Exabis Library

This course has been developed for gastroenterologists, surgeons, paediatricians, pathologists and other interdisciplinary medical experts interested in Inflammatory Bowel Disease(s) (IBD). One major aim of this e-learning activity is to increase competence and knowledge with regard to the diagnosis and management management of IBD patients.

After this case you will:

• Be able to identify the ideal diagnostic technique in various situations
• Be acquainted with several diagnostic options that can be used as guidance for clinical practice

Crohn Disease (CD) prevalence is rising worldwide. As altered genetics are improbable, this phenomenon likely relates to environmental-dietary changes linked with gut microbiome. We aimed to define host and microbial factors at CD diagnosis.

Multiomics analyses ofSOURCE cohort including clinical, biomarkers (CRP, fecal calprotectin), food frequency questionnaire (FFQ), serum metabolomics, mucosal terminal ileum (TI) transcriptomics, and fecal and mucosal biopsy samples for 16S microbial amplicon sequencing.

25 newly-diagnosed CD and 33 controls (median age 28 years, 50% males). Gender, age, and BMI did not differ between groups, but CRP (p=0.001) and calprotectin (p=E-10) were significantly higher in CD. FFQ results showed that compared to controls, pre-diagnosis CD patients consumed significantly more added sugar (g/day), starch (g/day) nitrite (mg/day), and significantly less vitamin K, D, vegetables, and olive oil (Fig 1). Microbial analyses highlighted significant differences (FDR<0.1) in amplicon sequence variants (ASVs) abundance between stool and biopsies samples (73 ASVs) and between CD and Controls samples (82 ASVs). Biopsy vs. stool samples were enriched for Veillonella, Fusobacterium, Neisseria, and Ruminococcus gnavus. CD showed higher abundance of Enterobacteriaceae and Ruminococcus gnavus with reduction of several Ruminococcaceae and Lachnospiraceae taxa (Fig. 1). Ileal transcriptomics differential expression (FC>1.5, FDR<0.05) replicated previous results with significant induction in CD of DUOX2, CXCL9, and DEFB4A and pathways linked to innate and adaptive immunity, and to extracellular matrix. CD down regulated genes included GUCA2B, SLC10A2, and GSTA1, and pathways linked with epithelial transporters. Serum metabolomics highlighted significant variations (FDR<0.25) in  Linoleic acid, aKG, Tryptophan, nicotinamide, Docosahexaenoic acid, oxalate, and GABA between CD and controls. We next tested for significant association (FDR<0.25) between diet and multi-OMICs (Fig. 2). Associations between gut microbiome and TI transcriptomics, and serum metabolomics showed that Erysipelotrichacea taxa positivity correlated with serum oxalate, and TI expression of CEACAM6 and DUOX2. Associations between diet and TI transcriptomics and serum metabolomics indicated that B12, tryptophan and riboflavin consumptions were negatively associated with the bile acid transporter SLC10A2 in the TI, and vegetables consumption was positively associated with oxalate degrading Oxalobacter.

Conclusions: FFQ identifies difference in diet at the onset of CD that may contribute to pathogenesis. Integration between dietary and OMICs layers disclosed novel correlations warranting further exploration.

Objectives:
1. To understand the role of the IBD dietitian in the MDT 
2. To review the current dietary approaches for IBD management
3. To discuss whether diet can be used as a prevention strategy

An expert panel of the European Crohn's and Colitis Organisation (ECCO) and European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) initiated a consensus process to produce the first pediatric specific ulcerative colitis (UC) guidelines based on a systematic literature review. Treatment strategies must reflect that pediatric-onset UC has a slightly different phenotype than adult-onset disease with more often extensive (pancolitis) and more aggressive disease course. Other pediatric-specific aspects include growth, puberty, bone density accrual and emotional development and body image acquisition. These differences and others influenced the development of pediatric treatment algorithms. It is recommended that virtually all children with UC must be treated with some maintenance therapy and 5-ASA requirement and dosing are often higher in children. A larger number of children are at risk for steroid-dependency, and this should not be tolerated; steroid sparing strategies with early use of immunosuppressors are recommended in high-risk patients. On the other hand, the safety profile of immunosuppressive therapy in children includes the rare forms of lymphomas and many future treatment years. Colectomy and pouch formation should be balanced in the treatment algorithms against the higher rate of future infertility in girls. The acute and on-going management of pediatric UC should be guided by evidence- and consensus-based balanced decisions, reflecting a vision of long-term treatment goals.

Understand whether upper GI pathology is found in UC, and byanswering the following questions:

1.      Do patients with ulcerative colitis have lesions in the upper GI tract?
2.     Are there lesions in the upper GI tract that are unique to ulcerative colitis? 
3.    If upper GI UC exist, are there any predisposing factors?
4.    Is it possible to use upper GI biopsies in patients with colitis, to distinguish UC from Crohn’s disease (CD)?

Inflammatory bowel disease specimens have specific features which, in general, differ between Ulcerative Colitis and Crohn's disease.
The typical characteristics of UC are diffuse mucosal alteration and a regular bowel wall, whereas CD specimens usually show thickening of the bowel wall, visceral adhesions and mucosal skip lesion. 
It is important to identify and recognise these features in order to section the surgical organs correctly. For this reason, there are recommendations for the cut up of IBD specimens. 

Educational objectives:
- To learn how to approach an IBD specimen
- To understand the macroscopic differences between UC and CD specimens
- To learn how to dissect an IBD specimen and why
- To understand the importance of cut up in IBD pathology

Artificial Intelligence and Digital Pathology are rapidly growing disciplines that have the potential to revolutionise the field of inflammatory bowel disease. ML and DL approaches offer the ability to synthesise and incorporate large amounts of data to improve diagnostic accuracy, uncover new disease associations, identify at risk individuals, and guide therapeutic decision making. While challenges to the routine use of DP and AI in IBD remain, continued exploration of possible applications are expected to accelerate the drive toward precision medicine.
-To understand basic principles of Digital Pathology and Artificial Intelligence.
-To review pros and cons of DP and AI.
-To have an overview of DP and AI in IBD pathology.

1. To define the appropriate timing between medical and surgical management of IBD
2. To review medical and surgical treatment indications of the complications of IBD  
3. To learn how to decide in multidisciplinary team between the two modalities of treatment 

Discussion of presented topics as a chair of the complete session

Discussion of Tailored medical therapy in UC and the surgical approach.