Introduction

Patients with ulcerative colitis (UC) are at an increased risk of cytomegalovirus (CMV) infection. CMV infection in acute severe ulcerative colitis (ASUC) may worsen disease severity and clinical outcomes. Current guidelines recommend colonic biopsies for the exclusion of CMV in all patients with ASUC. One study found that CMV positivity in ASUC was associated with greater need for rescue therapy, longer hospital length of stay (LOS) and higher readmission rates but found no difference in rate of colectomy.¹ We aimed to investigate the impact of positive CMV result on clinical outcomes in patients presenting with ASUC.

Aims & Methods

A retrospective review included all ASUC presentations to a quaternary hospital over a 10-year period based on modified Truelove and Witts’ criteria. ASUC presentations were grouped based on CMV positivity as determined by colonic biopsy. Data on pre-admission medications was collected. Data was collected on rates of rescue therapy, referral to colorectal surgery, colectomy, total parenteral nutrition (TPN). Outcomes assessed included intensive care unit (ICU) admission, 30- and 90-day readmission rates, 30- and 90-day mortality rates and mean LOS.

Results

A total of 172 ASUC presentations were identified. Of these, 133 had available colonic biopsy CMV results. 11 patients (8%) had positive CMV. Positive CMV result was significantly associated with increased need for TPN (36% vs 11%, p=0.02), ICU admission (27% vs 5%, p=0.004) and referral to colorectal surgery (82% vs 43%, p=0.01). Patients with CMV had longer LOS (27.1±14.0 vs 11.0±7.4, p=0.003). There were no significant differences in rates of rescue therapy, inpatient colectomy, readmission or mortality rates. 9 of the patients (82%) were treated with ganciclovir or valganciclovir. Patients on maintenance advanced UC therapies, including biologics and small molecule inhibitors, had significantly higher rate of CMV (22% vs 5%, p=0.01). Biologic therapy alone was associated with higher rate of CMV (24% vs 7%, p=0.02), whereas small molecule inhibitor alone was not (p=0.6). Pre-admission use of 5-aminosalicylates, high dose steroids, thiopurines or combination therapies were not associated with CMV positivity.

Table 1: Comparison data of clinical outcomes in ASUC between patients with and without CMV positivity on colonic biopsy

Conclusion

Patients with CMV positive colonic biopsies tend to require more inpatient interventions, including increased need for TPN, ICU admission, referral to colorectal surgery and longer hospital length of stay. Despite more complex admission course of ASUC patients with concurrent CMV infection, these patients were not observed to have worse outcomes than those without CMV diagnosis. Maintenance biologic and small molecule inhibitor use was associated with higher rates of CMV, reflecting the immunosuppressant effects of advanced UC therapies. CMV detection needs to be considered as a potential exacerbating factor in disease severity.

References

1. Huang D, Rennie M, Krasovec A, Nagubandi S, Liu S, Ge E, Khehra B, Au M, Sivagnanam S, Kwan V, Rogge C, Mitrev N, Kariyawasam V. Impact of cytomegalovirus on outcomes in acute severe ulcerative colitis: a retrospective observational study. Ther Adv Chronic Dis. 2024 Mar 28;15:20406223241233203. doi: 10.1177/20406223241233203. PMID: 38560721; PMCID: PMC10981253.

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

Autoimmune atrophic gastritis (AAG) is an immune-mediated disorder characterized by corpus oxyntic mucosa atrophy and impaired gastric acid secretion(1,2). The increased gastric cancer (GC) risk in AAG is still debated. One mechanism favoring gastric carcinogenesis may be increased intragastric pH leading to intragastric microenvironment changes and facilitating bacterial dysbiosis(3-5). Oral microbiota and periodontal-dental disorders alterations have been linked to increased GC risk as well(6-8). In AAG, the increased intragastric pH may lead to survival of swallowed bacteria, possibly further contributing to the increased GC risk. The oral and gastric microbiota composition together have not been investigated so far in AAG patients.

Aims & Methods

The aim of the study was to investigate the oral and gastric microbiota composition in AAGpts in order to clarify the role of oral bacteria in gastric dysbiosis.
We conducted a case-control study: n=20 histologically diagnosed AAGpts(F75%,age 64 yrs) and n=20 ctrs with healthy stomach(HS)(F45%,age 56 yrs). From all pts and ctrs a sputum sample was obtained in the morning fasting without tooth brushing. Within 1 hour after sputum collection, pts and ctrs underwent gastroscopy with biopsies (updated Sydney system) for histopathological assessment and one further corpus biopsy for DNA extraction. Sputum(n=40) and biopsy(n=40) samples were collected in vials with DNA shield and frozen at -20°C since processing. DNA was extracted (QIAmp DNA kit) and prepared (Illumina Nextera XT DNA Library Preparation Kit). Paired-end sequencing was performed (Illumina MiSeq sequencer,MiSeq Reagent Kit v3). Fastq files were filtered to remove low-quality reads; filtered reads were taxonomically classified and subjected to Homo sapiens filtering (METAnnotatorX2 pipeline, up-to-date RefSeq database, NCBI).

Results

AAGpts and ctrs were similar with regard to clinical features, oral hygiene and paraodontal-dental disorders. Bacterial abundance in biopsies was higher in AAGpts than in ctrs (403 vs 223,p=0.06), but not different in sputum (27,728 vs 31,544,p=0.54). On biopsies, AAGpts showed a lower Shannon Index than ctrs (2.553 vs 2.617, p=0.001). On sputum, AAGpts showed a higher Shannon Index than ctrs (2.828 vs 2.738, p=0.0). Beta-diversity (Bray-Curtis dissimilarity) was not different between pts and ctrs, neither in sputum nor biopsies.
At the taxa level, in biopsies Streptococcus oralis, Fusobacterium pseudoperiodonticum, Veillonella rogosae, and Gemella sanguinis were significantly associated with pts(p<0.03); while in sputum the most significant associations were G.sanguinis, Prevotella multisaccharivorax, F.nucleatum, and F.peridonticum(p<0.03). The most abundantly shared taxa between sputum and biopsy were S.oralis and P.histicola, while G.sanguinis, F.pseudoperidonticum, and V.rogosae were shared in pts only.

Conclusion

This study confirmed gastric dysbiosis in AAG as shown by lower biodiversity and evenness. Gastric bacterial abundance was higher in AAG, probably due to non-acidic gastric pH permitting overgrowth of gastric bacteria. Oral bacterial abundance was similar in AAG and ctr with higher biodiversity-evenness in AAG pts, probably due to upstream passage of unactivated bacteria from stomach to mouth. Oral taxa related to increased GC risk were more commonly associated to AAG and shared between mouth and stomach. In AAG these findings show the role of oral microbiota in gastric dysbiosis, possibly contributing to increased GC risk.

References

1) Lenti MV,Rugge M,Lahner E,Miceli E,Toh BH,Genta RM,De Block C,Hershko C,Di Sabatino A. “Autoimmune gastritis” Nat Rev Dis Primers. 2020 Jul 9;6(1):56.
2) Rugge M,Genta RM,Malfertheiner P,Dinis-Ribeiro M,El-Serag H,Graham DY,Kuipers EJ,Leung WK,Park JY,Rokkas T,Schulz C,El-Omar EM;RE.GA.IN;the Real-world Gastritis Initiative-updating the updates. Gut. 2024 Feb 23;73(3):407-441. doi: 10.1136/gutjnl-2023-331164. PMID: 38383142.
3) Conti L, Annibale B, Lahner E. Autoimmune Gastritis and Gastric Microbiota. Microorganisms. 2020;8(11):1827. Published 2020 Nov 19. doi:10.3390/microorganisms8111827
4) Lin L, Li W, Yan L, et al. Comparison of gastric microbiota in patients with different gastric lesions in high and low risk areas of gastric cancer. BMC Microbiol. 2025;25(1):202. Published 2025 Apr 9. doi:10.1186/s12866-025-03926-4
5) Conti L, Borro M, Milani C, et al. Gastric microbiota composition in patients with corpus atrophic gastritis. Dig Liver Dis. 2021;53(12):1580-1587. doi:10.1016/j.dld.2021.05.005
6) Huang C, Li Y, He C. Oral microbes and gastrointestinal cancers: new strategies and insights. Clin Transl Oncol. Published online April 5, 2025. doi:10.1007/s12094-025-03891-4
7) Xia R, Jiang Z, Zhou Y, et al. Oral microbiota and gastric cancer: recent highlights and knowledge gaps. J Oral Microbiol. 2024;16(1):2391640. Published 2024 Aug 16. doi:10.1080/20002297.2024.2391640
8) Aguiar FJN, Menezes FDS, Fagundes MA, et al. Gastric adenocarcinoma and periodontal disease: A systematic review and meta-analysis. Clinics (Sao Paulo). 2024;79:100321. Published 2024 Jan 31. doi:10.1016/j.clinsp.2023.100321