Exabis Library

-          To review the frequency and type of pancreatic manifestations in IBD

-          To have an overview of the morphological features of chronic and autoimmune pancreatitis

-          To emphasise the role of histopathology in the diagnosis of pancreatic manifestations in IBD

Pancreatic changes are present in up to 50% of IBD patients, but symptomatic disease is rare and mostly related to acute pancreatitis, chronic pancreatitis or autoimmune pancreatitis.

Acute pancreatitis in patients with IBD is usually related to gallstones or drugs (thiopurines, mesalamine) and is more common in Crohn’s disease (CD) than in ulcerative colitis (UC).

Chronic pancreatitis is quite rare and thought to be idiopathic or possibly related to obstruction, e.g. in patients with primary sclerosing cholangitis. There is no possibility to specifically diagnose IBD-associated chronic pancreatitis, and diagnosis is usually one of exclusion.

Autoimmune pancreatitis (AIP) is more frequent in IBD patients than in the general population, but it remains a rare disease. IBD, and especially UC, are most frequently associated with type 2 (= non IgG4-related) AIP and this association is characterized by an active and more aggressive disease with higher rates of colectomies. There are definite histopathologic criteria for the diagnosis of AIP, which can be successfully applied on biopsy material. Therefore, if AIP is suspected in IBD patients, a pancreatic biopsy can be useful to confirm the diagnosis and direct therapy.

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Educational objectives:

• To discuss the therapeutic options for paediatric patients with inflammatory bowel disease (IBD) refractory to standard medical therapy
• To review the current evidence for segmental resection for patients with Crohn’s disease (CD)
• To review the evidence for “out of the box” treatments such as tacrolimus for both diseases, thalidomide for CD, granulocyte- monocyte apheresis, fecal microbial transplantation, mesenchymal stromal or adipose cell therapy for refractory perianal fistulas, dual biologics and autologous hematopoietic stem cell transplant.

Presentation outline:

When patients with IBD fail standard medical therapies there are limited therapeutic options. The first step should be to optimize biologic therapy (based on therapeutic drug monitoring in anti-TNF treated patients or empiric escalation in patients treated with vedolizumab or ustekinumab). Tofacitinib should be considered for patients with ulcerative colitis (UC).

Surgical resection has an established benefit in segmental CD even in the colon.

The edition of nutritional therapy as a combination treatment with biologics may be considered for selected cases.

Tacrolimus was shown efficacious in UC and may serve as a bridge to other therapies such as vedolizumab or even in combination at low doses with vedolizumab.

Thalidomide was studies in CD but treatment is limited by adverse events in high rate and rarely sustainable.

Granulocyte- monocyte apheresis has a limited effect (mainly in UC). Fecal microbial transplantation has emerged a promising treatment with negligible side effects. However, studies using different techniques have yielded limited short-term benefit only.

Autologous hematopoietic stem cell transplant is regarded as a “last resort” option for patients with refractory CD but was studied so far only in adults with promising results though carrying a very high rate of adverse events.

Finally, in the last 2-3 years evidence accumulate on combination of different biologics. Though expensive, such combination may provide relief in refractory cases but more research is needed.

Direct health care costs have shifted towards drug-related expenditures in patients with inflammatory bowel disease (IBD). Frequently, patients will have to switch to a second- or third-line biological therapy due to no response or loss of response. The aim of this study was to describe the use and efficacy of biological therapy in a tertiary centre during a 10-year period and investigate the need for surgery.

The study population consisted of all bio-naïve IBD patients who initiated biological therapy between January 1, 2010 and February 19, 2020 at the Gastro unit, Hvidovre Hospital, Denmark. The electronic medical records were reviewed, and data were systematically registered. Failure of the biological therapy as no response and loss of response was defined by the need for surgery, steroid or shift in biological therapy.

The study population consisted of 291 (46.9%) patients with ulcerative colitis (UC), 327 (52.7%) with Crohn’s disease (CD) and 3 with (0.5%) IBD Unclassified (IBDU), who initiated biological therapy with a median follow-up of 3 (IQR=2-5) years from initiation of therapy. The annual number of patients who initiated biological therapy was increasing throughout the study period.

Most patients (457, 73.6%) received one biological drug, 126 (20.3%) received two, and 38 (6.1%) received three or more different types of biological drugs during the study period. Systemic steroid was required in 99 patients (15.9%) and the 5-year surgery-free survival was 76.5% (120 patients with surgery). 302 patients (54.3%) had effect of the first biological therapy at one year follow-up.

In multivariate Cox-regression analyses, concurrent treatment with thiopurines decreased the risk of failure of the first biological therapy in UC patients (hazard ratio (HR) 0.745, 95% CI: 0.559-0.992) but not in CD patients (HR 0.969, 95% CI: 0.722-1.300). Male gender decreased the risk of failure (HR: 0.677, 95% CI: 0.505-0.908) while higher age at initiation of biological therapy increased the risk (HR: 1.0152, 95% CI: 1.004-1.027) in CD patients. These factors had no impact in UC patients. Prior surgery, disease duration and location were not associated with increased risk of failure of first biological therapy.

In conclusion, an increasing number of IBD patients received biological therapy during the 10-year period at our tertiary centre. A considerable part of IBD patients in biological therapy will require surgery, additional steroids, or second line biological therapy. Our findings suggest a beneficial role of thiopurine in combination with biological therapy. Improved identification of patients not responding to first line biological therapy is of great importance.

1. To understand the impact of IBD on daily life.
2. To understand the concept of patient-reported outcomes (PRO).
3. To learn how to use the IBD-Disk in clinical practice.
4. To understand the main clinical factors associated with disability in IBD.