Early management of acute severe UC in the biologics era: development and international validation of a prognostic clinical index to predict steroid response.

OBJECTIVES: We aimed to determine whether changes in acute severe colitis (ASC) management have translated to improved outcomes and to develop a simple model predicting steroid non-response on admission. DESIGN: Outcomes of 131 adult ASC admissions (117 patients) in Oxford, UK between 2015 and 2019 were compared with data from 1992 to 1993. All patients received standard treatment with intravenous corticosteroids and endoscopic disease activity scoring (Ulcerative Colitis Endoscopic Index of Severity (UCEIS)). Steroid non-response was defined as receiving medical rescue therapy or surgery. A predictive model developed in the Oxford cohort was validated in Australia and India (Gold Coast University Hospital 2015-2020, n=110; All India Institute of Medical Sciences, New Delhi 2018-2020, n=62). RESULTS: In the 2015-2019 Oxford cohort, 15% required colectomy during admission vs 29% in 1992-1993 (p=0.033), while 71 (54%) patients received medical rescue therapy (27% ciclosporin, 27% anti-tumour necrosis factor, compared with 27% ciclosporin in 1992-1993 (p=0.0015). Admission C reactive protein (CRP) (false discovery rate, p=0.00066), albumin (0.0066) and UCEIS scores (0.015) predicted steroid non-response. A four-point model was developed involving CRP of ≥100 mg/L (one point), albumin of ≤25 g/L (one point), and UCEIS score of ≥4 (1 point) or ≥7 (2 points). Patients scoring 0, 1, 2, 3 and 4 in the validation cohorts had steroid response rates of 100, 75.0%, 54.9%, 18.2% and 0%, respectively. Scoring of ≥3 was 84% (95% CI 0.70 to 0.98) predictive of steroid failure (OR 11.9, 95% CI 10.8 to 13.0). Colectomy rates in the validation cohorts were were 8%-11%. CONCLUSIONS: Emergency colectomy rates for ASC have halved in 25 years to 8%-15% worldwide. Patients who will not respond to corticosteroids are readily identified on admission and may be prioritised for early intensification of therapy.

Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's disease.

BACKGROUND AND AIMS: Exclusive enteral nutrition (EEN) is not routinely used as induction therapy for adults with active Crohn's disease (CD). The aim of this study was to assess the effectiveness of EEN with oral polymeric formula as an adjunct for inducing clinical and biochemical remission in adults with active CD. METHODS: We performed a retrospective analysis of data from January 2018 to September 2019 on all patients with active CD who commenced EEN. The primary end point (PE) was clinical remission (Crohn's Disease Activity Index [CDAI] ≤150) or response (100-point decrease in CDAI) at 8 weeks. The secondary end point (SE) was biochemical remission (C-reactive protein level ≤5 mg/L or feces calprotectin level ≤150 mcg/g) at 8 weeks in those whose baseline values were elevated. We also aimed to identify predictors of response to EEN therapy. RESULTS: Sixty-six patients commenced EEN; 53 (of 66; 80.3%) completed the prescribed EEN course. At 8 weeks, 42 (of 66; 63.6%) patients achieved the PE, and 30 (of 53; 56.6%) patients achieved the SE. Patients receiving EEN for ≥6 weeks achieved the PE (72% vs 47.8%; odds ratio [OR], 2.8; P = 0.047; CI, 0.97-8.16) and SE (67.6% vs 36.8%; OR, 3.58; P = 0.035; CI, 1.1-11.63) more frequently compared with patients who received EEN for <6 weeks. Nine patients reported adverse effects. CONCLUSION: Polymeric EEN is well tolerated, safe, and effective in inducing clinical and biochemical remission in adults with active CD. EEN duration of ≥6 weeks has better outcomes.

Utility of bowel ultrasound in assessing disease activity in Crohn's disease.

BACKGROUND: Gastrointestinal ultrasound (GIUS) has been used increasingly for monitoring inflammatory bowel disease (IBD) patients. The aim of this study was to assess the utility of GIUS in assessing disease activity in Crohn's disease (CD). METHODS: Consecutive patients with CD (diagnosis established for at least 6 months) between July 2017 and July 2018 requiring assessment of disease activity were prospectively assessed by magnetic resonance enterography, colonoscopy (CS), and GIUS within a 2-week period and without any change in ongoing treatment. Features on GIUS which correlated with disease activity were assessed. Sensitivity and specificity of the GIUS in assessing disease activity and localization were calculated. RESULTS: Thirty-five patients were enrolled in the study. Bowel wall thickness (BWT) ≥ 3 mm and Doppler activity ≥ 2 had the highest sensitivity (100% and 95.6%, respectively) for detecting active disease on CS. BWT ≥ 3 mm had sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 83.3%, 92%, and 100%, respectively for assessing active disease. Combination of median BWT, Doppler activity, and loss of bowel wall stratification correlated with simplified endoscopic score (SES) for CD (r = 0.8, p 0.009) and Harvey-Bradshaw index (HBI, r = 0.76, p 0.04). For localizing active disease in the ileum, GIUS had a sensitivity of 93.7%, 80% for lesions in the right colon, 100% for transverse colon, and 89% for the left colon. Specificity was 100% for ileal and colonic lesions. CONCLUSION: Loss of stratification, BWT, and Doppler activity in the bowel wall correlate with endoscopic and clinical disease activity in CD. GIUS is a sensitive modality in assessing disease activity in CD.