp. 2610–2618. Available at: https://doi.org/10.1007/S11605-021-04913-6.
Shamsiddinova, A et al. (2024) 'Systematic review: oncological outcome of patients with Inflammatory Bowel Disease undergoing segmental colonic resection for colorectal cancer and dysplasia', accepted for publication in BJS Open. doi: 10.1093/bjsopen/zrae052

Introduction

Surgical management of hemorrhoidal disease (HD) in patients with inflammatory bowel disease (IBD) remains controversial due to concerns about impaired wound healing and disease flare, especially in Crohn’s disease (CD). In Europe, current evidence is mainly based on small historical single-center case series.¹

Aims & Methods

We sought to evaluate the safety and effectiveness of surgical treatments for HD in IBD patients and identify potential risk factors for complications. HEAD-IBD is a retrospective cohort study promoted by the Italian Group for the study of Inflammatory Bowel Disease (IG-IBD) and the Italian Society of Colorectal Surgery (SICCR). Patients with established IBD who underwent surgery for HD between December 2004 and March 2024 were included. Data were collected across multiple centres using the REDCap system. IBD activity was measured by the Harvey-Bradshaw Index for CD and the partial Mayo score for ulcerative colitis (UC). Surgical techniques, short- and long-term complications, disease flare, and continence status were analyzed. Only patients with ≥1 year follow-up were considered.

Results

A total of 38 patients were initially identified from 8 centres. Two patients with unclassified IBD were excluded from stratified analysis, leaving 36 patients (Table 1): 21 (58%) with UC and 15 (42%) with CD. Overall, 53% were male. The median age at surgery was 49 years (IQR 13) in UC and 37 years (IQR 22) in CD. At the time of surgery, biologic therapy was ongoing in 10% of UC and 40% of CD patients. Clinically active disease at the last gastroenterology visit was reported in 6 CD patients (40%) and 5 UC patients (24%). The time interval between the last IBD evaluation (clinical or endoscopic) and surgery was significantly longer in UC compared to CD patients (table 1). Distribution of Goligher grade suggested a higher proportion of grade III–IV disease in UC (72%) than in CD (53%). Open hemorrhoidectomy was the most frequent procedure in both groups (66% UC, 73% CD). Non-excisional techniques (DG-HAL +/- mucopexy) were used in 29% of UC and 27% of CD patients. Stapled hemorrhoidopexy was performed only in UC (10%). Median hospital stay was 1 day (IQR 1) in both groups. No 30-day or 6-month postoperative complications were reported in CD, while 14% of UC patients experienced early or mid-term complications. One UC patient experienced IBD flare at 6 months. At 12-month follow-up, one UC patient reported new-onset soiling; continence was otherwise preserved in all cases.

Conclusion

This multicenter study represents the largest European series on surgical treatment of HD in patients with IBD, confirming its safety, with low complication rates and no new perianal disease. Short- and mid-term complications occurred only in UC patients, possibly reflecting both more advanced HD (Goligher grade III–IV) and less intensive preoperative monitoring. These findings highlight the need for close gastroenterological pre-operative assessment and shared decision-making. The ongoing HEAD-IBD II prospective study will provide further insight into optimal management strategies.

References

1. Grossi U, Gallo G, Di Tanna G, et al. Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis. J Clin Med. 2022 Jan 28;11(3):709. doi: 10.3390/jcm11030709

Disclosure

None

Introduction

Eight hospitals in the southwest of the Netherlands collaborate to provide high quality, uniform care for inflammatory bowel disease (IBD). To achieve this, a care pathway (CP) was implemented for treating IBD with biologics and small molecules (1). The CP is a decision-support tool that provides guidelines for medication prescribing, procedures, treatment adjustments, and recommendations for follow-up.

Aims & Methods

This study aimed to evaluate the effect of a CP on patient outcomes and healthcare utilization.
A longitudinal multicentre non-randomised cohort study with a baseline observation period (December 2020 – December 2021) and a follow-up period (March 2022 – March 2023) was conducted, in which adult patients with IBD treated with biologics or small molecules were included. Outcomes were collected according to the International Consortium for Health Outcomes Measurement (ICHOM) standard set from electronic health records or through validated questionnaires. Missing data were handled using single imputation nested within a bootstrap procedure. Effect of the CP on these outcomes were analysed with case-mix adjusted (generalized) linear mixed models.

Results

A total of 1,173 patients participated in the study, with the majority being female (55%) and a median age of 45 years (IQR 33-58). Most patients had Crohn's disease (64%). The CP was associated with a 0.22 increase on the ibd-control-8 score (β=0.22, p=0.28), and an increase on the probability of achieving endoscopic/radiologic (β=0.14, p=0.29), biochemical (β=0.18, p=0.22) and patient-reported remission (β=0.19, p=0.21). Probability of clinician-reported remission decreased slightly (β=-0.09, p=0.59). Emergency room visits (β=-0.36, p=0.13), hospital admissions (β=-0.41, p=0.10), and length of stay (β=-0.09, p=0.56) reduced, although these associations were not significant. The CP had no effect on quality of life (β=0.00, p=0.83), anaemia probability (β=-0.01, p=0.95) or on nutritional status (β=-0.01, p=0.34).

Conclusion

A CP for the management of IBD with biologicals and small molecules has clinically significant potential to reduce healthcare utilization, while improving patient-reported disease control, and disease remission. These results emphasize that clinical care pathways can improve care and reduce healthcare utilisation for complex diseases. However, the adherence to the CP and whether these results lead to a reduction in healthcare costs should be further investigated.

References

(1) van Linschoten R, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, et al. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. (2044-6055 (Electronic))

Disclosure

Drs. Visser received a speaker fee from Lilly, Prof. Dr. van der Woude reports grants from Pfizer and Janssen and personal fees from AbbVie and Celltrion, Dr. van Noord reports personal fees from Janssen, Takeda, and Falk, Dr. West reports personal fees from AbbVie, Janssen, and Pfizer outside the submitted work.

Introduction

IBD is a global health problem. It is necessary to understand the evolution and treatment exposure in a cohort of newly diagnosed IBD patients in the biologic era in the South of Europe

Aims & Methods

Aims: 1) To describe the main epidemiological and clinical characteristics of patients at IBD diagnosis and the long-term outcomes; 2) to analyse the use of drugs for IBD, and the need of hospitalisations and surgeries; 3) to compare IBD management based on the type of disease and the resources of the hospitals.
Methods: Prospective, population-based nationwide registry. Adult patients diagnosed with IBD —Crohn’s disease (CD), ulcerative colitis (UC) or IBD unclassified— during 2017 in the 17 Spanish regions were included. Patients who consented were followed-up for 5 years (yr) after diagnosis. Treatment was grouped into 5 categories: mesalamine (oral or topical), steroids (intravenous, oral, or topical), immunomodulators (thiopurines, methotrexate or cyclosporine), biologics (anti-TNF, vedolizumab, ustekinumab) or JAK inhibitors (JAKi), and surgery. Hospitals were classified into high resources and low resources ones. Cumulative incidence of exposure to each of the studied treatments was estimated by Kaplan-Meier curves; curves were compared with log-rank test.

Results

A total of 3,301 incident cases of IBD diagnosed during 2017 in 108 hospitals, covering over 22 million inhabitants in Spain (about 50% of the population), were enrolled into the follow-up study. Main characteristics of the cohort are summarised in table 1A and 1B. Median diagnosis delayed was 3.5 months (5.6 in CD and 2.7 in UC, p<0.001). During the 5-yr follow-up, 25% of UC patients progressed to more extensive involvement, while 8% of CD patients with inflammatory behaviour progressed to either stricturing or fistulising behaviour. Most of the patients who received mesalamine, corticosteroids, or immunomodulators initiated treatment within the first 2 years after diagnosis (figure 1). However, the cumulative incidence of biologics/JAKi usage steadily increased over time, reaching 49% by the 5-yr timepoint in CD. In terms of surgeries, a progressive increase in cumulative incidence was observed in CD; however, the incidence of colectomy remained stable in UC from the 2^nd year post-diagnosis. The management and progression of IBD unclassified were similar to that of UC. Regarding the type of hospital, a higher cumulative incidence of biologics/JAKi usage, hospitalisations, and surgeries was observed in CD at high resources hospitals. No differences were observed in the use of other therapeutic resources or the management of UC.

Conclusion

In the EpidemIBD large-scale epidemiological study, we have observed that the delay in diagnosing IBD is shorter than previously described. Approximately 50% of patients with CD and 20% of patients with UC end up receiving biologics/JAKi in the first 5 yrs following diagnosis. The percentage of patients undergoing surgery was lower than previously reported; in the case of UC, the majority of colectomies occurred within the first 2 yrs after diagnosis.

Disclosure

MDMA has received consulting and/or speaker fees from AbbVie, Pfizer, Takeda, Janssen, Tillotts Pharma and Galapagos; and has received research funding from Abbvie, Janssen and Pfizer.
RF-I has served as a speaker, advisory member or has received research funding from Takeda, MSD, Abbvie, Janssen, Pfizer, Palex, Shire Pharmaceuticals, TillottsPharma, Faes, Adacyte, Ferring and Casenrecordati.
R. Lorente has served as a speaker, or has received research or education funding from Abbvie, Pfizer, Takeda, Janssen and Galapagos.
IV has served as a Speaker, consultant and advisory member for and has received funding for: MSD, Abbvie, Pfizer, Ferring, Shire Pharmaceuticals, Takeda, Tillots, Jannsen y Galápagos.
EF-S Tillotts Pharma (speaker and travel grants), Ferring (speaker and travel grants) ), Faes (travel grants), MSD (speaker and travel grants), Abbvie (speaker and travel grants), Falk (travel grants), Shire (speaker and travel grants), Takeda (speaker and travel grants).
LAG has served as speaker or has received research or education funding from MSD; Abbvie; Kern Pharma; Ferring; Faes Farma; Shire Pharmaceuticals; Pfizer; Takeda; Janssen; Tillots Pharma and OtsuKa Pharmaceutical

Introduction

In the southwest Netherlands, hospitals collaborate to provide high quality, uniform care for inflammatory bowel disease (IBD). To achieve this, a care pathway (CP) was implemented for treating IBD with biologics and small molecules (1). The CP consists of protocols addressing different stages in IBD treatment, such as initiation and switching of therapy, frequency and type of follow-up. This study assessed the adherence to the CP and identified barriers and facilitators to its implementation.

Aims & Methods

A mixed-methods study was conducted. Quantitative data was used to evaluate the adherence to different protocols of the CP and was collected retrospectively from electronic health records (EHRs) from December 2020 until March 2023. Surveys and semi-structured interviews were used to identify barriers and facilitators, using the Extended Normalisation Theory. Surveys were sent to all healthcare providers and interviews were conducted with gastroenterologists, IBD-nurses, healthcare assistants, and IT-personnel.

Results

A total of 299 patients were included. Adherence to the CP regarding the documentation of travel plans and vaccination status improved after implementing the CP (15% pre-implementation vs. 33% post-implementation), as well as written communication with general practitioners (31% vs. 83%) and body weight registration (12% vs. 50%). Among patients switching medication, 25% had a repeated screening for HIV, tuberculosis, and hepatitis B and C documented if prior tests were over a year old. Post-implementation, scheduling outpatient visits were more closely aligned with CP recommendations across CP protocols (57% vs. 100%), as did blood test ordering (10% vs. 44%). Disease activity scoring with validated questionnaires remained low (7% vs. 21%).  Adherence to registering medication adherence, current smoking status, and side effects during annual outpatient visits remained low (18% vs. 40%).
Of 85 surveys, 42 were completed, and 11 interviews were conducted. Facilitators were improving collaboration between healthcare providers and the potential to standardise care. Barriers included the complexity of the use in EHRs, difficulty for healthcare providers to change their current routine, and the heterogeneity of IBD.

Conclusion

A CP for the treatment of IBD with biologics and small molecules has been implemented to improve IBD care, however, adherence appears to be challenging, partially contributed to the difficulty healthcare providers experience in changing their behaviour. The gradual improvement indicates that increased familiarity with the CP may enhance adoption. Discrepancies between performed and documented tasks in EHRs may also contribute to lower adherence rates, which could be improved by audit and feedback sessions.

References

1. van Linschoten R, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, et al. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. (2044-6055 (Electronic))

Disclosure

Drs. Visser received speaker fees from Lilly outside the submitted work. Prof. Dr. van der Woude reports grants from Pfizer and Janssen and personal fees from AbbVie and Celltrion outside the submitted work. Dr. van Noord reports personal fees from Janssen, Takeda, and Falk outside the submitted work. Dr. West reports personal fees from AbbVie, Janssen, and Pfizer outside the submitted work.

Introduction

In the UK, FIT is offered to adults with symptoms suggestive of colorectal cancer (CRC). A positive result (>10µgHb/g) triggers a referral through a suspected colorectal cancer pathway for further investigation.¹ IBD and CRC share many similar symptoms. However, there is very limited evidence assessing the use of FIT in predicting the onset of IBD, following exclusion of CRC.

Aims & Methods

We aimed to assess the association between abnormal FIT results in symptomatic patients and the risk of new IBD diagnosis within a year, and how this varies with age and faecal calprotectin (FCP) results. This was done through a population-based observational study of all symptomatic FIT recorded in the Clinical Practice Research Datalink (CPRD) between January 2019 and June 2023 with one year follow up.² Patients with prior diagnoses of IBD or CRC were excluded. Kaplan-Meier estimates were used to assess cumulative 1-year IBD risk, stratified by age group, FIT results and FCP results.

Results

2762 (0.58%) of 473402 patients were diagnosed with IBD within 1-year of symptomatic FIT. The risk was 541/377485 (0.1%) in those with a FIT ≤10µgHb/g compared to 2221/95917 (2.3%) with FIT>10µgHb/g. A positive FIT is associated with increased risk of IBD diagnosis (p<0.001) . Table 1 summarises the 1-year risks of new IBD diagnoses within this symptomatic FIT population in strata of age and faecal calprotectin. As can be seen those with a negative FIT have a low risk of IBD diagnosis at all ages regardless of FCP. With rising FIT the risk rises in all age groups and is highest in the under 40s with a FIT >200µgHb/g and FCP >50µg/g at 38.9 % (95% CI: 34.62-43.07%). Even at this level of FIT, cumulative risk is only 3.8% (95% CI: 1.9-5.68%) when FCP ≤50µg/g. In contrast, the cumulative risk of IBD in patients age ≥70 is low, regardless of FIT levels, with 0.05% (95% CI: 0.04-0.07%) risk in those with FIT ≤10µgHb/g and 1.4% (95% CI: 1.16-1.65%) in FIT >200µgHb/g.

Conclusion

A combination of symptomatic FIT and FCP can stratify the risk of IBD diagnosis. This should lead to prioritisation of those at high risk for early colonoscopy even among the young who are unlikely to have colorectal cancer. Those with low risk of either diagnosis could be spared invasive testing.

References

1. National Institute for Health and Care Excellence. Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care [DG56]. 2023 24 August 2023 15 April 2025]; Available from: https://www.nice.org.uk/guidance/DG56.
2. Clinical Practice Research Datalink. CPRD Aurum December 2024 (Version 2024.12.001). [Data set] 2024 15/04/2025; Available from: https://www.cprd.com/doi/cprd-aurum-december-2024-dataset.

Introduction

Histologic activity has emerged as an aspirational therapeutic goal in IBD management. It is not yet a formal treatment-target in either CD or UC. However, it could be used as an adjunct to mucosal healing to represent a deeper level of healing. Recent studies show that histologic healing is associated with decreased risk of clinical relapse, medication escalation and corticosteroid use, both in ulcerative colitis and Crohn's disease [1,2]. We investigated histologic remission (HR) rates and potential predictors of achieving histologic remission in an IBD cohort.

Aims & Methods

We conducted a retrospective subgroup analysis of data collected from IBD patients enrolled in an ongoing prospective cohort study. Clinical, biological, endoscopic data (including the Mayo endoscopic subscore and SES-CD score) and histopathology results were available at multiple time-points for the enrolled patients (annual visits). Mucosal healing was defined as SES-CD <3 or Mayo endoscopic score=0[3]. Histologic healing was defined as microscopic normalization of mucosal biopsies.

Results

219 patients (88 CD, 131 UC) were enrolled in our study and were prospectively followed for a median length of 2 years (range 0-5 years), totaling 452 study visits. Mucosal healing was recorded for 51 (27 UC, 24 CD, 23,2%) patients at 76(16%) different study visits. Overall, only 35(15%) patients achieved histologic healing. In the mucosal healing subgroup, histologic remission was achieved in 30(58%) patients. After logistic regression analysis, none of the investigated factors was associated with histologic remission.

Conclusion

Mucosal healing and endoscopic remission rates are low in real-life settings. Frequently used patient and disease related factors, including mucosal healing are not reliable predictors for histologic remission.

References

[1] Christensen B, Erlich J, Gibson PR, Turner JR, Hart J, Rubin DT. Histologic Healing Is More Strongly Associated with Clinical Outcomes in Ileal Crohn's Disease than Endoscopic Healing. Clin Gastroenterol Hepatol. 2020 Oct;18(11):2518-2525.e1. doi: 10.1016/j.cgh.2019.11.056. Epub 2019 Dec 5.
[2]Battat R, Duijvestein M, Guizzetti L, Choudhary D, Boland BS, Dulai PS, Parker CE, Nguyen TM, Singh S, Vande Casteele N, Pai RK, Feagan BG, Sandborn WJ, Jairath V. Histologic Healing Rates of Medical Therapies for Ulcerative Colitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Gastroenterol. 2019 May;114(5):733-745. doi: 10.14309/ajg.0000000000000111.
[3] Turner D, Ricciuto A, Lewis A, D'Amico F, Dhaliwal J, Griffiths AM, Bettenworth D, Sandborn WJ, Sands BE, Reinisch W, Schölmerich J, Bemelman W, Danese S, Mary JY, Rubin D, Colombel JF, Peyrin-Biroulet L, Dotan I, Abreu MT, Dignass A; International Organization for the Study of IBD. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021 Apr;160(5):1570-1583. doi: 10.1053/j.gastro.2020.12.031. Epub 2021 Feb 19. PMID: 33359090.