The gut microbiota-derived metabolite indole-3-propionic acid (IPA) plays an important role in maintaining intestinal mucosal homeostasis, while the molecular mechanisms underlying IPA regulation on mucosal CD4+ T cell functions in inflammatory bowel disease (IBD) remain elusive. Here we investigated the roles of IPA in modulating mucosal CD4+ T cells and its therapeutic potential in treatment of human IBD. Leveraging metabolomics and microbial community analyses, we observed that the levels of IPA-producing microbiota (e.g. Peptostreptococcus, Clostridium, and Fournierella) and IPA were decreased, while the IPA-consuming microbiota (e.g. Parabacteroides, Erysipelatoclostridium, and Lachnoclostridium) were increased in the feces of IBD patients than those in healthy donors. Dextran sulfate sodium (DSS)-induced acute colitis and CD45RBhighCD4+ T cell transfer-induced chronic colitis models were then established in mice and treated orally with IPA to study its role in intestinal mucosal inflammation in vivo. We found that oral administration of IPA attenuated mucosal inflammation in both acute and chronic colitis models in mice, as characterized by increased body weight, and reduced levels of pro-inflammatory cytokines (e.g. TNF-α, IFN-γ, and IL-17A) and histological scores in the colon. We further utilized RNA sequencing, molecular docking simulations, and surface plasmon resonance analyses and identified that IPA exerts its biological effects by interacting with heat shock protein 70 (HSP70), leading to inducing Th1/Th17 cell apoptosis. Consistently, ectopic expression of HSP70 in CD4+ T cells conferred resistance to IPA-induced Th1/Th17 cell apoptosis. Therefore, these findings identify a previously unrecognized pathway by which IPA modulates intestinal inflammation and provide a promising avenue for the treatment of IBD.

Inflammatory bowel disease (IBD) is a relapsing-remitting illness requiring proactive monitoring of gut inflammation. We aimed to determine the correlations of plasma myeloperoxidase (pMPO) and calprotectin (pCal), two neutrophil proteins, with existing measures of disease activity.

Adults with IBD undergoing ileocolonoscopy were recruited prospectively. Baseline assessments included blood tests (pMPO, pCal, and C-reactive protein ([CRP]), symptom questionnaires, and endoscopic indices (simple endoscopic score for CD [SES-CD] and UC endoscopic index of severity [UCEIS]). Active IBD was defined as SES-CD > 2 and UCEIS ≥ 2. Spearman's rank correlations assessed the associations between blood markers and endoscopic activity. The area under the receiver operating characteristics curves (AUROC) and univariable logistic regression assessed the ability of blood markers (at optimal thresholds) to identify active disease.

In total, 170 participants were included (female, n = 92; Crohn's disease [CD], n = 99; median age 46 years, IQR 35-58). Plasma biomarkers more accurately identified active IBD in individuals with UC (AUROCpMPO = 0.76, P < .001; AUROCpCal = 0.66, P < .05; AUROCCRP = 0.73, P < .001) than in CD (AUROCpMPO = 0.62, P > .05; AUROCpCal = 0.65, P < .01; AUROCCRP = 0.66, P < .01). In all patients with IBD, the addition of pCal (AUROC = 0.73, P < .001) and pMPO (AUROC = 0.73, P < .001) to CRP added benefit compared to CRP (AUROC = 0.70, P < .001) alone. Plasma myeloperoxidase > 13.86 ng/mL (odds ratio [OR] = 10.13, 3.4-30.16) and pCal > 961.72 ng/mL (OR = 3.38, 1.21-9.4) were associated with an increased odds of having endoscopically active UC.

Plasma MPO shows promise as a potential blood-based biomarker of IBD activity, especially in UC. The combined use of pMPO and CRP adds diagnostic utility in discriminating between active versus quiescent IBD.

Concentrations of the neutrophil protein myeloperoxidase are elevated in the feces of individuals with endoscopically active inflammatory bowel disease (IBD). Its enzyme activity could give an immediate readout of endoscopic inflammation. We investigated whether fecal myeloperoxidase activity (fMPOa) is associated with IBD endoscopic inflammation. We also investigated whether myeloperoxidase promotes oxidative stress in IBD.

Myeloperoxidase enzyme activity was measured using an enzyme-linked immunosorbent assay (ELISA fMPOa), a novel CM-sepharose extraction assay (CM-S fMPOa), or by quantifying urinary glutathione sulfonamide (GSA) by tandem mass spectrometry. GSA is a specific biomarker of myeloperoxidase activity. IBD activity was assessed using the ulcerative colitis endoscopic index of severity or the simple endoscopic score for Crohn's disease (SES-CD). Spearman's correlation and receiver operating characteristic curves evaluated biomarker utility.

IBD patients (n = 172) were recruited prospectively (ulcerative colitis, n = 72; Crohn's disease, n = 100). fMPO was mostly active. Its enzyme activity, measured either as ELISA fMPOa or CM-S fMPOa, correlated with endoscopic inflammation in both ulcerative colitis and Crohn's disease. Urinary GSA is also correlated with endoscopic disease inflammation. Correlations of urinary GSA with disease measures and other biomarkers were stronger in ulcerative colitis than in Crohn's disease.

Myeloperoxidase is active in IBD and its enzyme activity is a reliable marker of IBD endoscopic inflammation. Our results with the CM-S fMPOa assay demonstrate the potential for an immediate and accurate measure of fMPO enzyme activity as a robust, low-cost test for IBD activity. Myeloperoxidase may contribute to tissue damage in IBD.

Aims/Background Endoscopic scoring systems are recommended internationally for assessing disease activity, response to therapy and mucosal healing. However, their real-world application remains inconsistent. This study aimed to evaluate the impact of an educational intervention on endoscopic scoring documentation and identify factors influencing its use. Methods A retrospective observational study was conducted at four hospital sites in Greater Manchester, UK. Data from endoscopies performed on ulcerative colitis (UC) patients were compared before and after an educational intervention. Logistic regression was used to analyse factors affecting documentation rates. Results Endoscopic score documentation increased from 39% (pre-intervention) to 46% (post-intervention) (p = 0.162). Nurse endoscopists had the highest documentation rates (83%), while surgeons had the lowest (8%). Attendance at educational sessions significantly increased documentation rates (29% vs. 74-80%, p < 0.001). Conclusion Educational interventions modestly improved endoscopic scoring documentation. Further targeted training and standardised reporting templates are needed to enhance adherence and patient outcomes in UC management.

The International Bowel Ultrasound Segmental Activity Score (IBUS-SAS) is an intestinal ultrasound (IUS) score validated for Crohn's disease, potentially applicable to ulcerative colitis (UC). We aimed to confirm the applicability of IBUS-SAS to UC, while comparing its performance with other IUS scores.

Adult patients with UC undergoing colonoscopy were prospectively included and scored with both the Mayo Endoscopic Subscore (MES) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). Intestinal ultrasound was performed within 4 weeks of endoscopy, measuring IBUS-SAS and other 5 UC-developed IUS scores. The Spearman's rank coefficient (ρ) was used to perform correlations, while receiver operating characteristic curves were compared with the Hanley & McNeil method.

In total, 185 patients were included. The IBUS-SAS showed a strong correlation with both the MES (ρ = .72, P < .01) and the UCEIS (ρ = .73, P < .01). Its area under the curve to detect an endoscopic activity of at least moderate severity (MES ≥ 2 and UCEIS ≥ 5) was 0.87 and 0.89, respectively. The optimal cutoffs of IBUS-SAS to detect a MES ≥ 2 and an UCEIS ≥ 5 were > 19 (sensitivity 79%, specificity 84%) and > 23 (sensitivity 88%, specificity 75%), respectively. Consistently, all the investigated IUS scores correlated with both the MES and the UCEIS (P < .01).

The IBUS-SAS has an optimal performance in the assessment of UC endoscopic activity, despite having been initially developed for CD. Therefore, it might be adopted as a reference score both for CD and UC activity.

Inflammatory bowel disease (IBD) is a complex condition influenced by various intestinal factors. Advances in next-generation sequencing, high-throughput omics, and molecular network technologies have significantly accelerated research in this field. The emergence of artificial intelligence (AI) has further enhanced the efficient utilization and interpretation of datasets, enabling the discovery of clinically actionable insights. AI is now extensively applied in gastroenterology, where it aids in endoscopic analyses, including the diagnosis of colorectal cancer, precancerous polyps, gastrointestinal inflammatory lesions, and bleeding. Additionally, AI supports clinicians in patient stratification, predicting disease progression and treatment responses, and adjusting treatment plans in a timely manner. This approach not only reduces healthcare costs but also improves patient health and safety. This review outlines the principles of AI, the current research landscape, and future directions for its applications in IBD, with the goal of advancing targeted treatment strategies.

Multi-omic and multimodal datasets with detailed clinical annotations offer significant potential to advance our understanding of inflammatory bowel diseases (IBD), refine diagnostics, and enable personalized therapeutic strategies. In this multi-cohort study, we performed an extensive multi-omic and multimodal analysis of 1,002 clinically annotated patients with IBD and non-IBD controls, incorporating whole-exome and RNA sequencing of normal and inflamed gut tissues, serum proteomics, and histopathological assessments from images of H&E-stained tissue sections. Transcriptomic profiles of normal and inflamed tissues revealed distinct site-specific inflammatory signatures in Crohn's disease (CD) and ulcerative colitis (UC). Leveraging serum proteomics, we developed an inflammatory protein severity signature that reflects underlying intestinal molecular inflammation. Furthermore, foundation model-based deep learning accurately predicted histologic disease activity scores from images of H&E-stained intestinal tissue sections, offering a robust tool for clinical evaluation. Our integrative analysis highlights the potential of combining multi-omics and advanced computational approaches to improve our understanding and management of IBD.

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

As the target of therapy in Ulcerative colitis (UC) has changed from symptomatic relief to mucosal healing, endoscopic visualization is mandatory. Colon capsule endoscopy (CCE) may serve as a less invasive and more tolerable alternative to standard colonoscopy (SC) for the monitoring of UC.

To evaluate the diagnostic accuracy, adverse events and tolerability for CCE compared to SC.

Systematic review.

A systematic literature search was conducted in PubMed, Embase and Web of Science.

Search results were imported into Covidence and screened. Included studies underwent risk of bias assessment using Methodological Index for Non-Randomized Studies (MINORS), and relevant data, including completeness of the procedure, type of bowel preparation and adverse events, was extracted. Pooled estimates of diagnostic accuracy were calculated from the studies providing the necessary data.

Out of 2804 articles, six studies were eligible for inclusion. Three provided the necessary data to calculate pooled estimates of diagnostic accuracy in recognizing mucosal inflammation: pooled sensitivity of 93%, specificity of 68.8%, positive predictive value of 89.4%, and negative predictive value of 78.6%. The adverse events, such as nausea and abdominal distension, were predominantly related to bowel preparation regimens.

CCE has the potential for monitoring UC. However, the specificity and NPV must be improved. Bowel preparation regimens must be optimized to improve patient experience and the effectiveness of CCE.

Prospero ID CRD42023450210.

Inflammatory bowel diseases with the 2 main forms - ulcerative colitis and Crohn's disease - are chronic relapsing diseases of the gastrointestinal tract in which dysregulation of the intestinal immune system against commensal components of the microbiome leads to perpetuated intestinal inflammation based on a genetic predisposition. While in the past symptom control was the focus of therapy, more recent data show that achieving endoscopic remission is superior to sole clinical symptom control for the further course and prognosis of the diseases. In this review article, we will present the significance of endoscopy for inflammatory bowel diseases, describe established scoring systems for endoscopic graduation of inflammatory activity and, last but not least, also present and review new endoscopic developments.

Endoscopic scoring indices for ulcerative colitis and Crohn's disease are subject to inter-endoscopist variability. There is increasing interest in the development of deep learning models to standardize endoscopic assessment of intestinal diseases. Here, we summarize and critically appraise the literature on artificial intelligence-assisted endoscopic characterization of inflammatory bowel disease severity.

A systematic search of Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and IEEE Xplore was performed to identify reports of AI systems used for endoscopic severity classification of IBD. Selected studies were critically appraised for methodological and reporting quality using APPRAISE-AI.

Thirty-one studies published between 2019 and 2024 were included. Of 31 studies, 28 studies examined endoscopic classification of ulcerative colitis and 3 examined Crohn's disease. Researchers sought to accomplish a wide range of classification tasks, including binary and multilevel classification, based on still images or full-length colonoscopy videos. Overall scores for study quality ranged from 41 (moderate quality) to 64 (high quality) out of 100, with 28 out of 31 studies within the moderate quality range. The highest-scoring domains were clinical relevance and reporting quality, while the lowest-scoring domains were robustness of results and reproducibility.

Multiple AI models have demonstrated the potential for clinical translation for ulcerative colitis. Research concerning the endoscopic severity assessment of Crohn's disease is limited and should be further explored. More rigorous external validation of AI models and increased transparency of data and codes are needed to improve the quality of AI studies.

There is an unmet medical need for noninvasive techniques to determine disease activity in inflammatory bowel disease (IBD) and intestinal ultrasound (IUS) has shown promising performance in this regard. In addition to parameters such as bowel wall thickness, stratification, and mesenteric fat, color Doppler signals are used to determine inflammatory activity in the gut. However, whether superb microvascular imaging (SMI), a microvascular flow imaging technique, improves the diagnostic accuracy is currently unclear.

We performed a prospective single-center cross-sectional cohort study including 62 patients with ulcerative colitis (UC). IUS was performed on the sigmoid colon within 30 days of colonoscopy and the International Bowel Ultrasound (IBUS) group Segmental Activity Score (SAS) as well as SMI signals were determined and correlated to established endoscopic, clinical, and biochemical read-outs of disease activity.

Semiquantitative scoring of SMI signals had a substantial interobserver agreement between 2 blinded and expert central readers. It showed excellent correlation to endoscopic, clinical, and biochemical disease activity. While SMI did not improve the overall diagnostic performance of the IBUS-SAS to predict endoscopic disease activity, SMI alone was highly precise and superior to Doppler imaging in predicting endoscopic remission.

IUS is a highly precise noninvasive diagnostic tool to monitor disease activity in UC, in particular for predicting endoscopic remission. Assessing the SMI signals in the bowel wall of patients with IBD seems a promising tool to simplify IUS diagnostics in IBD that warrants further research.

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Endoscopic classification of ulcerative colitis (UC) shows high interobserver variation. Previous research demonstrated that artificial intelligence (AI) can match the accuracy of central reading in scoring still images. We now extend this assessment to longer colon segments and integrate AI into clinical workflows, evaluating its use for real-time, video-based classification of disease severity, and as a support system for physicians.

We trained a convolutional neural network with the Mayo Endoscopic Subscores (MESs) of 2,561 images and 53 videos from 645 patients. The model differentiated scorable from unscorable endoscopy sections through open-set recognition. Validation involved 140 video clips from 44 patients with UC. Six inflammatory bowel disease (IBD) experts and 16 nonexperts rated these videos, with expert scores as the gold standard. We assessed the model's performance and the value as a supporting system. Last, the model underwent an alpha test on a real-world patient as a real-time endoscopic support.

The model achieved an accuracy of 82%, with no significant differences between the experts and the AI. When used as a supporting system, it improved non-IBD experts' performance by 12% and disagreed with the primary physician in 20%-39% of cases. During the alpha test, it was successfully integrated into clinical practice, accurately distinguishing between MES 0 and MES 1, consistent with endoscopists' assessments.

Our innovative AI model shows significant potential for enhancing the accuracy of UC severity classification and improving the proficiency of non-IBD experts. It is designed for clinical use and has proven feasible in real-world testing.

Leucine-rich alpha 2 glycoprotein (LRG) is one of the serum biomarkers for disease activity of ulcerative colitis (UC). We focused on the correlation between the changes of LRG and the changes of endoscopic and histologic activity of UC, in comparison to the changes of fecal calprotectin (Fcal), fecal immunochemical test (FIT), and C-reactive protein (CRP). Seventy-nine patients with two or more colonoscopies were enrolled, and 123 paired colonoscopies and 121 paired biopsies were examined. With regard to the change of endoscopic/histologic activity between the preceding and subsequent colonoscopy, there was improvement (n = 29/45), unchanging (n = 63/36), and worsening (n = 31/40). The correlations between the changes of marker levels and endoscopic/histologic activity were Fcal; r = 0.50/0.39 and FIT; r = 0.41/0.40, LRG; r = 0.42/0.40 and CRP; r = 0.22/0.17. Furthermore, when the correlation between the changes of LRG levels and the changes of endoscopic/histological activity was compared with those of other markers, the correlation of LRG tended to be superior to those of CRP (CRP vs. LRG; p = 0.08/0.01). LRG is equivalent to fecal markers and superior to CRP, when inferring changes in disease activity of UC based on changes in its level.

Pediatric-onset ulcerative colitis (pUC) represents a more aggressive disease phenotype compared with adult-onset UC. We hypothesized that this difference can, in part, be explained by the composition of the microbiota.

In a prospective, longitudinal study, we included pediatric (N = 30) and adult (N = 30) patients with newly or previously (>1 year) diagnosed UC. We analyzed the microbiota composition in the mucosa-adherent microbiota at baseline, using 16S rRNA gene sequencing, and the fecal microbiota at baseline and at 3-month intervals, using shotgun metagenomics.

For fecal samples, the bacterial composition differed between pUC and aUC in newly diagnosed patients (β-diversity, Bray Curtis: R2 = 0.08, P = .02). In colon biopsies, microbial diversity was higher in aUC compared with pUC (α-diversity, Shannon: estimated difference 0.54, P = .006). In the mucosa-adherent microbiota, Alistipes finegoldii was negatively associated with disease activity in pUC while being positively associated in aUC (estimate: -0.255 and 0.098, P = .003 and P = .02 in pUC and aUC, respectively). Finally, we showed reduced stability of the fecal microbiota in pediatric patients, evidenced by a different composition of the fecal microbiota in newly and previously diagnosed pUC, a pattern not found in adults.

Our results indicate that pediatric UC patients have a more unstable fecal microbiota and a lower α diversity than adult patients and that the microbiota composition differs between aUC and pUC patients. These findings offer some explanation for the observed differences between pUC and aUC and indicate that individualized approaches are needed if microbiota modifications are to be used in the future treatment of UC.

Growing interest exists in deep remission, beyond clinical and endoscopic remission, to enhance long-term prognosis in patients with ulcerative colitis (UC). Our study aimed to evaluate the risk of relapse according to tissue expression levels of calprotectin and neutrophil elastase (NE) in patients with quiescent UC.

Rectal biopsies were performed on 218 patients with UC in clinical and endoscopic remission. Histological activity was prospectively scored using the Robarts Histological Index. Tissue calprotectin and NE levels were evaluated using immunohistochemistry. Optimal tissue calprotectin and NE cutoffs for relapse were determined using log-rank analysis. Cox proportional hazard analyses evaluated relapse risk factors.

Tissue calprotectin and NE levels were significantly higher in patients with histological activity than in those in histological remission (P < .001). The optimal cutoffs of tissue calprotectin and NE for relapse were 10.61 and 22.08 per mm2, respectively. The 3-year clinical relapse risk was significantly lower in the low-tissue NE group than in the high-tissue NE group (P = .009); however, it did not differ between the low- and high-tissue calprotectin group (P = .094). In multivariate analyses, a low level of tissue NE expression was independently associated with a lower risk of 3-year clinical relapse (adjusted hazard ratio = 0.453, 95% confidence interval = 0.225-0.911, P = .026), unlike histological index and tissue calprotectin.

In patients with UC who have achieved clinical and endoscopic remission, tissue expression of NE is a better predictor of long-term relapse than histological activity.

The Groupe d'Etude sur les Affections Inflammatoires Digestives (GETAID) was founded in Paris in 1983 by Professor Robert Modigliani and colleagues. From the beginning, the aim of this international (France, Belgium, and Switzerland), multicenter, French-speaking group was to address clinical questions raised by patients or physicians in their daily practice or the inflammatory bowel disease community, by focusing on clinical research on treatments through randomized controlled trials, prospective cohorts, and cross-sectional studies, quantifying the severity of various facets of the disease when necessary for these studies. This very innovative approach has contributed to the advancement of knowledge in inflammatory bowel diseases by publishing more than 120 original articles in peer-reviewed journals throughout the GETAID's 40-year history, most of them in top publications in gastroenterology and hepatology journals. In this paper, we will see what GETAID's contribution has been over the last 4 decades and review the reasons for its success and forthcoming challenges.

The remarkable recent developments in image-enhanced endoscopy (IEE) have significantly contributed to the advancement of diagnostic techniques. Linked color imaging (LCI) is an IEE technique in which color differences are expanded by processing image data to enhance short-wavelength narrow-band light. This feature of LCI causes reddish areas to appear redder and whitish areas to appear whiter. Because most colorectal lesions, such as neoplastic and inflammatory lesions, have a reddish tone, LCI is an effective tool for identifying colorectal lesions by clarifying the redder areas and distinguishing them from the surrounding normal mucosa. To date, eight randomized controlled trials have been conducted to evaluate the effectiveness of LCI in identifying colorectal adenomatous lesions. The results of a meta-analysis integrating these studies demonstrated that LCI was superior to white-light endoscopy for detecting colorectal adenomatous lesions. LCI also improves the detection of serrated lesions by enhancing their whiteness. Furthermore, accumulating evidence suggests that LCI is superior to white-light endoscopy for the diagnosis of the colonic mucosa in patients with ulcerative colitis. In this review, based on a comprehensive search of the current literature since the implementation of LCI, the utility of LCI in the detection and diagnosis of colorectal lesions is discussed. Additionally, the latest data, including attempts to combine artificial intelligence and LCI, are presented.

Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract (GI) with a high incidence rate globally, and IBD patients are often accompanied by zinc deficiency. This review aims to summarize the potential therapeutic value of zinc supplementation in IBD clinical patients and animal models. Zinc supplementation can relieve the severity of IBD especially in patients with zinc deficiency. The clinical severity of IBD were mainly evaluated through some scoring methods involving clinical performance, endoscopic observation, blood biochemistry, and pathologic biopsy. Through conducting animal experiments, it has been found that zinc plays an important role in alleviating clinical symptoms and improving pathological lesions. In both clinical observation and animal experiment of IBD, the therapeutic mechanisms of zinc interventions have been found to be related to immunomodulation, intestinal epithelial repair, and gut microbiota's balance. Furthermore, the antioxidant activity of zinc was clarified in animal experiment. Appropriate zinc supplementation is beneficial for IBD therapy, and the present evidence highlights that alleviating zinc-deficient status can effectively improve the severity of clinical symptoms in IBD patients and animal models.

The differences in the clinical course of Crohn's disease (CD) and ulcerative colitis (UC) among Asian countries remain unknown. Thus, we compared the clinical characteristics, treatment, and one-year outcomes of newly diagnosed inflammatory bowel disease (IBD) patients between Vietnam and Korea.

A retrospective cohort study was conducted at seven tertiary hospitals in these countries between January 2020 and January 2021. Data on demographics, diseases, treatment, and outcomes during 1 year after diagnosis were collected.

Among 225 patients (60 from Vietnam and 165 from Korea), 140 and 85 were diagnosed with UC and CD, respectively. Severe activity (p < 0.01) and extensive colitis (p < 0.01) in UC, along with complicated behavior in CD (p < 0.01), were more frequently observed in Vietnamese patients compared to Korean patients. The proportion of UC patients using corticosteroids (p < 0.01), immunomodulators (p < 0.01), and biologics (p = 0.026) was significantly higher in Vietnam. In contrast, the proportion of UC patients using topical mesalamine (p < 0.01) was significantly higher in Korea. The intervals from CD diagnosis to biologic therapy initiation (p = 0.04), as well as from UC diagnosis to corticosteroid (p < 0.01), immunomodulator (p < 0.01), and biologic therapy (p < 0.01) commencement, were significantly shorter in Vietnamese patients compared to Korean patients. However, the proportions of endoscopic healing and complications at 1-year follow-up did not significantly differ between the countries (p > 0.05).

Although Vietnamese IBD patients had higher baseline clinical and phenotypic severity than their Korean counterparts, no significant differences in short-term outcomes were observed, potentially reflecting the impact of the higher rate and early biologic usage in Vietnamese patients.

Validated scoring methods such as the Mayo Clinic Endoscopic Subscore (MCES) evaluate ulcerative colitis (UC) severity at the worst colon segment, without considering disease extent. We present the Ulcerative Colitis Severity Classification and Localized Extent (UC-SCALE) algorithm, which provides a comprehensive and automated evaluation of endoscopic severity and disease extent in UC.

Ulcerative Colitis Severity Classification and Localized Extent consists of 3 main elements: (1) a quality filter selecting readable images (frames) from colonoscopy videos, (2) a scoring system assigning an MCES to each readable frame, and (3) a camera localization algorithm assigning each frame to a location within the colon. Ulcerative Colitis Severity Classification and Localized Extent was trained and tested using 4326 sigmoidoscopy videos from phase III Etrolizumab clinical trials.

The high agreement between UC-SCALE and central reading at the level of the colon section (𝜅 = 0.80), and the agreement between central and local reading (𝜅 = 0.84), suggested a similar inter-rater agreement between UC-SCALE and experienced readers. Furthermore, UC-SCALE correlated with disease activity markers such calprotectin, C-reactive protein and patient-reported outcomes, Physician Global Assessment and Geboes Histologic scores (rs 0.40-0.55, ps < 0.0001). Finally, the value of using UC-SCALE was demonstrated by assessing individual endoscopic severity between baseline and induction.

Our fully automated scoring system enables accurate, objective, and localized assessment of endoscopic severity in UC patients. In addition, we provide a topological representation of the score as a marker of disease severity that correlates highly with clinical metrics. Ulcerative Colitis Severity Classification and Localized Extent reproduces central reading and holds promise to enhance disease severity evaluation in both clinical trials and everyday practice.

The Mayo endoscopic subscore [MES] is the most popular endoscopic disease activity measure of ulcerative colitis [UC]. Artificial intelligence [AI]-assisted colonoscopy is expected to reduce diagnostic variability among endoscopists. However, no study has been conducted to ascertain whether AI-based MES assignments can help predict clinical relapse, nor has AI been verified to improve the diagnostic performance of non-specialists.

This open-label, prospective cohort study enrolled 110 patients with UC in clinical remission. The AI algorithm was developed using 74 713 images from 898 patients who underwent colonoscopy at three centres. Patients were followed up after colonoscopy for 12 months, and clinical relapse was defined as a partial Mayo score > 2. A multi-video, multi-reader analysis involving 124 videos was conducted to determine whether the AI system reduced the diagnostic variability among six non-specialists.

The clinical relapse rate for patients with AI-based MES = 1 (24.5% [12/49]) was significantly higher [log-rank test, p = 0.01] than that for patients with AI-based MES = 0 (3.2% [1/31]). Relapse occurred during the 12-month follow-up period in 16.2% [13/80] of patients with AI-based MES = 0 or 1 and 50.0% [10/20] of those with AI-based MES = 2 or 3 [log-rank test, p = 0.03]. Using AI resulted in better inter- and intra-observer reproducibility than endoscopists alone.

Colonoscopy using the AI-based MES system can stratify the risk of clinical relapse in patients with UC and improve the diagnostic performance of non-specialists.

Over the past decades, an increased importance has been given to gastrointestinal (GI) endoscopy in the management of children with inflammatory bowel diseases (IBD), considering that mucosal healing has been recognized as the optimal endpoint in the treat-to-target paradigm. The recent advances in technology and anesthesia have facilitated the comprehensive evaluation of the GI tract. In this review, we will discuss the role of ileocolonoscopy, upper GI endoscopy, and device-assisted enteroscopy in the work-up and management of pediatric Crohn's disease (CD) and ulcerative colitis, with particular attention on non-invasive endoscopic techniques, such as wireless capsule endoscopy. We will also analyze the most commonly used endoscopic scoring systems, including small bowel scoring systems and endoscopic recurrence grading of neo-terminal ileum CD. Moreover, we will focus on the endoscopic management of complications, such as strictures, that commonly require surgery. Lastly, we will discuss cancer surveillance in children with IBD, with particular consideration of the role of high-definition endoscopic equipment and chromoendoscopy in dysplasia detection rates.

The lack of clear definition and classification for "moderate ulcerative colitis (UC)" creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

The management of inflammatory bowel disease has seen significant advancements with the introduction of endoscopic examinations, allowing for diagnosis, assessment of inflammation severity, and monitoring of treatment response. The frequency of follow-up endoscopies is personalized based on the factors such as the disease course and treatment response. Endoscopic findings should be well described, and biopsies should be acquired in a thoughtful, protocolized manner. While endoscopy is essential, it has certain limitations. It can be invasive, cause discomfort and associated with possible complications.

There are several available endoscopic scoring systems that are designed to assess disease activity in inflammatory bowel disease. The most widely known is the Mayo endoscopic subscore for ulcerative colitis. These schemas are not routinely used in clinical practice, largely due to their complexity or lack of granularity, although they are standard for outcomes measurement in large clinical trials. While some schemas have been validated using independent cohorts, there is high inherent interobserver variation. Furthermore, derivation of these scoring systems has been subject to selection bias and limited challenge bias.

We aimed to investigate the characteristics of pediatric ulcerative colitis (UC) at diagnosis in Korea.

This was a multicenter, registry-based, inception cohort study conducted in Korea between 2021 and 2023. Children and adolescents newly diagnosed with UC < 18 years were included. Baseline clinicodemographics, results from laboratory, endoscopic exams, and Paris classification factors were collected, and associations between factors at diagnosis were investigated.

A total 205 patients with UC were included. Male-to-female ratio was 1.59:1, and the median age at diagnosis was 14.7 years (interquartile range 11.9-16.2). Disease extent of E1 comprised 12.2% (25/205), E2 24.9% (51/205), E3 11.2% (23/205), and E4 51.7% (106/205) of the patients. S1 comprised 13.7% (28/205) of the patients. The proportion of patients with a disease severity of S1 was significantly higher in patients with E4 compared to the other groups (E1: 0% vs. E2: 2% vs. E3: 0% vs. E4: 24.5%, P < 0.001). Significant differences between disease extent groups were also observed in Pediatric Ulcerative Colitis Activity Index (median 25 vs. 35 vs. 40 vs. 45, respectively, P < 0.001), hemoglobin (median 13.5 vs. 13.2 vs. 11.6 vs. 11.4 g/dL, respectively, P < 0.001), platelet count (median 301 vs. 324 vs. 372 vs. 377 × 10³/μL, respectively, P = 0.001), C-reactive protein (median 0.05 vs. 0.10 vs. 0.17 vs. 0.38 mg/dL, respectively, P < 0.001), and Ulcerative Colitis Endoscopic Index of Severity (median 4 vs. 4 vs. 4 vs. 5, respectively, P = 0.006). No significant differences were observed in factors between groups divided according to sex and diagnosis age.

This study represents the largest multicenter pediatric inflammatory bowel disease cohort in Korea. Disease severity was associated with disease extent in pediatric patients with UC at diagnosis.

Clinical Research Information Service Identifier: KCT0008723.

Interventional clinical trials in acute severe ulcerative colitis (ASUC) are characterized by substantial heterogeneity due to a lack of consensus in several key areas of trial design-this impedes clinical research efforts to identify novel therapies. The objective of this initiative was to achieve the first consensus and provide clear position statements on ASUC trial design.

A modified Delphi consensus approach was employed with a panel of 20 clinicians with international representation and expertise in ASUC trial design and delivery. Agreement was defined as at least 75% of participants voting as "agree" with each statement.

In total, 30 statements achieved consensus and were approved. Statements centred on proposing suitable eligibility criteria (disease extent, disease severity, prior therapy exposure), optimizing trial design (randomization, stratification, corticosteroid handling, timing of assessments), and recommending primary and secondary endpoints alongside defining key efficacy outcomes (clinical and endoscopic response and remission, treatment failure, quality of life).

The expansion of drugs to treat moderate-severe ulcerative colitis over the past decade, particularly the rapidly acting Janus kinase inhibitors, is promising and has reignited the interest in identifying suitable therapeutic candidates for ASUC. Clinical trials in this high-risk population are challenging to conduct and this consensus provides a framework for future trials to advance drug development.

Acute severe ulcerative colitis is a medical emergency requiring inpatient treatment with intravenous steroids. Approximately one-third of patients do not respond to steroids sufficiently and require medical rescue therapy. Infliximab and cyclosporine are equally effective rescue agents, though infliximab is often preferred by clinicians for ease of use and greater familiarity. The use of cyclosporine is becoming more frequent, however, in patients previously exposed to infliximab. Those patients not exhibiting an adequate response to rescue therapy require colectomy. There is increasing interest in modified medical treatment to rescue the need for surgery. Janus kinase inhibitors may provide benefits when used alongside steroids from admission or as a rescue agent, but further randomised trials are needed to clearly establish their role. Intensified dosing of infliximab when used as a rescue therapy has shown mixed results but seems sensible in patients with low albumin and high disease burden. In this review, we describe the current established treatment pathways and report newer developments and evolving concepts that may in the future improve the care of patients with acute severe ulcerative colitis.

Inflammatory bowel disease (IBD) is a global disease that is evolving with increasing incidence. However, there are few works on computationally assisted diagnosis of IBD based on pathological images. Therefore, based on the UK and Chinese IBD diagnostic guidelines, our study established an artificial intelligence-assisted diagnostic system for histologic grading of inflammatory activity in ulcerative colitis (UC).

We proposed an efficient deep-learning (DL) method for grading inflammatory activity in whole-slide images (WSIs) of UC pathology. Our model was constructed using 603 UC WSIs from Nanjing Drum Tower Hospital for model train set and internal test set. We collected 212 UC WSIs from Zhujiang Hospital as an external test set. Initially, the pre-trained ResNet50 model on the ImageNet dataset was employed to extract image patch features from UC patients. Subsequently, a multi-instance learning (MIL) approach with embedded self-attention was utilized to aggregate tissue image patch features, representing the entire WSI. Finally, the model was trained based on the aggregated features and WSI annotations provided by senior gastrointestinal pathologists to predict the level of inflammatory activity in UC WSIs.

In the task of distinguishing the presence or absence of inflammatory activity, the Area Under Curve (AUC) value in the internal test set is 0.863 (95% confidence interval [CI] 0.829, 0.898), with a sensitivity of 0.913 (95% [CI] 0.866, 0.961), and specificity of 0.816 (95% [CI] 0.771, 0.861). The AUC in the external test set is 0.947 (95% confidence interval [CI] 0.939, 0.955), with a sensitivity of 0.889 (905% [CI] 0.837, 0.940), and specificity of 0.858 (95% [CI] 0.777, 0.939). For distinguishing different levels of inflammatory activity in UC, the average Macro-AUC in the internal test set and the external test set are 0.827 (95% [CI] 0.803, 0.850) and 0.908 (95% [CI] 0.882, 0.935). the average Micro-AUC in the internal test set and the external test set are 0.816 (95% [CI] 0.792, 0.840) and 0.898 (95% [CI] 0.869, 0.926).

Comparative analysis with diagnoses made by pathologists at different expertise levels revealed that the algorithm reached a proficiency comparable to the pathologist with 5 years of experience. Furthermore, our algorithm performed superior to other MIL algorithms.

Ustekinumab (UST) is an anti-interleukin-12/23 antibody used in the treatment of inflammatory bowel disease. This study includes patients treated at four hospitals in Stockholm to provide long-term real-world data.

Retrospective study including patients diagnosed with ulcerative colitis and treated with UST between the years 2019 and 2021. Patients were followed until withdrawal of treatment, or until a predefined end of study, 31 July 2021. Disease activity was assessed with Physician Global Assessment (PGA); Ulcerative Colitis Endoscopic Index of Severity (UCEIS), laboratory parameters, and drug persistence. The primary outcome was steroid-free remission (PGA = 0) and response (decrease PGA ≥ 1 from baseline) at 3 and 12 months, respectively.

A total of 96 patients, 44 women and 52 men were included. The patients had either extensive colitis (69%), left-sided colitis (29%), or proctitis (3%). All but two patients were anti-TNF-experienced; 94 (98%) had failed ≥1, 59 (61%) ≥ 2, and 34 (35%) had failed ≥ 3 anti-TNF drugs. In addition, 28 (29%) had failed vedolizumab. At inclusion, 92/96 patients (96%) had active disease and four patients were in remission. Among patients who were treated with UST, 9/71 (13%) were in steroid-free remission at 3 months, and 26/33 (78%) were at 12 months. Withdrawal rates at 3 and 12 months, were 12 and 26%, respectively, mainly due to persisting disease activity (20%).

In this group of patients with difficult-to-treat ulcerative colitis, UST was shown to be effective in the majority, with high drug persistence at 12 months in combination with a favorable safety profile.

Proctitis refers to inflammation in the rectum and may result in rectal bleeding, discharge, urgency, tenesmus, and lower abdominal pain. It is a common presentation, particularly in genitourinary medicine and gastroenterology, as the two most common causes are sexually transmitted infections and inflammatory bowel disease. The incidence of infective proctitis is rising, particularly amongst high-risk groups, including men who have sex with men, those with HIV seropositive status, and those participating in high-risk sexual behaviours. The most commonly isolated organisms are Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema palladium, herpes simplex virus, and Mycoplasma genitalium. Recently, proctitis was also identified as a common feature during the Mpox outbreak. Distinguishing infective proctitis from inflammatory bowel disease remains a significant clinical challenge as there is significant overlap in the clinical presentation and their endoscopic and histological features. This review compares and highlights the distinguishing hallmarks of both inflammatory and infective causes of proctitis. It provides a practical guide to describe the key features that clinicians should focus on in both clinical and key diagnostic investigations to avoid potential misdiagnosis.

Intestinal ultrasound (IUS) is an emerging modality in monitoring disease activity in ulcerative colitis (UC). Here, we aimed to identify early IUS predictors of treatment response as evaluated by endoscopy and assessed the kinetics of IUS changes.

This prospective, longitudinal study included UC patients with endoscopic disease activity (endoscopic Mayo score [EMS] ≥2) starting anti-inflammatory treatment. Clinical scores, biochemical parameters and IUS were assessed at baseline (W0), at week 2 (W2), at W6(W6), and at the time of second endoscopy (W8-W26). Per colonic segment, endoscopic remission (EMS = 0), improvement (EMS ≤1), response (decrease in EMS ≥1), and clinical remission (Lichtiger score ≤3) were assessed and correlated with common IUS parameters. Additionally, drug-specific responsiveness of bowel wall thickness (BWT) was assessed.

A total of 51 patients were included and followed, and 33 patients underwent second endoscopy. BWT was lower from W6 onward for patients reaching endoscopic improvement (3.0 ± 1.2 mm vs 4.1 ± 1.3 mm; P = .026), remission (2.5 ± 1.2 mm vs 4.1 ± 1.1 mm; P = .002), and clinical remission (3.01 ± 1.34 mm vs 3.85 ± 1.20 mm; P = .035). Decrease in BWT was more pronounced in endoscopic responders (-40 ± 25% vs -4 ± 28%; P = .001) at W8 to W26. At W6, BWT ≤3.0 mm (odds ratio [OR], 25.13; 95% confidence interval, 2.01-3.14; P = .012) and color Doppler signal (OR, 0.35; 95% confidence interval, 0.14-0.88; P = .026) predicted endoscopic remission and improvement, respectively. Submucosal layer thickness at W6 predicted endoscopic remission (OR, 0.09; P = .018) and improvement (OR, 0.14; P = .02). Furthermore, BWT decreased significantly at W2 for infliximab and tofacitinib and at W6 for vedolizumab.

BWT and color Doppler signal predicted endoscopic targets already after 6 weeks of treatment and response was drug specific. IUS allows close monitoring of treatment in UC and is a surrogate marker of endoscopy.