Exabis Library

Endoscopy plays an essential role in the diagnosis, management, prognosis, and surveillance of inflammatory bowel disease (IBD), but surprisingly there are few available guidelines.1,2 This prompted the ECCO Guidelines Committee (GuiCom) members to promote a Consensus on the appropriate indication and application of different endoscopic modalities in IBD. Since the development of guidelines is an expensive and time-consuming process, this Consensus may help to avoid duplication of effort in the future. It may also identify issues where the evidence is lacking and controlled studies are awaited.

Educational objective:

-        To analyse Th17 plasticity in T-cell transfer colitis mouse model, and correlate this with the microbiota composition.

-        To understand whether antibiotics affect Th17 plasticity through microbiota-dependent processes.

Summary. During Inflammatory Bowel Disease (IBD), CD4+ effector T cells are main mediators of the tissue damage. Among them, Th17 cells strongly contribute to the inflammatory response. Interestingly, our lab previously showed that Th17 cells can convert into regulatory T cells, thereby controlling inflammation. However, the forces controlling the plasticity of T cells during IBD remain largely unknown. Our aim is to understand, how CD4+ T-cell plasticity can be modulated from a pro-inflammatory towards an anti-inflammatory profile during IBD. In this regard, both Th17 and Foxp3 regulatory T cells can recognize microbiota-antigens. Moreover, changes in the microbiota are commonly observed in IBD. Therefore, we hypothesize that the microbiota might be a key candidate to modulate T-cell plasticity. To address our goal, T-cell transfer mouse IBD model was performed by transferring CD4+ naïve T-cells into Rag1-/- mice. To study Th17 T-cell plasticity, we used as donors IL-17A Fate-mapping mice. Ciprofloxacin and metronidazole, antibiotics commonly given to IBD patients, were used to treat the mice. After T-cell transfer colitis induction, ciprofloxacin and metronidazole treatment ameliorated gut inflammation. In line with this, we observed a relative expansion of bacteria previously associated with beneficial IBD outcomes (e.g. Bifidobacterium). More interestingly, colon CD4+ T-cells showed an increased conversion from Th17 towards a Foxp3+ Treg profile (Foxp3ExTh17)(p=0.03).

Summary:

This presentation summarises the second ECCO Guideline on Malignancy in IBD. The guideline includes 24 statements, each underpinned by a systematic review of the literature. The topics covered include risk of cancer in IBD, malignancy risk associated with small molecule and biological therapies, and management of IBD in patients with a history of cancer.

Of course, this is too much to cover in a single presentation. As such, we will focus on the key developments since our previous guidance, as outlined below. 

Educational objectives:

1) To recap prevention of colorectal cancer in IBD, with a focus on  
- colorectal cancer screening and surveillance  
- detection and management of dysplasia in IBD
2) To review IBD therapy and associated cancer risk 
3) To understand how best to approach managing IBD in patients with active or recent malignancy 

Educational objectives
- To introduce the updated ECCO guidelines on IBD and malignancy
- To highlight the latest evidence on colonoscopy surveillance in IBD
- To discuss the malignancy risk of specific therapies in IBD
- To discuss the management of patients with IBD and active malignancies

Education objectives
1. To present the updated ECCO consensus on Sexuality, Fertility, Pregnancy and Lacation
2. To discuss pregnancy and IBD
3. To review safety of drugs during pregnancy and lactation in IBD

New ECCO pregnancy guideline
1. Pre conception counseling, optimal disease control, planning, adherence
2. Drug safety at conception and during pregnancy
3. Management of disease exacerbation during pregnancy, assessment and therapeutic options
4. Management of biologics during pregnancy and post-partum
5. Multidisciplinary decision concerning through the entire pregnancy and important decision like mode of delivery

1. to present the new ECCO guidelines on therapeutic in ulcerative colitis
2. to present for acute severe ulcerative colitis, both medical and surgical management
3. to discuss Medical Versus Surgical Management of Refractory Moderate-to-severe UC
4. to give an overview on Preoperative Optimisation of Refractory Moderate-to-severe UC
5. to discuss Surgical Strategy and technical surgical aspects of Refractory Moderate-to-severe UC

Educational objectives
- To discuss the new ECCO guidelines on ulcerative colitis
- To consider the role of GRADE methodology in driving guideline quality
- To highlight relevant sections of the medical and surgical guidelines that may inform practice

The presentation will provide an update on the recently updated ECCO guideline on the prevention, diagnosis and management of infections in IBD

Introduction: One of the founding core activities of the European Crohn’s and Colitis Organisation [ECCO] is to educate gastroenterologists interested in inflammatory bowel disease [IBD]. The first ECCO Course on IBD for Junior Gastroenterologists was held in 2003, and will be held for the 15th time at the ECCO Congress 2017 in Barcelona. The first ECCO Educational Workshop took place in 2007, and since then 55 workshops have been organised in 40 countries around the globe, using the statements created in the ECCO evidence-based consensus processes as teaching material [for example the ECCO Crohn’s disease consensus1]. Finally, in 2013 ECCO launched e-CCO, the online learning platform with a mission to improve the care of patients with IBD in all its aspects by providing a comprehensive package of education for all health care professionals interested in IBD. The current e-CCO e-learning portfolio comprises 18 extensive e-courses based on the ECCO guidelines, and close to 40 original videos on basic IBD topics and current controversies in the treatment of IBD. The e-library is made up of presentations [on slides and on video] from the ECCO congresses, created and delivered by some of the foremost experts in IBD. With the increasing incidence of IBD in Europe and a growing interest in our activities, ECCO has decided to create the ECCO IBD Curriculum to serve as a backbone for its educational efforts, and also as a guide for interested gastroenterologists.

A European IBD Voyage

Séverine Vermeire

University Hospital Leuven Belgium

 Ever since the early foundations of ECCO, groundbreaking discoveries in IBD have significantly impacted on how we look at the disease and approach IBD in the clinic today. Many of these discoveries not only had their origin in Europe but also laid the foundations for collaboration across and beyond our continent. The parallel expansion and diversification of ECCO embraced these discoveries, and facilitated further growth towards improvements for patients and patient care.

One early landmark discovery was the familial aggregation and increased disease concordance  among monozygotic twins, observations first described in Scandinavian cohorts but later confirmed by many, and pointed towards a strong genetic susceptibility. Soon, the first genome-wide linkage and later association scans were a fact and the international IBD Genetics Consortium, born in Oxford, UK was the start of almost 25 years of collaborative research culminating in the discovery of the NOD2/CARD15 gene in 2001 and many other important findings such as the role of autophagy  and innate immunity. Another groundbreaking discovery originally described by teams from London, UK and Hannover, Germany, was the recognition of monogenetic Very Early Onset (VEO) IBD. The VEO-IBD Consortium now has global participation and provides guidelines for the work up and management of these complex patients. VEO-IBD research has been pivotal in unravelling disease pathways such as general immune dysregulation, T and B cell defects, phagocytic defects, hyper- and auto-inflammatory conditions and  epithelial barrier dysfunction.

Incidence trends of disease across Europe from North to South were put on the map by the EC-IBD study group and were later expanded from West to East by the EpiCom collaborative study Group which ECCO fostered. Till today, these epidemiological trends are crucial to help in deciphering disease pathogenesis and the role of the exposome.

Collaboration between the gastroenterology, abdominal surgery and pathology departments in Leuven, Belgium in the late eighties and nineties on postoperative Crohn’s recurrence showed the importance of faecal stream diversion and antibiotics in preventing postoperative relapse. This in turn triggered interest in the role of the microbiome with pioneer studies from Berlin, Germany and in antimicrobial serology such as ASCA in the early stages of disease; research which took off in Lille, France and rapidly spread globally. In later years the role of the mesenteric fat in disease pathogenesis was recognized and closer collaboration between surgeons and IBD pathologists within ECCO was born. Till today, no effective postoperative prevention exists but new research tools including  single cell and spatial transcriptomics and metabolomics bring hope.

European groups such as the French GETAID, the Leuven, Barcelona and Nancy IBD Centers have pioneered clinical research  in development of endoscopic, radiologic and histologic scores for disease severity such as the CDEIS, SES-CD, Rutgeerts score, Maria and Nancy index. Almost 30 years later, new technologies such as machine learning and Artificial Intelligence are paving the way for a more accurate  disease classification, and molecular methods have started to create a dream that disease clearance may become reality soon.

1. To understand the role of head to head trials in positioning therapies

2. To be familiar with the large pipeline of new agents for IBD including the late stage products focused on JAK inhibition, anti-p19 (interleukin 23) antibodies, and S1P modulators

3. To be familiar with the multiple agents targeting gut delivery that in early stage development

4. To be familiar with the evolving role of precision medicine and artificial intelligence in the care of IBD patients

5. To be familiar with novel clinical trial approaches are increasingly being employed in IBD including adaptive design, umbrella trials, basket trials, and platform trials

Introduction: Biosimilars of infliximab were first approved by the European Medicine Agency in 2013, based on pre-clinical studies on biosimilarity and on clinical data coming from two randomised controlled trials conducted in rheumatoid arthritis [RA] and ankylosing spondylitis [AS]. Initially the European Crohn’s Colitis Organisation [ECCO] raised some caution on the use of biosimilars.5 This cautious approach was also supported by several national inflammatory bowel disease [IBD] societies5–12 [Table 1]. An insufficient understanding of the characteristics and use of biosimilars became evident in a web survey among ECCO members in the same period.

Biologics have become key agents for the management of Crohn’s disease and ulcerative colitis. Biosimilars are biological medicines similar to previously authorized biologics and are already available in some countries. This ECCO Position Statement defines the collective view of European specialist in inflammatory bowel disease (IBD) concerning biosimilars. Biosimilars are not comparable to generic small molecules, since both efficacy and toxicity are difficult to predict due to subtle molecular changes that can have profound effects on clinical efficacy and immunogenicity. Direct evidence of safety and benefit from clinical trials in IBD, post-marketing pharmacoviligance, and unequivocal identification of the product as a biosimilar should be requirements before approval. Switching from an established biologic to a biosimilar to save costs is likely to be as inappropriate and inefecctive as switching between current biologics that act on the same target, except when there is loss of response.