Background: Disease phenotype and outcome of late-onset Crohn’s disease are still poorly defined. Methods: In this Italian nationwide multicentre retrospective study, patients diagnosed ≥65 years (late-onset) were compared with young adult-onset with 16–39 years and adult-onset Crohn’s disease 40–64 years. Data were collected for 3 years following diagnosis. Results: A total of 631 patients (late-onset 153, adult-onset 161, young adult-onset 317) were included. Colonic disease was more frequent in late-onset (P < 0005), stenosing behaviour was more frequent than in adult-onset (P < 0003), but fistulising disease was uncommon. Surgery rates were not different between the three age groups. Systemic steroids were prescribed more frequently in young adult-onset in the first year, but low bioavailability steroids were used more frequently in late-onset in the first 2 years after diagnosis (P < 0.036, P < 0.041, respectively). The use of immunomodulators and anti-TNF’s even in patients with more complicated disease, that is, B2 or B3 behaviour (Montreal classification), remained significantly inferior (P < 0.0001) in late-onset compared to young adult-onset. Age at diagnosis, Charlson comorbidity index, and steroid used in the first year were negatively associated with the use of immunomodulators and biologics. Comorbidities, related medications and hospitalizations were more frequent in late-onset. Polypharmacy was present in 56% of elderly Crohn’s disease patients. Conclusion: Thirty-two percent of late-onset Crohn’s disease presented with complicated disease behaviour. Despite a comparable use of steroids and surgery, immunomodulators and biologics were used in a small number of patients.

Introduction and aim: The transitional process of young patients affected by inflammatory bowel disease from pediatric to adult care is a crucial step. Our study aimed to investigate the 1-year success outcome of this transitional process. Methods: From 2013 to 2018, we evaluated the transitional process of patients with Crohn's disease or ulcerative colitis. For each patient, the following parameters 12 months before and 12 months after the transition were evaluated: Body Mass Index, disease activity and smoker status, number of outpatient visits and the pharmacological therapy, the number of disease exacerbations, hospitalizations and surgical interventions. Results: We enrolled 106 patients with IBD. No statistically significant difference was found between patients' Body Mass Index before and after transition. There was a significant reduction in the number of exacerbations and hospitalizations in the 12 months post-transition (pre-transition exacerbations: 0.74 +/- 0.79, post-transition exacerbations: 0.35 +/- 0.57, p < 0.001; pre-transition hospitalizations: 0.28 +/- 0.44, post-transition hospitalizations: 0.1 +/- 0.3, p < 0.001). In contrast, there was no significant difference in the number of outpatient visits (3.40 +/- 1.4 vs 3.25 +/- 1.2; p = ns) and of patients undergoing surgery (0.9% vs 1.8%, p = ns). Conclusion: The parameters used as success indicators of the transition program confirm the achievement of continuity of care from Pediatrics to adult Gastroenterology, in a critical phase of the natural history of IBD patients. (c) 2018 Editrice Gastroenterologica Italiana S. r. l. Published by Elsevier Ltd. All rights reserved.

Having a simple score able to predict the risk of surgery, combining clinical, endoscopic and imaging features, could tailor the management of patients with Crohn’s disease (CD). Aim: to prospectively evaluate the one-year risk factors for surgery in CD and to build a risk matrix model for predicting the 1-year probability of surgery. Enrolled CD patients underwent prospectively clinical, laboratory, endoscopy and bowel sonography (BS) examinations within one week. Firstly, the optimal cut-off values for Simple Endoscopic Score for CD (SES-CD), bowel wall thickness (BWT) at BS and disease extension at BS in predicting surgery were identified by ROC curves; then binary logistic regression and Cox’s regression were conducted. Finally, the probabilities of surgery were computed for selected baseline levels of covariates and results were arranged in a prediction matrix model. Among 100 CD patients included in the study (males 58%, mean age 36.2 ± 11.5), 30% underwent surgery within one year. SES-CD>9 (OR 15.3; p < 0.001), BWT >7 mm (OR 15.8; p < 0.001), disease extension >33 cm (OR 8.23; p < 0.001) and stricturing/penetrating behaviour (OR 4.3; p < 0.001) were the only independent factors for one-year surgery both at binary logistic and Cox’s regression. Finally the matrix model combined these risk factors, and the probability of surgery ranged from 0.48% to 87.5% (16 combinations) (Figure 1). The risk matrix model, combining clinical, endoscopic and ultrasonographic findings, can accurately predict the one-year risk of surgery in CD. This tool could be of relevance into clinical practice, as it could be the basis for a tailored management of CD patients.

Background and Aim: To evaluate the usefulness of a low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet on patients with irritable bowel syndrome (IBS), non-active inflammatory bowel diseases (IBD), and celiac disease (CD) on a gluten-free diet (GFD). Methods: Dietetic interventional prospective study. IBS, IBD, and CD subjects were evaluated to check if they fulfilled the Rome III criteria. Each subject was educated to follow a low FODMAP diet after being evaluated by filling out questionnaires that assessed the quality of life (QoL) and symptoms experienced (IBS-SSS and SF-36), and was reevaluated after 1 and 3 months. Results: One hundred twenty-seven subjects were enrolled: 56 with IBS, 30 with IBD, and 41 with CD. IBS-SSS showed that abdominal symptoms improved after 1 and 3 months of diet in all subjects, with significant difference among the 3 groups at T0 (average scores IBS: 293 ± 137, IBD: 206 ± 86, CD: 222 ± 65, p < 0.001), but no difference at T3 (IBS: 88 ± 54, IBD: 73 ± 45, CD: 77 ± 49, p = ns). By analyzing the SF-36 questionnaire, we did not observe any difference between the 3 groups, in terms of response to diet (p = ns), we observed a clinical improvement from T0 to T3 for most of the questionnaire’s domains. Conclusions: A low FODMAP diet could be a valid option to counter ­abdominal symptoms in patients with IBS, non-active IBD, or CD on a GFD, and thus, improve their QoL and social ­relations.

BACKGROUND:In the management of Crohn's disease [CD] patients, having a simple score combining clinical, endoscopic, and imaging features to predict the risk of surgery could help to tailor treatment more effectively.AIMS:We aimed to prospectively evaluate the 1-year risk factors for surgery in refractory/severe CD and to generate a risk matrix for predicting the probability of surgery at 1 year.METHODS:CD patients needing a disease re-assessment at our tertiary inflammatory bowel disease [IBD] centre underwent clinical, laboratory, endoscopic, and bowel sonography [BS] examinations within 1 week. The optimal cut-off values in predicting surgery were identified using receiver operating characteristic [ROC] curves for the Simple Endoscopic Score for CD [SES-CD], bowel wall thickness [BWT] at BS, and small bowel CD extension at BS. Binary logistic regression and Cox regression were then carried out. Finally, the probabilities of surgery were calculated for selected baseline levels of covariates and results were arranged in a prediction matrix.RESULTS:Of 100 CD patients, 30 underwent surgery within 1 year. SES-CD ≥9 (odds ratio [OR] 15.3; p <0.001], BWT ≥7 mm [OR 15.8; p <0.001], small bowel CD extension at BS ≥33 cm [OR 8.23; p <0.001], and stricturing/penetrating behaviour [OR 4.3; p <0.001] were the only independent factors predictive of surgery at 1 year, based on binary logistic and Cox regressions. Our matrix model combined these risk factors, and the probability of surgery ranged from 0.48% to 87.5% [16 combinations].CONCLUSIONS:Our risk matrix combining clinical, endoscopic, and ultrasonographic findings can accurately predict the 1-year risk of surgery in patients with severe/refractory CD requiring a disease re-evaluation. This tool could be of value in clinical practice, serving as the basis for a tailored management of CD patients.

The Fracture Risk Assessment (FRAX) tool has been developed to estimate patients' 10-yr probability of fracture, thus establishing which patients should undergo dual-energy X-ray Absorptiometry (DXA) scan. This study aimed to evaluate if the FRAX tool can replace or optimize the use of DXA scan in celiac disease (CD). We prospectively enrolled all CD patients aged over 40 yr diagnosed at our third-level unit. At time of CD diagnosis, all patients underwent FRAX score calculation for risk of major osteoporotic and hip fractures and DXA scan (used as gold standard) to assess the accuracy of the FRAX score. The FRAX score calculation was based on the following 10 variables: age (>40 yr), sex (M/F), body mass index, history of previous fracture (yes/no), parent fractured hip (yes/no), current smoking (yes/no), use of steroids (yes/no), rheumatoid arthritis (yes/no), secondary osteoporosis (yes/no), and alcohol ≥3 units/d (yes/no). DXA assessment was performed within 1 week from FRAX calculation. The FRAX score was dichotomized as normal or pathologic in accordance with the National Osteoporosis Guideline Group. A total of 160 CD patients were enrolled (M/F = 20/140; mean age 48.7 yr). A pathologic FRAX score was evident in 14 out of 160 patients (8.7%), whereas osteoporosis based on DXA scan was found in 10 patients (6%) (κ = 0.6); 3 patients with osteoporosis (1.9%) showed a 10-yr risk of major fracture >10% according to the National Osteoporosis Guideline Group criteria. With regard to diagnostic accuracy, the FRAX score showed sensitivity of 0%, specificity of 91%, positive predictive value of 0%, and negative predictive value of 94%. The prevalence of osteoporosis in adult CD appears to be quite low and only a small proportion of patients would require a DXA investigation. The FRAX score could be an effective tool to avoid useless DXA scans in CD patients in view of its high negative predictive value.

Background: Several recent studies have shown FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) free diet is efficient in subjects with Irritable Bowel Syndrome (IBS). Patients with Inflammatory Bowel Diseases (IBD) and celiac disease (CD) can experience functional gastrointestinal symptoms not related to inflammation, but data about the use of low FODMAPs diet in these settings are still scarce. Aim: To evaluate the usefulness of a low FODMAPs diet in patients with IBS, IBD and CD on gluten-free diet (GFD). Methods: We performed a dietetic interventional prospective study evaluating the effect of a low FODMAPs diet in patients with IBS, CD following at least a 1-year-GFD and IBD without signs of active inflammation, who experienced functional symptoms. Each subject was submitted to a low FODMAPs diet, after filling out questionnaires on quality of life and symptoms (IBS-SSS and SF-36), and was re-evaluated after 1 and 3 months. Results: 127 subjects were enrolled: 56 with IBS, 30 with IBD and 41 with CD. The analysis of the IBS-SSS explained if the symptomatology reported by the patient was mild (score <175), moderate (score 175–300) or severe (score 300–500) before starting the diet (T0) and one month (T1) and three months (T3) after prescription of a low FODMAPs diet. The overall average score of the study population was 250±113 SD at T0, 146±68 SD at T1 and 81±50 SD at T3 (p<0.001). Furthermore, by analysing the SF-36 questionnaire, we did not observe any significant difference between the groups in terms of response to diet (p=NS), even if we observed a clinical improvement from T0 to T3 after the start of the diet for the most of the questionnaire's domains. Conclusions: A low FODMAPs diet could be a valid tool to contrast functional disorders in patients with IBS, non-active IBD and CD on GFD, thus improving the quality of life and the social relations.

BACKGROUND:Transmural healing (TH) of Crohn's disease (CD) is a still unexplored and interesting outcome correlated to concept of deep remission.AIM:To assess the rate of TH in CD patients treated with anti-TNF alpha agents using two cross-sectional procedures: bowel sonography (BS) and magnetic resonance enterography (MRE).METHODS:We performed a 2-year observational longitudinal study, evaluating steroid-free clinical remission (CR), mucosal healing (MH), and TH in CD patients who would complete a 2-year treatment period with anti-TNFs. All patients underwent endoscopy, BS, and MRE before and after 2 years of treatment.RESULTS:Forty out of 80 CD patients were treated with anti-TNFs for 2 years. CR was achieved in 24 patients (60%) while MH in 14 (35%). Using BS, TH was observed in 10 patients (25%), while using MRE, TH was observed in 9 patients (23%) (k=0.90; P<0.01). A good agreement was observed between MH and TH, both using BS (k=0.63; P<0.01) and MRE (k=0.64; P<0.01). A poor agreement was found between CR and TH, with both BS and MRE (k=0.27 and 0.29, respectively; P<0.01); even though all patients with TH had achieved CR.CONCLUSIONS:TH can be achieved in about 25% of CD patients treated with anti-TNFs, as shown by BS and MRE. BS could be used as the first cross-sectional procedure to detect TH.

Introduction: Coeliac disease (CD) is the most common Th1-mediated enteropathy, frequently associated with other immune-mediated disorders (IMD).Aims: To evaluate: (1) the prevalence of IMD at the time of and after CD diagnosis; (2) a possible change in immune response to gluten free diet (GFD); (3) the potential role of GFD in reducing and/or preventing IMD in CD.Methods: Prospective study including all consecutive adult CD patients who underwent investigations for Th1-Th17/Th2-IMD at the time of CD diagnosis and after a 5-year follow-up period.Results: 1255 CD were enrolled. Of these, 257 patients (20.5%) showed IMD at the time of CD diagnosis, with 58.4% presenting a Th1/Th17-IMD. After a 5-year follow-up period, 682 patients (54.3%) showed new IMD despite GFD. Of these, 57.3% presented a Th1/Th17-IMD and 42.7% a Th2-IMD (p = 0.8). When compared the prevalence of each type of IMD before and after CD diagnosis, we did not identify any significant "switch" from Th1/Th17- to Th2-IMD or vice versa. The number of patients with Th1/Th17- and/or Th2-IMD increased during the GFD period (20.5% vs 54.3%; p < 0.01; OR 1.9).Conclusions: The prevalence of IMD at the time of CD diagnosis is high and it seems to increase in the follow-up period despite GFD. (C) 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background: Anaemia (AN) is frequently associated with inflammatory bowel diseases (IBD) and can negatively influence the quality of life of patients.Aim: To evaluate the prevalence and causes of AN in IBD.Methods: We prospectively performed a one-year multicentre observational study including all IBD cases attending six Units. We also investigated patients' main serological parameters.Results: The study population included 965 IBD patients (582 CD; 383 UC), of whom 142 were in-patients and 823 out-patients. AN was diagnosed in 134 out of 965 IBD patients (14%). No significant difference in AN prevalence was observed between CD and UC. The prevalence of AN was higher in the hospitalized IBD (26% in- vs. 11.7% out-patients; p < 0.01; OR 2.2) and in active disease (CD: 34% active vs. 16% inactive; p < 0.01; OR 2.1 - UC: 26% active vs. 19% inactive; p = 0.03; OR 1.3). Iron deficiency was present in 72 patients (53.7%), AN of chronic diseases in 12 (8.2%), mixed type AN in 11 (8.2%), thalassemia in 9 (6.7%), and macrocytic AN in 8 (5.9%).Conclusions: In Southern Italy, AN is common in IBD and is more frequent in active disease and hospitalized patients. Iron deficiency still remains the major cause of AN in IBD. (C) 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Key clinical messageA 22‐year‐old male with extensive steroid‐dependent/azathioprine‐refractory ulcerative colitis and preexistent severe refractory acne pustolosa (AP) was successfully treated with adalimumab for both conditions. Severe AP could be considered a further indication, instead of a relative restriction, to anti‐TNFα in steroid‐dependent IBD patients needing therapy with this class of drugs.

Background: Late-onset UC represents an important issue for the near future, but its outcomes and relative therapeutic strategies are yet poorly studied. Aim: To better define the natural history of late-onset ulcerative colitis. Methods: In a multicenter retrospective study, we investigated the disease presentation and course in the first 3 years in 1091 UC patients divided into 3 age-groups: diagnosis >65 years, 40-64 years, and <40 years. Disease patterns, medical and surgical therapies, and risk factors for disease outcomes were analyzed. Results: Chronic active or relapsing disease accounts for 44% of patients with late-onset UC. Across all age-groups, these disease patterns require 3-6 times more steroids than remitting disease, but immunomodulators and, to a lesser extent, biologics are less frequently prescribed in the elderly. Advanced age, concomitant diseases and related therapies were found to be inversely associated with the use of immunomodulators or biologics, but not with surgery. Conclusions: The conclusion that late-onset UC follows a mild course may apply only to a subset of patients. an important percentage of elderly patients present with more aggressive disease. Since steroid use and surgery rates did not differ in this subgroup, lower use of immunosuppressive therapy and biologics may reflect concerns in prescribing these therapies in the elderly. (C) 2016 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.

Background: Telephone helplines are a useful vehicle for the management of chronic diseases even though data on how these can ease management of inflammatory bowel disease (IBD) is still scarce. AIM: to analyze our two-years' experience with the first telephone helpline dedicated to IBD in Italy.Methods: The main outcomes of using a contact center (CC) at our Unit were analyzed; all data was prospectively collected. Patients' requests were classified into medical or non-medical. The percentage of hospitalized patients in the pre-CC period was compared to that after CC activation, to assess the potential clinical gain of using CC. The calls were divided into 5 categories to evaluate a potential correlation between patients' number of calls and risk of hospitalization.Results: The CC received 11,080 calls and handled 11,972 requests. In particular, 63% of patients phoned monthly for a medical consultation, and 37% called for non-medical reasons. In 2012, the followed-up patients were 1658 with 230 IBD-caused hospitalizations (14%); in 2014, the followed-up patients were 1962 with 182 hospitalizations (9%) (p<0.01). The risk of hospitalization exponentially increased with the number of calls: from 3% for 0-5 calls to 41% with >30 calls (p< 0.01).Conclusion: A dedicated CC could provide additional clinical gain, care, and support for IBD patients. (C) 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

54 healthy individuals.The SNP genotyping was done by an ARMS-PCR technique.Results: A better agreement was observed between test's Results in controls (k = 0.40) than in patients (k = 0.16).Results found by TST were more positive than those obtained by QFT-GIT and this was the case for both groups: controls [24.1% versus7.5%]and patients [14.3% versus 9.9%], respectively.Although QFT-GIT Results were unaffected by IM therapy, the mean mitogen response was reduced in immunosuppressed patients (8.06 UI/ml) when compared to the rest of patients and controls (12.70 UI/ml).Similarly, lesser TST positivity was observed in those under IM (9.8% versus 20.5%).Among the 12 QFT+ subjects, 10 (88.3%) had the susceptibility allele (A).Additionally, 6 of them were homozygote for this allele (AA).Conclusions: Although IM weakens the immunity strength, QFT-GIT seems to be as previously described, more accurate for detecting LTBI's cases that would otherwise be missed using solely TST.In a large vaccinated population, QFT-GIT appears more reliable for excluding a false positive TST.Even though, the (INFG +874T/A) SNP has been frequently associated with active tuberculosis, it seems that this SNP can also be associated with the latent form.All these preliminary Results will be ascertained as long as the size of both groups is enlarged.