You might be interested in…Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a condition impacting various body systems including musculoskeletal, ocular, skin, hepatobiliary, pulmonary, cardiac, and haematological systems. The extraintestinal manifestations of IBD are frequent, common in both ulcerative colitis (UC) and Crohn’s disease (CD) and impact the morbidity and mortality of patients.

This systematic review and meta-analysis review paper1 considers the topic in detail. The findings were that the prevalence of at least one joint, ocular, or skin extraintestinal manifestation in all IBD, UC, and CD was 24 per cent, 27 per cent, and 35 per cent respectively. The prevalence between UC and CD were similar for pyoderma gangrenosum and axial joint manifestations. Ocular manifestations were found to be more common in CD than in UC.

Dr Ray O’Connor

Peripheral joint manifestations and erythema nodosum were found to be more common in CD than UC. These findings are stark in that they highlight how common these important and potentially serious conditions are in patients living with IBD.

Paediatric-onset IBD is a complex and heterogenous condition. Incidence of disease in those aged <18 years has doubled over the last 25 years, with concurrent increased prevalence and no decrease in disease severity. This review2 highlights recent clinical developments in paediatric IBD. The tools available at diagnosis for investigation have developed over the last 10 years, including better utilisation of faecal calprotectin, improved small bowel imaging and video capsule endoscopy.

Alongside this, management options have increased and include biological and small molecule therapies targeting alternative pathways (such as interleukin 12/23, integrins and Janus kinase/signal transducers and activators of transcription, JAK-STAT pathways) and better understanding of therapeutic drug monitoring for more established agents, such as infliximab.

What role is there for diet? Diet is an environmental exposure implicated in the development of IBD. This review3 describes how nutrition therapy for IBD has been shown to reduce intestinal inflammation, promote healing, and alleviate symptoms, as well as improve patients’ nutrition status. Although the mechanisms of action of most nutrition therapies for IBD are not well understood, the diets are theorized to eliminate triggers for gut dysbiosis and mucosal immune dysfunction associated with the typical Western diet.

Exclusive enteral nutrition and the Crohn’s disease exclusion diet are increasingly being used as the primary treatment modality for the induction of remission and/or maintenance therapy in children, and in some adults, with CD. Several other diets, such as the Mediterranean diet, anti-inflammatory diet for IBD, and diets excluding gluten, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), lactose, or other compounds, may be helpful in symptom management in both CD and UC, though evidence for biochemical efficacy is limited.

The role of diet components in IBD pathogenesis is discussed as well as diets currently used in the management of children and adults with IBD.

IBD is increasingly recognised as a continuum of disease, with a proportion of patients presenting with classical Crohn’s disease or ulcerative colitis phenotypes. Nonresponse to biologic agents in patients with inflammatory bowel disease (IBD) poses a significant public health burden, and the prediction of response to biologics offers valuable insights for IBD management.

Given the pivotal role of gut microbiota and their endogenous metabolites in IBD, the authors conducted a systematic review4 to investigate the potential of faecal microbiota and mucosal microbiota and endogenous metabolomic markers as predictors for biotherapy response in IBD patients. This is a complex paper and difficult to read for the non-specialist. The conclusion however is that faecal microbiota and mucosal microbiota as well as their endogenous metabolites could provide a predictive tool for assessing the response of IBD patients to various biological agents and serve as a valuable reference for precise drug selection in clinical IBD patients.

Intestinal ultrasound (IUS) is a non-invasive, accurate, and well-tolerated tool that provides real-time assessment of IBD activity and is therefore an ideal monitoring tool. This review5 describes the evolving role of IUS in each phase of clinical management of IBD.  The authors describe how accumulating evidence has demonstrated that IUS is an excellent tool for the assessment of suspected IBD, with a very high negative predictive value.

It accurately assesses disease activity, disease complications, and in the pre-treatment phase, provides a benchmark for subsequent follow-up. They describe how IUS can detect early therapeutic response and correlates well with other established monitoring modalities with arguably superior predictive capabilities and ability to assess a deeper degree of remission in the form of transmural healing. They conclude that IUS has a crucial role in the management of IBD and has ushered in a new era of monitoring with more rapid evaluation and the opportunity for early optimization, deeper therapeutic targets, and improved outcomes.

References:

1. Kilic Y et al. Prevalence of Extraintestinal Manifestations in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis. 2024 Feb 1;30(2):230-239. doi: 10.1093/ibd/izad061.
2. Ashton J et al. Inflammatory bowel disease: recent developments. Arch Dis Child 2024;109:370–376. doi:10.1136/archdischild-2023-325668.
3. Deas J et al. Dietary therapies for adult and pediatric inflammatory bowel disease. Nutr Clin Pract. 2024 Jun;39(3):530-545. doi: 10.1002/ncp.11146. Epub 2024 Mar 20.
4. Wang C et al. Gut microbiota and metabolites as predictors of biologics response in inflammatory bowel disease: A comprehensive systematic review. Microbiological Research 282 (2024) 127660 https://doi.org/10.1016/j.micres.2024.127660
5. Cleveland N et al. Clinical Application of Intestinal Ultrasound in Inflammatory Bowel Disease. Curr Gastroenterol Rep. 2024 February ; 26(2): 31–40. doi:10.1007/s11894-024-00915-x.