Are we ready to use new endoscopic scores for ulcerative colitis?

For ulcerative colitis (UC), the variability in inflammatory activity along the colon poses a challenge in management. The focus on achieving endoscopic healing in UC is evident, where the UC Endoscopic Index of Severity and Mayo Endoscopic Subscore are commonly used for evaluation. However, these indices primarily consider the most severely affected region. Liu et al recent study validates the Toronto Inflammatory Bowel Disease Global Endoscopic Reporting (TIGER) score offering a comprehensive assessment of inflammatory activity across diverse segments of the colon and rectum and a reliable index correlating strongly with UC Endoscopic Index of Severity and moderately with Mayo Endoscopic Subscore (MES). Despite recommendation, certain aspects warrant further investigation. Fecal calprotectin, an intermediate target, correlates with TIGER and should be explored. Determining TIGER scores defining endoscopic remission and response, evaluating agreement with histological activity, and assessing inter-endoscopist agreement for TIGER require scrutiny. Exploring the correlation between TIGER and intestinal ultrasound, akin to MES, adds value.

Eradication rate and adherence with high-dose amoxicillin and proton pump inhibitor as first-line treatment for Helicobacter pylori infection: Experience from University Hospital in Chile.

INTRODUCTION: In Chile, more than 70% of adults are infected by Helicobacter pylori. Clarithromycin should not be used in any regimen if there is >15% resistance to this antibiotic, being greater than 26% in our population. In this scenario, the effectiveness of triple therapy (proton pump inhibitor [PPI], clarithromycin, amoxicillin) was only 63.8%. AIM: To evaluate the eradication rate and safety of dual therapy (esomeprazole and amoxicillin) in high doses, through a prospective, observational, and descriptive study. METHODS: Patients with a positive urease test obtained in an upper digestive endoscopy were included. Any other previous H. pylori eradication regimen were excluded. All patients were treated with esomeprazole 40 mg three times a day and amoxicillin 750 mg four times a day for 14 days. The eradication rate of the dual therapy was evaluated with the H. pylori stool antigen test (the Pylori-Strip® test used) 6 weeks after completing the eradication treatment and with at least 14 days without PPI, being a negative result, confirmation of the effectiveness of this regimen. RESULTS: Of 122 patients, 106 had a negative H. pylori antigen in stool; The intention-to-treat and per protocol analysis, the eradication rates were 91.8% [95% CI: 87%-97%] and 94% [95% CI: 90%-98%], respectively. Four patients discontinued treatment due to adverse effects. Smoking and adherence to treatment were associated with eradication rate. CONCLUSIONS: In this cohort of patients with H. pylori infection, high-dose dual therapy has a high eradication rate and good adherence, raising the possibility that it could be used as first-line therapy in our country. Studies with a larger number of patients should confirm these results.

Treatment with hyperbaric oxygen in a Crohn`s disease patient.

Despite advances in the treatment of inflammatory bowel disease, particularly with biological therapies and new small molecules, a significant gap still exists in achieving persistent remission from a symptomatic, biomarker, and endoscopic perspective. In this context, hyperbaric oxygen therapy (HBOT) is considered as a therapeutic strategy. This approach has also been suggested for managing ischemic ulcers located at anastomotic sites. In this clinical case, we describe the clinical and endoscopic evolution of a challenging-to-manage Crohn's disease (CD) patient with an ischemic ulcer at the ileo-rectal anastomosis who underwent HBOT.

Mesalamine induced hepatotoxicity. Is mesalamine safe?

Dear Editor: Mesalamine is a medication used widely in the treatment of patients with inflammatory bowel disease. Although mesalamine is considered safe, hepatotoxicity has been reported with an incidence of 0-4%. We present the clinical picture of a patient with hepatotoxicity due to mesalamine. A 79-year-old woman in the context of chronic diarrhea, a left-sided ulcerative colitis diagnosis was made, and treatment was initiated with oral mesalamine 4 g per day, and mesalamine suppositories. Before starting treatment, she had normal liver test results. After three months, she presented with headache, fatigue, and intermittent low fever. Her laboratory tests showed a liver profile with a cholestatic pattern, and elevation of inflammatory parameters. Mesalamine was suspended, and an extensive study was performed. Cholangioresonance reported intra and extrahepatic bile duct dilation without obstruction, and thickening of the intrahepatic bile duct. She progressed with worsening of the liver profile without signs of liver failure. A liver biopsy was performed, which showed chronic non-suppurative cholangitis with granulomas and focal concentric fibrosis related to medium-caliber bile ducts, and IgG4 stain was negative.

Personalized therapy in inflammatory bowel disease. / Terapia personalizada en la enfermedad inflamatoria intestinal.

Inflammatory bowel diseases (IBD), with ulcerative colitis and Crohn's disease being their most common presentations, comprise a spectrum of diverse disease phenotypes, exhibiting variable behaviors ranging from an indolent course to aggressive phenotypes that impact quality of life of these patients. The last two decades have been marked by the development of new medications (biological therapy and novel small molecules) with diverse mechanisms of action, which have revolutionized the management of IBD, thereby enhancing the quality of life for these patients. This landscape of multiple therapeutic options underscores the need to define which medication will benefit each patient the most and at what speed it should be started. The objective of this review is to present personalized approaches for patients with IBD, thus contributing to therapeutic management.

Effectiveness of infliximab in common variable immunodeficiency associated with enteropathy.

Common Variable Immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults, with non-infectious gastrointestinal involvement present in up to 50% of patients, with the small intestine and colon being the most affected areas. Reports have evaluated the effectiveness of biologic therapy in this scenario. Here, we describe the clinical, endoscopic, and histological findings of a patient who presented a satisfactory response to infliximab.

Corticoides en la enfermedad inflamatoria intestinal: ¿siguen siendo una opción terapéutica? / Corticosteroids in inflammatory bowel disease: Are they still a therapeutic option?

A pesar del desarrollo y de la incorporación de nuevas estrategias terapéuticas, como son la terapia biológica y las moléculas pequeñas, los corticoides aún cumplen un papel importante en la inducción de la remisión de la enfermedad inflamatoria intestinal (EII). Variables como la indicación en el momento apropiado, la dosis correcta, la duración en intervalos adecuados, la seguridad de estos fármacos y las alternativas farmacológicas disponibles deben ser siempre consideradas por el equipo tratante al momento de su indicación en pacientes con EII. Aunque el uso de corticoides es considerado un marcador de calidad de atención en pacientes con EII, en la actualidad el uso de estos fármacos en la práctica clínica de la EII dista mucho de ser el más correcto. Este artículo de revisión no pretende ser solamente una revisión clásica de las indicaciones de los corticoides, sino que explicamos aquí los escenarios en los que en nuestra opinión no serían una opción adecuada para nuestros pacientes, así como los errores más frecuentes que cometemos en nuestra práctica clínica diaria al utilizarlos. (AU)

Despite the development and incorporation of new therapeutic strategies, such as biologic therapy and small molecules, corticosteroids still play an important role in inducting inflammatory bowel diseases (IBD) remission. Variables like indicating the right doses at the right time, in adequate intervals, the security of these drugs and the pharmacological alternatives available must be considered by the providers when they are indicated to patients with IBD. Although the use of corticosteroids is considered as a marker of quality of care in patients with IBD, the use of these drugs in the clinical practice of IBD is far from being the correct one. This review article is not intended to be just a classic review of the indications for corticosteroids. Here we explain the scenarios in which, in our opinion, steroids would not be an appropriate option for our patients, as well as the most frequent mistakes we make in our daily practice when using them. (AU)

Vancomycin in the treatment of inflammatory bowel disease: there is a role beyond Clostridioides difficile infection.

The development of new biological agents and small molecules has revolutionized the treatment of Inflammatory Bowel Disease (IBD). However, many patients do not respond or gradually lose their response, necessitating the search for other therapeutic strategies (1). In this clinical case, we describe the evolution of a patient with difficult-to-manage Crohn's Disease (CD) who was treated with oral vancomycin.

Safety of Janus Kinase Inhibitors in Inflammatory Bowel Diseases.

In recent years, better knowledge of the pathophysiology of inflammatory bowel diseases (IBD) has led to a relevant expansion of the therapeutic arsenal for these conditions. Janus kinase (JAK) inhibitors are a family of small molecules that block one or more of the intracellular tyrosine kinases, including JAK-1, JAK-2, JAK-3 and TYK-2. Tofacitinib, a non-selective small molecule JAK inhibitor, and upadacitinib and filgotinib, which are selective JAK-1 inhibitors, have been approved by the US Food and Drug Administration (FDA) for moderate-to-severe active ulcerative colitis. Compared to biological drugs, JAK inhibitors have a short half-life, rapid onset of action, and no immunogenicity. Both clinical trials and real-world evidence support the use of JAK inhibitors in the treatment of IBD. However, these therapies have been linked with multiple adverse events (AEs) including infection, hypercholesterolemia, venous thromboembolism, major adverse cardiovascular events, and malignancy. While early studies recognized several potential AEs, post-marketing trials have shown that tofacitinib may increase the risk of thromboembolic diseases and major cardiovascular events. The latter are seen in patients aged 50 years or older with cardiovascular risk factors. Hence, the benefits of treatment and risk stratification need to be considered when positioning tofacitinib. Novel JAK inhibitors with a more selective effect on JAK-1 have proven to be effective in both Crohn's disease and ulcerative colitis, offering a potentially safer and efficacious therapeutic option to patients, including those with previous non-response to other therapies such as biologics. Nevertheless, long-term effectiveness and safety data are required.

Current perspectives on pediatric inflammatory bowel disease focusing on transitional care management. What should we consider?

The prevalence of inflammatory bowel disease (IBD) continues to rise around the globe. Although the percentage of pediatric IBD patients seems to be increasing, rates are surprisingly heterogeneous among different populations. Although the pathogenesis of IBD is believed to be multifactorial, a genetic predisposition may be especially relevant in pediatric-onset IBD. Phenotypic characteristics can also be significantly different when comparing pediatric and adult-onset IBD. Patients that develop the disease at a younger age usually present with more extensive and more aggressive disease and develop complications faster when compared to those that develop it during adulthood. Children with IBD are found to have frequent mood disorders and have a higher risk of developing socio-economic hardship, failing to meet development milestones. Therefore, IBD management should always involve a multidisciplinary team that is not limited to medical providers. Most institutions do not have an established transition protocol and lack the resources and training for transition care. Although there is no consensus on an optimal timing to transition the patient's care to an adult team, it is usually accepted they should be eligible for adult care when most of the key transition points have been met. Management strategies should be tailored to each patient's developmental level and environment. A successful transition can improve the long-term outcomes such as sustained remission, medication adherence, mental health and social and academic performance, while decreasing healthcare utilization. Every institution that manages pediatric IBD patients should have a well-established transition protocol in order to make sure to maintain continuity of care.

Corticosteroids in inflammatory bowel disease: Are they still a therapeutic option? / Corticoides en la enfermedad inflamatoria intestinal: ¿siguen siendo una opción terapéutica?

Despite the development and incorporation of new therapeutic strategies, such as biologic therapy and small molecules, corticosteroids still play an important role in inducting inflammatory bowel diseases (IBD) remission. Variables like indicating the right doses at the right time, in adequate intervals, the security of these drugs and the pharmacological alternatives available must be considered by the providers when they are indicated to patients with IBD. Although the use of corticosteroids is considered as a marker of quality of care in patients with IBD, the use of these drugs in the clinical practice of IBD is far from being the correct one. This review article is not intended to be just a classic review of the indications for corticosteroids. Here we explain the scenarios in which, in our opinion, steroids would not be an appropriate option for our patients, as well as the most frequent mistakes we make in our daily practice when using them.

Trasplante de microbiota fecal por colonoscopía en una mujer embarazada con infección recurrente por Clostridioides difficile

El diagnóstico de la infección por Clostridioides dfficile (ICD) ha aumentado en el embarazo y periparto. Cambios fisiológicos e inmunológicos normales durante el embarazo pueden incrementar el riesgo de ICD. Mujeres embarazadas con ICD tienen una mayor frecuencia de fracaso al tratamiento y una significativa morbilidad y mortalidad. El trasplante de microbiota fecal (TMF) se ha convertido en el tratamiento estándar de la ICD recurrente y refractaria. Sin embargo, existen escasos datos sobre sus resultados en mujeres embarazadas. Presentamos el caso de una mujer embarazada que se sometió con éxito a un TMF para el tratamiento de una ICD recurrente.

The diagnosis of Clostridioides dfficile infection (CDI) in pregnant and peripartum women has increased. In this scenario, there are higher rates of treatment failure and a significant maternal morbidity and mortality. Fecal microbiota transplant (FMT) has become the gold standard for the treatment of recurrent and refractory CDI however, there are few data on its results in pregnant patients. This case showed that FMT could be a therapeutic strategy in pregnant women with recurrent CDI.

Trasplante de microbiota fecal por colonoscopía en paciente mayor de 65 años con infección recurrente de Clostridioides difficile: aún una estrategia subutilizada / Fecal microbiota transplantation in an older patient with Clostridioides difficile recurrent infection. Report of one case

Clostridioides difficile infection (CDI) is a major public health problem and responsible for significant morbidity and mortality. Eighty percent of CDIs occur in adults older than 65 years of age due to a decreased gastrointestinal microbial diversity, immunosenescence and frailty. Thus, the most reported risk factor for recurrent CDI is older age since nearly 60% of cases occur in individuals aged ≥ 65 years. Fecal microbiota transplantation (FMT) is a highly cost-effective alternative to antibiotic treatment for patients with recurrent CDI. We report a 75-year-old male with recurrent CDI, who received a FMT after several unsuccessful antimicrobial treatments. He had a satisfactory evolution after the procedure and remained without diarrhea during the ensuing five months.

Anemia en la enfermedad inflamatoria intestinal: un objetivo subestimado / Anemia in inflammatory bowel disease

Anemia is the most common extraintestinal manifestation of inflammatory bowel disease (IBD). Although there are several causes of anemia in IBD, the two most frequent etiologies are iron deficiency anemia and anemia of chronic disease. Despite the high prevalence of anemia in IBD and its significant impact on patient's quality of life, this complication is still underdiagnosed and undertreated by providers. Active screening for anemia, structured assessment, comprehensive management, and multidisciplinary collaboration are needed in IBD patients. The cornerstone of anemia management depends on the underlying etiology along with normalization of inflammatory activity. Although, oral iron is effective for the treatment of mild iron deficiency-related anemia, intravenous iron formulations have a good safety profile and can be used as first-line therapy in patients with active IBD, severe anemia and previous intolerance prior to oral iron. After proper treatment of anemia, careful monitoring is necessary to prevent its recurrence. Herein, we discuss the etiology, screening, diagnosis, therapy selection, and follow-up for anemia in IBD.

Regulation of the Intestinal Extra-Adrenal Steroidogenic Pathway Component LRH-1 by Glucocorticoids in Ulcerative Colitis.

Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) and can be treated with glucocorticoids (GC), although some patients are unresponsive to this therapy. The transcription factor LRH-1/NR5A2 is critical to intestinal cortisol production (intestinal steroidogenesis), being reduced in UC patients. However, the relationship between LRH-1 expression and distribution with altered corticosteroid responses is unknown. To address this, we categorized UC patients by their steroid response. Here, we found that steroid-dependent and refractory patients presented reduced glucocorticoid receptor (GR)-mediated intestinal steroidogenesis compared to healthy individuals and responder patients, possibly related to increased colonic mucosa GR isoform beta (GRß) content and cytoplasmic LRH-1 levels in epithelial and lamina propria cells. Interestingly, an intestinal epithelium-specific GR-induced knockout (GRiKO) dextran sodium sulfate (DSS)-colitis mice model presented decreased epithelial LRH-1 expression, whilst it increased in the lamina propria compared to DSS-treated control mice. Mechanistically, GR directly induced NR5A2 gene expression in CCD841CoN cells and human colonic organoids. Furthermore, GR bound to two glucocorticoid-response elements within the NR5A2 promoter in dexamethasone-stimulated CCD841CoN cells. We conclude that GR contributes to intestinal steroidogenesis by inducing LRH-1 in epithelial cells, suggesting LRH-1 as a potential marker for glucocorticoid-impaired response in UC. However, further studies with a larger patient cohort will be necessary to confirm role of LRH-1 as a therapeutic biomarker.

Endoscopic colorectal cancer surveillance in inflammatory bowel disease: Considerations that we must not forget.

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, is a chronic immune-mediated inflammatory disease that primarily affects the gastrointestinal tract and is characterized by periods of activity and remission. The inflammatory activity of the disease involving the colon and rectum increases the risk of colorectal cancer (CRC) over the years. Although prevention strategies are evolving, regular surveillance for early detection of neoplasia as a secondary prevention strategy is paramount in the care of IBD patients. In this review article, we discuss the current evidence of the risks of developing CRC and evaluate the best available strategies for screening and surveillance, as well as future opportunities for cancer prevention.