Introduction

Accurate diagnosis and monitoring of inflammatory bowel diseases (IBD) are essential for effective management and reduction of complications. Intestinal ultrasound (IUS) is a non-invasive and cost-effective imaging modality for IBD assessment, yet its widespread adoption is limited by operator dependency and interobserver variability. Artificial intelligence (AI) offers the potential to overcome these limitations by improving diagnostic accuracy and standardizing interpretation.

Aims & Methods

This study aimed to develop an AI-assisted model for the automatic detection of active inflammation in IUS images, using bowel wall thickness (BWT) as a key marker. We further aimed to create an automatic tool for detecting bowel segments within ultrasound images and to extend its application from single images to cine loops. Grayscale ultrasound images and cine-loops of the terminal ileum were collected from Crohn’s disease patients undergoing IUS at a tertiary center. The dataset included both normal and abnormal BWT and was annotated by an experienced operator. Preprocessing involved anonymization and normalization. Automated segmentation algorithms were used to isolate bowel wall structures, and deep learning techniques, including convolutional neural networks (CNNs) and YOLO (You Only Look Once) object detection, were employed to analyze the images.

Results

The study included 2,735 grayscale ultrasound images and cine-loops of the terminal ileum from patients with Crohn's disease. The dataset was divided into three sets: a training set of 1980 images, a validation set of 220 images, and a test set of 515 images. Our model achieved robust performance metrics, including sensitivity, specificity, and accuracy of 99.1%, 94.6%, and 91.5%, respectively, for BWT detection, with an area under the receiver operating characteristic curve (AUC) of 0.85. Our model was validated on 10 independent cine-loops, comprising 7 abnormal and 3 normal cases. It accurately identified bowel wall thickening (BWT) in all seven abnormal cases, correctly classifying them as abnormal. Additionally, the model successfully confirmed the absence of BWT in all three normal cine-loops, categorizing them appropriately as normal.

Conclusion

This study represents a significant advancement in the application of artificial intelligence to intestinal ultrasound interpretation by integrating automated segmentation, automatic analysis capabilities, and cine-loop evaluation. Our model extends beyond traditional static image analysis, paving the way for real-time and dynamic assessments of bowel inflammation. This approach highlights the potential of our AI tools to reduce operator dependency, improve diagnostic accuracy, and enhance clinical workflows, making IUS more accessible and reliable for clinicians with varying levels of expertise.

Disclosure

Prof. Dan Carter has received speaker’s fees, research support, or consultancy fees from Takeda, Janssen, AbbVie, and Taro

Introduction

Genetic variants associated to a higher risk of developing eosinophilic esophagitis (EoE) and other atopic conditions have been described. However, no study has investigated how these genetic variants influence clinical features of EoE or the atopic concomitances that usually accompanied this disease.

Aims & Methods

This study aims to assess whether single nucleotide polymorphisms (SNPs) in genes related to EoE and atopies associate with disease features and atopic concomitances in a large, representative cohort. Patients diagnosed of EoE according to clinical guidelines were recruited from 4 Spanish referral hospitals and demographical and clinical data were obtained both retrospectively and prospectively. The concomitant atopies analyzed were rhinitis, conjunctivitis, asthma, dermatitis and any food allergy. The recruited cohort was randomly divided into discovery (DC) and validation cohorts (VC) (70% and 30%, respectively). Genotyping was performed using an Open Array platform with 60 SNPs on DNA obtained from peripheral blood. Chi-square or Fisher’s exact test were used for statistical comparisons.

Results

Overall, 647 patients (74.7% male, 32.4±15.2 mean age) were included; 81% of them with an inflammatory phenotype. Rhinitis was the most common atopy (55.8%), while dermatitis was the least frequent (17.5%). Food allergy was documented in 28% of patients.
In relation to EoE characteristics, four SNPs were initially associated with endoscopic findings (measured by EREFS score) and with peak eosinophil counts in esophageal biopsies within the discovery cohort. However, only rs77569859 in the CAPN14 gene remained statistically significant in the validation cohort. TC and CC genotypes of this variant, present in 23.7% of the cohort, were associated with lower EREFS score under a dominant model (3.30±1.60 vs 2.92±1.66, p=0.011 DC/0.002 VC). Additionally, rs76562819, also in CAPN14 gene, showed a trend toward a lower peak eosinophil count per high power field (47.7±24.4 vs 66.6±48.3, p=0.005 DC/0.116VC) under a recessive model (AG and GG genotypes in 11.3% of our patients).
Regarding atopic comorbidities, rs1800925-TT in IL13 (found in 5.7% of our patients) was associated a higher prevalence of conjunctivitis (60% vs 39% in the overall cohort, p=0.020 DC/0.057 VC) and showed a trend toward increased asthma prevalence (54% vs 35%, p=0.056 DC/0.155 VC). A weaker association with asthma was observed for STAT6 rs324015, with an increased prevalence in patients with AG and GG genotypes (41% vs 32%, p=0.079 DC/0.162 VC; present in 34.9 % of the cohort). For dermatitis, a protective effect was seen in patients with the TT genotype of rs2032582 in ABCB1 gene (found in 16.1% of our patients), as the prevalence decreased from 19% to 8% (p=0.033 DC/0.157 VC). No consistent associations were found for rhinitis or food allergy with any SNP across both cohorts.

Conclusion

We have identified significant associations between genetic variants and both clinical features and atopic comorbidities in Spanish patients with EoE, highlighting the potential of genetic profiling to improve clinical characterization and patient management.

Introduction

The global burden of Inflammatory bowel disease (IBD), encompassing ulcerative colitis (UC) and Crohn’s disease (CD), is increasing. Due to its chronic nature, IBD entails long-term healthcare resource use, contributing to substantial economic and environmental costs. Digestive endoscopy, while a cornerstone of disease monitoring, is associated with high energy consumption, greenhouse gas (GHG) emissions, and medical waste. Intestinal ultrasound (IUS) has emerged as a non-invasive, accurate, and potentially more sustainable alternative.

Aims & Methods

The present study aimed to compare the environmental impacts in terms of CO₂ emissions, energy consumption (kWh), and disposable waste of IUS and endoscopy for therapeutic monitoring in IBD. In this single-center, retrospective observational study conducted at IRCCS Humanitas Research Hospital (Rozzano, Milan), all consecutive IUS and lower gastrointestinal endoscopies performed for therapeutic monitoring in IBD patients between January 2022 and December 2025 were included. Procedures for oncologic surveillance in long-standing disease, isolated rectal involvement (<15 cm from the anal verge), or without confirmed IBD were excluded. Clinical and procedural data were collected. Environmental metrics such as CO₂ emissions, energy consumption (kWh), and disposable waste were estimated using validated conversion factors and compared using appropriate statistical tests (Independent-samples t-test or Mann–Whitney U test).

Results

Endoscopic procedures performed during study period (n=2698) ↓ Exclusion criteria - Endoscopic procedures in trial setting (n=1157) -Endoscopic surveillance in UC (n= 216) -Pouchoscopies & ulcerative proctitis monitoring (n=162) - Operative/ emergency procedures (n=71) ↓ Endoscopic procedures included in the analysis (n=1092) Colonoscopies (n= 710)↵ ↳ Sigmoidoscopies (n=382)

intestinal ultrasounds performed during study period (n=1541) ↓ Exclusion criteria - Indications other than disease monitoring/ patient BMI> 30 Kg/m2 (n= 231) ↓ Intestinal ultrasounds included in the analysis (n=1310) ​

Flowchart 1. Visual representation of the process of selecting procedures to be included in the final analysis. UC: Ulcerative colitis; BMI: Body Mass Index.

During the study period, a total of 1092 endoscopic procedures, comprising 710 colonoscopies and 382 sigmoidoscopies, along with 1310 IUS were performed in 1028 IBD patients (58% UC, 42% CD). Estimated resource use for all endoscopic procedures totaled 1,256 kWh of electricity, 72,080 L of CO₂ emissions, and 585.6 kg of disposable waste, based on procedural averages (~1.5 kWh, 80 L of CO₂, 650 g waste per colonoscopy; ~50% of values for sigmoidoscopies). In contrast, IUS was associated with an estimated 524 kWh of electricity and 196.5 kg of disposable waste (average ~0.4 kWh, almost no CO₂ consumption, 150 g waste per exam). Compared to endoscopy, IUS reduced energy use by 82%, CO₂ emissions by 95%, and waste generation by 66% (P < 0.05 for all comparisons).

Conclusion

While gastrointestinal endoscopy remains indispensable in certain clinical scenarios, its environmental impact is considerable. In contrast, IUS emits almost no equivalent of CO₂, consumes significantly less energy per examination and produces negligible wastes. For therapeutic monitoring in IBD, IUS has demonstrated high diagnostic accuracy with a markedly lower ecological footprint. These findings promote IUS as a sustainable and environmentally friendly alternative for routine IBD monitoring in appropriate scenarios.

Disclosure

A Armuzzi has received consulting and/or advisory board fees from AbbVie, Allergan, Amgen, Arena, Biogen, Bristol-Myers Squibb, Celltrion, Eli-Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Mylan, Pfizer, Protagonist Therapeutics, Roche, Samsung Bioepis, Sandoz, Takeda, lecture and/or speaker bureau fees from AbbVie, Amgen, Arena, Biogen, Bristol-Myers Squibb, Celltrion, Eli-Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Mitsubishi Tanabe, Novartis, Pfizer, Roche, Sandoz, Takeda, Tigenix, and research grants from MSD, Pfizer, Takeda and Biogen. A Repici received consulting fee from Medtronic, Fuji and Olympus and has received research grant from Alfa Sigma, Norgine, Boston and Erbe. C Bezzio received speaker’s fees and consulting fees from for Takeda, MSD, Ferring, Abbvie, Galapagos and Janssen. A Dal Buono has received speaker’s fees from Pfizer, MSD, Eli-Lilly, Celltrion, Janssen, and consulting fees from Ferring. R Gabbiadini has received speaker’s fees from Pfizer, MSD, Ferring, Eli-Lilly, Celltrion, Janssen, consulting fees from Pfizer and Abbvie. G. Privitera has received speaker’s fees from Janssen and Alphasigma. B. Masoni and G. Franchellucci declare no conflict of interests.

Introduction

A reduction of bowel wall thickness (BWT) on intestinal ultrasound (IUS) is an early predictor of endoscopic response in ulcerative colitis (UC).¹ Shear-wave elastography (SWE) may offer additional prognostic information.

Aims & Methods

We aimed to identify early IUS parameters predicting treatment response to filgotinib, a selective JAK-1 inhibitor. This prospective observational study included UC patients with endoscopically active disease starting on filgotinib 200 mg daily. IUS parameters, including SWE, were assessed at baseline (T0), week 4 (T1) and at second endoscopy (T2). The endoscopic Mayo score (EMS) was assessed at T0 and at T2 in both the most-affected segment and the sigmoid. Endoscopic response was defined as a decrease in EMS of at least 1 point.

Results

A total of 23 patients were included. 10 patients were female (10/23, 44%), the mean disease duration was 14.4 years (SD±10.4), and 14 patients (14/23, 61%) had failed 2 or more biologics. Endoscopic response was observed in 6 of the 21 patients (29%) who underwent a second endoscopy after a median of 14 weeks (IQR 12-17). The submucosal thickness in the sigmoid decreased significantly more between T0 and T1 in endoscopic responders compared to non-responders (-40±23.9% vs -11.5±24.5%, p=0.022). At T1, a BWT decrease of ≥1.33 mm or ≥24.7% (OR 32.5 [2.38-443.15], p=0.009 and OR: 13.8 [1.21-156.6], p=0.035) and a submucosal thickness decrease of ≥20.8% (OR: 13.8 [1.21-156.6], p=0.035) predicted endoscopic response at T2. Additionally, improvement in Colour Doppler Signal (CDS) at T1 predicted endoscopic response (OR: 20.0 [1.66-241.7], p=0.018). SWE values in the sigmoid at T0, T1 and T2 were not significantly different between endoscopic responders and non-responders in the sigmoid. While the change in SWE values at T2 compared to baseline was significantly different between the two groups (9.9± 11.5 kPa vs. -8.1 ± 11.4 kPa, p=0.002), the difference at T1 was not significant and did not predict endoscopic response in the sigmoid (OR: 1.07 [0.99-1.16], p=0.088).

Logistic regression for endoscopic response (EMS ≥1 decrease) based on IUS B-mode parameters at week 4 (T1) in the sigmoid	Univariable Odds ratio (95% CI)	P-value
BWT (per mm increase)	0.34 [0.99-1.17]	0.087
BWT (per % increase)	0.97 [0.92-1.01]	0.118
BWT decrease ≥1.33 mm	32.5 [2.38-443.15]	0.009
BWT decrease ≥ 24.72%	13.8 [1.21-156.6]	0.035
Submucosa (per % increase)	0.95 [0.89-1.00]	0.049
Submucosa decrease ≥20.76%	13.8 [1.21-156.6]	0.035​
CDS (per one category increase)	0.26 [0.09-0.77]	0.015
CDS (≥1 decrease in mLimberg classification)	20.0 [1.66-241.7]	0.018
CDS (mLimberg of 0)	28.0 [1.99-394.4]	0.014

Conclusion

On IUS, BWT, submucosal thickness and CDS predict endoscopic response after four weeks of filgotinib treatment. SWE values in the sigmoid changed differently among endoscopic responders and non-responders, but did not predict treatment response.

References

1. de Voogd FA et al. Early Intestinal Ultrasound Predicts Clinical and Endoscopic Treatment Response and Demonstrates Drug-Specific Kinetics in Moderate-to-Severe Ulcerative Colitis. Inflamm Bowel Dis 2023. DOI: 10.1093/ibd/izad274.

Disclosure

MP: none;
CT: none;
FV: received speaker’s fees from AbbVie, Pfizer and Takeda;
RJ: none,
ML: Consultancy/lecture fees from Abbvie, Bristol Myers Squibb, Eli Lilly, Galapagos, Janssen-Cilag, Johnson & Johnson, Medtronic, Pfizer, Takeda, Tillotts. Grants received from Alfasigma, NFU transformation deal, ZonMW and TKI.
RG: received speakers free from Janssen-Cilag BV and Pfizer Inc.
GD: has served as advisor for AbbVie, Abivax, Alimentiv,, Astrazeneca, Bristol Meiers Squibb, Boehringer Ingelheim, Celltrion, Eli Lilly, , GlaxoSmithKline, Johnson and Johnson, Merck Sharp Dome, Pfizer, Polpharm, Sanofi, Takeda, Tillotts, and received speaker fees from AbbVie, Eli Lilly, Johnson and Johnson, Merck Sharp Dome, , Pfizer, Takeda, Tillotts,.
KG: KB Gecse has received grants from AbbVie, Pfizer Inc, Celltrion and Galapagos; consultancy fees from AbbVie, Arena Pharmaceuticals, ImmunicTherapeutics, Janssen Pharmaceuticals, Novartis, Pfizer Inc., and Takeda and speaker’s honoraria from Abbvie, Celltrion, Eli Lilly, Ferring, Janssen Pharmaceuticals, Pfizer Inc, Takeda and Tillotts.

Introduction

Endoscopic resection techniques, particularly endoscopic submucosal dissection (ESD), are increasingly adapted for lesions located beyond the gastrointestinal tract, including the hypopharynx. Atypical lesions in the pyriform sinus are uncommon and pose significant diagnostic and therapeutic challenges due to their anatomical complexity and limited endoscopic experience. We present a rare case of a flat mucosal lesion in the left pyriform sinus, initially suggestive of low-grade dysplasia (LGD) managed by ESD for excisional biopsy. Our optical diagnosis and resection strategy were based on a previously published case by Di et al., who demonstrated the feasibility of modified ESD in the hypopharyngeal region. (BMC Cancer 17, 712 (2017).

Aims & Methods

A 28-year-old female presented with upper abdominal pain and was referred for diagnostic esophagogastroduodenoscopy (EGD). She was a non-smoker with no relevant oncological family history. Routine examination of the esophagus, stomach, and duodenum was unremarkable. However, careful inspection of the hypopharynx revealed a flat elevated lesion (Paris 0-IIa), approximately 10×10 mm in size, with a demarcated border, located in the left pyriform sinus. Under narrow-band imaging (NBI) with dual focus, intrapapillary capillary loop (IPCL) pattern type IV was observed, raising suspicion for low-grade neoplasia or high-grade neoplasia. The lesion was photo-documented, and the patient was referred for therapeutic resection.
ESD was performed under general anesthesia. En bloc excision was achieved without adverse events; the resection time was 12 minutes.

Results

Histopathologic analysis revealed stratified non-keratinizing squamous epithelium overlying subepithelial lymphoid tissue, consistent with mucosa-associated lymphoid tissue (MALT). Areas of lymphoid follicular hyperplasia with fused follicles were present. The epithelium was non-dysplastic, with regenerative changes and mild intraepithelial lymphocytosis. Immunohistochemistry revealed non-block-type p16 staining, and Ki-67 expression was limited to the basal layer. No morphological or immunohistochemical evidence of high-grade squamous intraepithelial lesion (HSIL) was found.
The patient experienced mild local discomfort for two weeks post-procedure, controlled with ibuprofen. Follow-up endoscopy at one month confirmed complete healing with no recurrence.

Conclusion

This case highlights the growing applicability of advanced endoscopic techniques beyond the gastrointestinal tract and emphasizes the diagnostic limitations of optical assessment in small hypopharyngeal lesions. Despite features suggestive of squamous dysplasia, accurate diagnosis relied on excisional biopsy. ESD proved to be a safe and effective therapeutic option in this anatomically challenging location.

References

Di, L., Fu, KI., Xie, R. et al. A modified endoscopic submucosal dissection for a superficial hypopharyngeal cancer: a case report and technical discussion. BMC Cancer 17, 712 (2017). https://doi.org/10.1186/s12885-017-3685-7