Pyoderma gangrenosum (PG) is a rare but challenging extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD), affecting 6–48% of IBD patients. This retrospective study analyzes affected patients and evaluates therapeutic strategies for both IBD remission and PG resolution. A multicenter retrospective analysis was conducted on patients with IBD and PG in 8 tertiary centers in Germany and Austria. Demographic data, prior therapies, surgeries, treatment of PG were collected, and treatment responses assessed. The cohort included 50 patients (median age: 43 years; 68% female). Crohn’s disease (CD) was present in 58%, ulcerative colitis (UC) in 42%. Fifty percent of patients had prior surgery, 68% having an intestinal stoma. 48% were experienced to biologic therapy, predominantly anti-TNF therapy (83%). PG mainly affected the lower extremities (52%) and peristomal areas (24%). Systemic steroids were used in 52% of patients and led to PG resolution in only 12%. Anti-TNF therapy was the main approach, used in 68% of patients, with resolution achieved in 80%. Calcineurin inhibitors were given to 26% of patients and induced resolution in 38%. Three of six non-responders were successfully switched to infliximab. Overall PG resolution was achieved in 80%, correlating with IBD remission in 78%. The median time to PG resolution was five months. Anti-TNF therapy was an effective treatment for PG in IBD patients, even in those with prior non-response to calcineurin inhibitors. Systemic steroids showed low response rates. PG healing mostly aligned with IBD remission, underlining the need for tailored long-term therapy.

PURPOSE:Handheld ultrasound (HHUS) devices are increasingly used in clinical practice due to their portability and cost-effectiveness. However, HHUS image quality remains variable, and a standardized expert-based evaluation protocol is lacking. This study compares the image quality of B-mode recordings of five HHUS models with a high-end reference system (HEUS) using a blinded assessment to identify differences, covariates, offering a standardized evaluation framework. MATERIALS AND METHODS:In this blinded, multi-center study, video sequences of the liver, pancreas, and sigmoid colon were recorded in ten volunteers using five HHUS devices - Vscan Air, Butterfly iQ+, Philips Lumify, Clarius C3, and Clarius C3 HD3 - and one HEUS (GE Logiq E10). 22 physicians with many years of abdominal ultrasound experience rated blinded clips for five image quality parameters. RESULTS:The HEUS consistently received the highest ratings. Image quality differed significantly between HHUS devices. Clarius systems showed the smallest deviation from the reference, followed by Vscan Air and Philips Lumify. All image parameters significantly correlated with the overall impression, without a single dominant factor. The patients´ BMI had no relevant influence. Examiner experience was less impactful than device familiarity and personal preference. CONCLUSION:The image quality of HEUS remained superior to all tested HHUS devices. Further subdivision of image quality aspects did not provide additional information. Furthermore, we could not identify significant covariates in our setup. These findings could justify simplified setups with reduced questionnaires and requirements for examiners. Zielsetzung: Portable Ultraschallsysteme (HHUS) finden aufgrund ihrer Mobilität und Kosteneffizienz zunehmend Anwendung in der Praxis. Ihre Bildqualität ist jedoch variabel und ein standardisiertes, expertenbasiertes Bewertungsprotokoll fehlt bislang. Ziel dieser Studie ist der Vergleich von fünf HHUS-Modellen gegenüber einem High-End-Referenzsystem (HEUS) in einem verblindeten Design sowie die Analyse relevanter Kovariablen, die zur Entwicklung eines standardisierten Bewertungsverfahrens beitragen können. MATERIAL UND METHODEN:In dieser multizentrischen, verblindeten Studie wurden Videos von Leber, Pankreas und Sigma bei 10 Probanden mit fünf HHUS-Geräten (Vscan Air, Butterfly iQ+, Philips Lumify, Clarius C3 und C3 HD3) sowie einem HEUS (Ge Logiq E10) aufgezeichnet. 22 Experten mit langjähriger Ultraschallerfahrung bewerteten die verblindeten Videos nach verschiedenen Kriterien zur Bildqualität. Ergebnisse: Das HEUS erzielte die besten Bewertungen, die HHUS unterschieden sich signifikant. Clarius-Systeme wichen am wenigsten vom HEUS ab, gefolgt von Vscan Air und Philips Lumify. Alle Bildparameter korrelierten signifikant mit dem Gesamteindruck, ohne dass ein dominanter Parameter identifizierbar war. Der BMI hatte keinen relevanten Einfluss. Die Erfahrung der Gutachter war weniger entscheidend als Gerätevertrautheit und persönliche Präferenz. Schlussfolgerung: Die Bildqualität des HEUS war allen getesteten HHUS überlegen. Eine weitere Unterteilung in einzelne Aspekte der Bildqualität lieferte keine zusätzlichen Informationen. Es wurden keine relevanten Kovariablen identifiziert, was für die Etablierung vereinfachter Bewertungsprotokolle mit reduzierten Fragebögen spricht.

Pyoderma gangrenosum (PG) is a rare but challenging extraintestinal manifestation (EIM) of inflammatory bowel diseases (IBD), affecting 6%–48% of IBD patients. This retrospective study analyzed affected patients and evaluated therapeutic strategies for both IBD remission and PG resolution. A multicenter retrospective analysis was conducted on patients with IBD and PG in eight tertiary IBD centers. Demographic data, prior therapies, surgeries, and treatment of PG were collected retrospectively, and treatment responses were assessed. The cohort included 50 patients (median age: 43 years; 68% female). Crohn’s disease was present in 58% and ulcerative colitis in 42%. Fifty percent of patients had prior surgery, 68% had an intestinal stoma in their medical history. 48% were experienced with biologic therapy, predominantly anti-tumor necrosis factor (TNF) therapy (83%). PG mainly affected the lower extremities (52%) and peristomal areas (24%). Systemic steroids were used in 52% (26/50) and led to PG resolution in only 11.5% (3/26). Anti-TNF therapy was the main approach, used in 68% (34/50) of patients, with resolution achieved in 80% (27/34). Calcineurin inhibitors were given to 26% (13/50) of patients and induced resolution in 38% (5/13). Three of six non-responders were successfully switched to infliximab. Overall, PG resolution was achieved in 80% (40/50), correlating with IBD remission in 78% (31/40) of these patients. The median time to PG resolution was 4 months. Anti-TNF therapy was an effective treatment for PG in IBD patients, even in those with prior nonresponse to calcineurin inhibitors. Systemic steroids showed low response rates. PG healing mostly aligned with IBD remission, underlining the need for tailored long-term therapy.

OBJECTIVE:Perianal fistulas in Crohn's disease (CD) are associated with a high burden of illness and their treatment is challenging. Recent data indicate promising short-term efficacy of bone marrow-derived mesenchymal stromal cell (bmMSC) therapy. The aim of this case series is to gather more information on the long-term effectiveness and safety. METHODS:Between 2013 and 2017, bmMSCs were administered under compassionate use to patients at a university hospital in Germany, as no stem cell therapy was approved at the time. Inclusion criteria were inactive CD (Harvey-Bradshaw Index <5) without proctitis, at least one treatment-refractory perianal fistula (with or without rectovaginal additional fistulas) and prior tumour necrosis factor-alpha inhibitor and/or surgical exposure. After curettage of the fistula tract, patients received repeated intrafistular injections with up to 300 million bmMSCs. We retrospectively analysed patient records to assess disease course, clinical fistula remission and radiological activity using the modified van Assche index. RESULTS:Six female patients with a total of 13 fistulas (9 trans-sphincteric, 2 extrasphincteric and 2 rectovaginal) underwent bmMSC application. Median radiological and clinical long-term follow-up was 80 months (range 44-98 months) after first local bmMSC injection. 8 of 13 fistulas (62%) exhibited complete closure. For rectovaginal fistulas, long-term remission (98 months) was 50% (1 of 2). Pelvic MRI showed a decrease in modified Van Assche index from baseline to long-term follow-up. No immediate adverse events related to bmMSC injections were observed. One patient was diagnosed with a local adenocarcinoma of the rectum 106 months after first bmMSC injection. MRI control 11 months prior showed complete fistula remission. The tumour exhibited a female karyotype, while bmMSC had been derived from a male volunteer. CONCLUSION:In this analysis, 62% of complex perianal and 50% of rectovaginal fistulas showed long-term remission up to 8 years post-bmMSC therapy. Further real-world data are needed.

Purpose Since handheld ultrasound devices are becoming increasingly ubiquitous, objective criteria to determine image quality are needed. We therefore conducted a comparison of objective quality measures and clinical performance. Material and Methods A comparison of handheld devices (Butterfly IQ+, Clarius HD, Clarius HD3, Philips Lumify, GE VScan Air) and workstations (GE Logiq E10, Toshiba Aplio 500) was performed using a phantom. As a comparison, clinical investigations were performed by two experienced ultrasonographers by measuring the resolution of anatomical structures in the liver, pancreas, and intestine in ten subjects. Results Axial full width at half maximum resolution (FWHM) of 100 mu m phantom pins at depths between one and twelve cm ranged from 0.6-1.9mm without correlation to pin depth. Lateral FWHM resolution ranged from 1.3-8.7mm and was positively correlated with depth (r=0.6). Axial and lateral resolution differed between devices (p<0.001) with the lowest median lateral resolution observed in the E10 (5.4mm) and the lowest axial resolution (1.6mm) for the IQ+ device. Although devices showed no significant differences in most clinical applications, ultrasonographers were able to differentiate a median of two additional layers in the wall of the sigmoid colon and one additional structure in segmental portal fields (p<0.05) using cartwheel devices. Conclusion While handheld devices showed superior or similar performance in the phantom and routine measurements, workstations still provided superior clinical imaging and resolution of anatomical substructures, indicating a lack of objective measurements to evaluate clinical ultrasound devices.

Immunogenicity is a major reason for secondary loss of response to infliximab (IFX). Recent work suggested potentially lower immunogenicity of subcutaneous (SC) compared to intravenous (IV) IFX. However, it is unknown whether re-exposure to IFX SC after secondary loss of response and immunogenicity to its intravenous formulation is safe and effective. In a retrospective cohort study conducted at two medical centers, patients with clinically (Harvey-Bradshaw Index ≥ 5) and/or biochemically (fecal calprotectin > 250 µg/g) active Crohn’s disease (CD) and previous immunogenic failure of IFX IV underwent exposure to IFX SC. Harvey-Bradshaw Index, fecal calprotectin, IFX serum concentration, and anti-drug antibodies were assessed until month 12. Twenty CD patients were included. The majority of patients (90

Background and Aims: Postoperative pancreatic leakage and fistulae (POPF) are a leading adverse event after partial pancreatic resection. Treatment algorithms are currently not standardized. Evidence regarding the role of endoscopy is scarce. Methods: One hundred ninety-six POPF patients with (n = 132) and without (n = 64) concomitant pancreatic fluid collections (PFCs) from centers in Berlin, Kiel, and Dresden were analyzed retrospectively. Clinical resolution was used as the primary endpoint of analysis. Results: Analysis was stratified by the presence or absence of a PFC because these patients differed in treatment pathway and the presence of systemic inflammation with a median C-reactive protein of 30.7 mg/dL in patients without a PFC versus 131.0 mg/dL in patients with a PFC (P = 3.4 x 10(-4)). In patients with PFCs, EUS-guided intervention led to resolution in a median of 8 days as compared with 25 days for percutaneous drainage and 248 days for surgery (P = 3.75 x 10(-14)). There was a trend toward a higher success rate of EUS-guided intervention as a primary treatment modality with 85% (P = .034), followed by percutaneous drainage (64%) and surgery (41%). When applied as a rescue intervention (n = 24), EUS led to clinical resolution in 96% of cases. In patients without PFCs, EUS-guided internalization in a novel endoscopic technique led to resolution after a median of 4 days as compared with 51 days for a remaining surgical drainage (P = 9.3 x 10(-9)). Conclusions: In this retrospective analysis, EUS-guided drainage of POPF led to a more rapid resolution. EUS may be considered as a viable option in the management of PFCs and POPF and should be evaluated in prospective studies.

Fig 1.The expression of ZIP7 was downregulated in the intestinal mucosa of Il10 -/- mice (A: control, B: mild disease, C: severe disease; a, b, c is magnification of A, B, C respectively), which was associated with disease activity (D, E).Fig 2. ZIP7 induces leakier intestinal barrier (A, B), which was associated with activation of SHANK3-PKCe-dependent pathway in IBD (C, D).

BACKGROUND & AIMS:Little is known about the effects of endoscopic balloon dilation (EBD) for strictures of the upper gastrointestinal (UGI) tract in patients with Crohn's disease (CD). We performed a pooled analysis of the efficacy and safety of EBD for UGI CD-associated strictures. METHODS:We searched Embase, Medline, and the Cochrane library, as well as bibliographies of relevant articles, for cohort studies of adults with CD and strictures of the stomach or duodenum (up to the ligament of Treitz) who underwent EBD through December 2016. We obtained data from 7 international referral centers on 94 patients who underwent 141 EBDs. We performed a patient-level meta-analysis of data from published and unpublished cohort studies to determine mechanical and clinical success. We performed a time-to-event analysis to assess symptom recurrence and need for redilation or surgery. The patients analyzed had strictures of the duodenum (n = 107), stomach (n = 30), or spanning both (n = 4). RESULTS:The rate of technical success for EBD was 100%, with 87% short-term clinical efficacy; major complications arose from 2.9% of all procedures. During a median follow-up period of 23.1 months, 70.5% of patients had a recurrence of symptoms, 59.6% required redilation, and 30.8% required surgical intervention. Patients whose disease was located in the small bowel had a higher risk for symptom recurrence (hazard ratio [HR], 2.1; P = .003). Asian race (HR, 2.8; P < .001) and location of disease in the small bowel (HR, 1.9; P = .004) increased the need for redilation. Prestenotic dilation was a risk factor for needing surgery earlier (HR, 1.9; P = .001). CONCLUSIONS:In a meta-analysis, we found EBD for CD-associated strictures of the UGI to be an effective alternative to surgery, with a high rate of short-term technical and clinical success, moderate long-term efficacy, and an acceptable rate of complications.

Pancreatic fluid collections (PFCs) including pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) frequently develop in the context of pancreatitis. Lumen-apposing self-expanding metal stents (LAMS) are increasingly used for the endoscopic management of infected and symptomatic PFCs since they facilitate direct endoscopic inspection and necrosectomy of WONs.1–3 However, two reports recently published in Gut 4 5 demonstrated high rates of haemorrhage associated with LAMS that were observed in up to 25% of patients and often occurred in a delayed manner with serious and fatal bleeding episodes reported. These data raised important concerns about the safety of LAMS and the optimal management of patients with infected or symptomatic PFCs. As a limitation, the reports by Bang et al 4 and Stecher et al 5 were based on relatively small group sizes of 12 and 46 LAMS-treated patients, respectively. To investigate whether the reported safety signals are similarly observed in …