Sandra Neuman

Detection of Small Bowel Mucosal Healing and Deep Remission in Patients With Known Small Bowel Crohn’s Disease Using Biomarkers, Capsule Endoscopy, and Imaging

Objectives:Mucosal healing (MH) and deep remission (DR) are associated with improved outcomes in Crohn’s disease (CD). However, most of the current data pertain to colonic MH and DR, whereas the evidence regarding the prevalence and impact of small bowel (SB) MH is scarce. The aim of this study was to to evaluate the prevalence of SBMH and DR in quiescent SBCD.Methods:Patients with known SBCD in clinical remission (CDAI<150) or with mild symptoms (CDAI<220) were prospectively recruited and underwent video capsule endoscopy after verification of SB patency. Inflammation was quantified using the Lewis score (LS). SBMH was defined as LS<135, whereas a significant inflammation was defined as LS>790. Clinico-biomarker remission was defined as a combination of clinical remission and normal biomarkers. DR was defined as a combination of clinico-biomarker remission and MH.Results:Fifty-six patients with proven SB patency were enrolled; 52 (92.9%) patients were in clinical remission and 21 (40.4%) in clinico-biomarker remission. SBMH was demonstrated in 8/52 (15.4%) of patients in clinical remission. Moderate-to-severe SB inflammation was demonstrated in 11/52 (21.1%) of patients in clinical remission and in 1/21 (4.7%) of patients in clinical and biomarker remission. Only 7/52 (13.5%) patients were in DR.Conclusions:SB inflammation is detected in the majority of CD patients in clinical and biomarker remission. SBMH and DR were rare and were independent of treatment modality. Our findings represent the true inflammatory burden in quiescent patients with SBCD.

Magnetic resonance enterography versus capsule endoscopy activity indices for quantification of small bowel inflammation in Crohn's disease.

Background: Video capsule endoscopy (VCE) and magnetic resonance enterography (MRE) are the prime modalities for the evaluation of small bowel (SB) Crohn’s disease (CD). Mucosal inflammation on VCE is quantified using the Lewis score (LS). Diffusion-weighted (DW) magnetic resonance imaging (MRI) allows for accurate assessment of SB inflammation without administration of intravenous contrast material. The Magnetic Resonance Index of Activity (MaRiA) and the Clermont index are quantitative activity indices validated for contrast-enhanced MRE and DW-MRE, respectively. The aim of this study was to compare the quantification of distal SB inflammation by VCE and MR-related activity indices. Methods: Patients with known quiescent SB CD were prospectively recruited and underwent MRE and VCE. LS, MaRIA and Clermont scores were calculated for the distal SB. Results: Both MRI-based indices significantly correlated with the LS and the Clermont index (r = 0.50, p = 0.001 and r = 0.53, p = 0.001, respectively). Both MaRIA and Clermont scores were significantly lower in patients with mucosal healing (LS < 135). The area under the curve (AUC) with both MR scores was moderate for prediction of any mucosal inflammation (LS ⩾ 135) and excellent for prediction of moderate-to-severe inflammation (LS ⩾ 790) (0.71 and 0.74 versus 0.93 and 0.91 for MaRIA and Clermont score, respectively). Conclusions: Modest correlation between VCE- and MRE-based quantitative indices of inflammation in patients with quiescent SB CD was observed. Between-modality correlation was higher in patients with endoscopically severe disease. DW-MRE gauged by Clermont score was at least as accurate as contrast-enhanced MRE for quantification of SB inflammation.

Magnetic resonance enterography or video capsule endoscopy – what do Crohn’s disease patients prefer?

Background Despite differences in the information obtained by capsule endoscopy (CE) and magnetic resonance enterography (MRE), one of these modalities is usually needed when evaluating disease activity. There are no data on patients’ preference that would help guide the choice between these two modalities in these instances. Aim To compare patients’ tolerance and preference to MRE versus CE. Patients and methods Patients with known small bowel Crohn’s disease (CD) in clinical remission (Crohn’s disease activity index [CDAI] <150) or with mild symptoms (CDAI <220) were prospectively recruited. All patients underwent MRE followed by CE. Patients were asked to fill out a questionnaire addressing specific points regarding inconvenience during the preparation for the procedures, the procedures, and postprocedures. Side effects and procedure preference were addressed. Questionnaires were included for analysis only when more than 95% of the items were addressed. Results Fifty-six patients fulfilled inclusion criteria. Pre-exam discomfort, during-exam discomfort, nausea, vomiting, bloating, and abdominal pain were all significantly more prominent in MRE as compared to CE (P<0.0001, P<0.0001, P<0.0001, P=0.009, P=0.0002, P<0.0001, respectively). MRE was perceived as a more difficult procedure (P<0.0001). Furthermore, MRE was associated with a specific adverse event – claustrophobia. Seventy-eight percent of patients (44 patients) preferred to repeat CE as compared to 22% (P<0.0001) who preferred MRE. Conclusion CE was better tolerated by CD patients compared to MRE and was preferred by 78% of patients. The superior tolerability of CE should be considered along with the diagnostic features, and more data sought when choosing between these two modalities for CD patients for long-term follow-up.

Structural bowel damage in quiescent Crohn’s disease ☆

BACKGROUND Crohns disease is associated with accumulation of progressive structural bowel damage (SBD) leading to the development of stenotic and penetrating complications. The data pertaining to the course of progression of SBD is scarce. The Lemann index (LI) is a novel tool for evaluation of SBD that incorporates pan-enteric clinical, endoscopic and imaging data. AIMS To evaluate the progression of SBD in quiescent CD patients. METHODS Patients with known quiescent small bowel Crohns disease (CD) for at least 3 months (CDAI<220) were prospectively recruited and underwent repeated magnetic resonance enterographies (MRE) and video capsule endoscopies (VCE). Patients were assessed for SBD on initial and follow-up evaluation using relevant clinicopathological data, MRE and VCE results. Significant structural bowel damage (SBD) was identified as LI>4.8, and progression of SBD as LI>0.3. RESULTS Sixty one patients were enrolled in the study. Significant SBD was detected 13 (21.4%) on enrollment. Duration of disease (p=0.036) and history of CD-related surgery (p=0.0001) were associated with significant BD. Forty one patients underwent a follow-up MRE (14.8±2.5 months apart). LI was similar at baseline and follow-up. There was a negligible change in LI between the evaluations. CONCLUSIONS In patients with quiescent Crohns disease, structural bowel damage was stable over a median of 14 months follow-up.

Helicobacter pylori prevalence and clinical significance in patients with quiescent Crohn’s disease

BackgroundHelicobacter pylori (HP) infection is present in about 50% of the global population, and is associated with chronic gastritis, peptic disease and gastric malignancies. HP prevalence in Crohn’s disease (CD) patients was shown to be low compared to the general population, and its influence on disease activity is yet to be determined. Our aims were to determine the prevalence of HP in a selected group of CD patients with quiescent disease, and to assess the influence of its eradication on disease activity and endoscopic and laboratory activity measures.MethodsConsecutive CD patients with quiescent disease underwent meticulous disease evaluation with MR enterography (MRE), video capsule endoscopy (VCE), CRP, fecal calprotectin and CDAI. All patients were tested for the presence of HP using stool antigen detection kit. Patients infected with HP were offered eradication treatment with sequential therapy. HP eradication was confirmed using urease breath test and stool antigen test. The influence of HP eradication on disease activity was assessed.ResultsOut of 56 patients enrolled, six patients (10.7%) had HP infection. Of them, five patients had gastro- duodenitis per VCE. All HP positive patients were offered eradication treatment and underwent successful eradication. Notably, 23 (50%) of patients had proximal disease per VCE, most of them (78%) were HP negative.CDAI, CRP, fecal calprotectin and VCE Lewis inflammatory score did not change significantly following HP eradication, Gastric findings on VCE were not impacted by HP eradication.ConclusionsThe prevalence of HP infection in patients with quiescent CD is relatively low. Eradication of the bacteria did not significantly change neither disease activity measures nor the presence of gastro- duodenitis per VCE, suggesting it might be part of proximal CD. The influence of HP on CD activity merits further investigation.

Partners of patients with inflammatory bowel disease: how important is their support?

Background Chronic inflammatory bowel disease (IBD) causes significant distress for patients and their families. Data assessing the need of these patients for support and sharing with their partners are scarce. The aim of this study was to assess patients’ views regarding sharing of information with their partners. Methods Ambulatory IBD patients treated at the Chaim Sheba Medical Center between January 2011 and January 2013 were asked to complete an anonymous questionnaire. Patients who had a stable partner and completed more than 95% of the questionnaire were included. Results Of 134 patients who agreed to complete the questionnaire, 101 met the inclusion criteria, 53 were men (mean age 45±15 years), and 50% had academic education. Only 42% of patients reported that their partner accompanied them to the doctor. However, 93% shared health problems with their partner, 64% would have liked their partner to receive more medical information, and 70% would like their partner to be more involved. The majority (88%) believed that more partner involvement could help them deal better with the disease, and 70% thought that support groups for partners should be established. No association was found between patients’ demographic data and their answers. Patients who felt that partner involvement could help them to deal with the disease tended to share medical information with their partners and wanted them to be more involved in health care decision-making (P<0.001). Conclusion Most IBD patients in our study wanted their partner to be more involved with their health problems, and believed that greater partner involvement could help them deal better with their disease. Therefore, more attention should be focused on gaining better cooperation from patients’ families.

Prospective Observational Evaluation of Time-Dependency of Adalimumab Immunogenicity and Drug Concentrations: The Poetic Study

OBJECTIVES: Adalimumab is usually self‐injected at home, making prospective serial‐sampling studies challenging and scarce. This has led to a gap in knowledge about evolution of anti‐adalimumab antibodies (AAAs) over time and its correlation with clinical and inflammatory outcomes. METHODS: A program for home visits by physicians at induction, every 3 months and at event of relapse, was established prospectively for Crohns disease (CD) patients. At each visit, patients’ clinical scores were determined and sera were obtained for C‐reactive protein, drug, and AAA levels. This cohort was compared to a parallel prospective cohort of infliximab‐treated CD patients. In a subgroup of 29 patients, trough and in‐between‐trough levels were compared, to elucidate the importance of timing of sampling during the injection cycle. RESULTS: Ninety‐eight CD patients starting adalimumab were prospectively followed (median follow‐up 44 weeks) and 621 serum samples were analyzed. Thirty‐three patients (32%) developed AAA; 18/33 (55%) of them as early as week 2, and 26/33 (79%) by week 14. Induction period AAAs were strongly associated with primary non‐response (odds ratio (OR) = 5.4, 95% confidence interval (CI): 1.6–17.8, p = 0.005). As compared to antibodies‐to‐infliximab (ATI), AAA formation rate over time was significantly lower (p = 0.01) and AAA were much more specific—85% of AAA events were associated with loss‐of‐response compared with 58% rate for ATI (p = 0.01). In 29 patients sampled serially during an injection cycle, levels of drug and AAA seemed comparable between four time‐points during a single cycle both in patients with or without AAA (n = 8, n = 21, respectively). CONCLUSIONS: When followed prospectively and serially, AAAs are found to arise earlier than previously appreciated and their impact may be more pronounced for primary rather than secondary, non‐response. Drug and AAA levels were similar both at trough and in‐between injections, enabling to simplify therapeutic drug monitoring of adalimumab.

Su1224 Small Bowel Mucosal Healing and Deep Remission in Patients With Known Small Bowel Crohn's Disease

Small bowel mucosal healing and deep remission in patients with known small bowel Crohns disease. U. Kopylov*1, D. Yablecovitch2, A. Lahat2, S. Neuman2, N. Levhar2, E. Klang3, M.M. Amitai3, S. Ben-Horin2, R. Eliakim2 1Sheba Medical Center, Gastroenterology, Tel Hashomer, Israel, 2Chaim Sheba Medical Center, Gastroenterology, Ramat Gan, Israel, 3Sheba Medical Center, Department of Diagnostic Imaging, Tel Hashomer, Israel