BACKGROUND:Small bowel Crohn's disease (SBCD) is increasingly treated with biological therapies. Predicting response or remission (RoR) for individual patients is difficult and complicates treatment strategy. We aimed to determine if motility magnetic resonance imaging (mMRI) is superior to CRP and fecal calprotectin (FC) for the prediction of RoR at 1 year in patients commencing biologics for SBCD. METHODS:Prospective, multicenter (n = 13) cohort study of patients with active non-stricturing SBCD requiring anti-TNFα or anti-IL-12/23 treatment. We measured mMRI and CRP at baseline and post-induction (visit 2: 12-30 weeks), and FC in a subset. RoR was assessed at 1 year using clinical and structural magnetic resonance enterography parameters. We compared sensitivity, specificity, and area under the receiver operating characteristic curve (ROC-AUC) of changes in mMRI and CRP to predict RoR at 1 year. Secondary outcomes compared mMRI with FC, and prediction of improved quality of life (QoL). RESULTS:Eighty-six participants completed all assessments. Stable or improved mMRI at visit 2 was more sensitive than normalization of CRP for RoR (mMRI:71.0%, 95%CI 52.0-85.8; CRP:45.2%, 95%CI 27.3-64.0%, P = .008) but less specific (mMRI:30.9%, 95%CI 19.1-44.8; CRP:67.3%, 95%CI 53.3-79.3%, P < .001). There was no significant difference in ROC-AUC (mMRI:0.48; CRP:0.53, P = .65). Similar results were obtained for FC. None of mMRI, CRP, or FC predicted patient QoL at 1 year. CONCLUSIONS:Although improved mMRI is more sensitive than CRP and FC to predict RoR at 1 year, it is less specific. No factor predicted patient QoL. Motility MRI remains a marker of disease activity at given timepoints.

Abstract Background Endoscopic recurrence of Crohn’s disease after ileocaecal resection is a major concern and has been linked to multiple factors. Endoscopic evidence of postoperative recurrence (ePOR) in the first 6 months ranging between 40-70%.1 Effects of mesenteric sparing versus extended resection in ileocaecal resection is thought to be one of the factors contributing to ePOR.2 Methods All ileocacecal resections for Crohn’s Disease performed between March 2018 and December 2023 and with surveillance ileocolonoscopy were included in this retrospective analysis. Surgical procedure was standardised with ligation of the ileocolic pedicle at 2-3cm from the origin. Mesentery was excised from the point of vessel ligation directly to the limits of bowel resection. Extracorporeal ileocolonic anastomosis was performed in a stapled, side-to-side, antiperistaltic configuration with closure of the mesenteric defect. Principles of Enhanced Recovery After Surgery were adhered to. All specimens received histological analysis. Surveillance colonoscopy was performed with Modified Rutgeerts Score assigned by the endoscopist with retrospective review by a second endoscopist. Results Seventeen patients were eligible for inclusion. Median age was 36 years. Eleven patients (65%) received biologic therapy prior to surgery. Twelve patients (71%) received laparoscopic surgery. Median operative duration was 129 minutes. One patient (6%) had a Clavien-Dindo grade 3+ morbidity (radiological drainage of a collection) with no anastomotic leaks. Median length of stay was 7 days. Histological analysis demonstrated clear margins in all specimens. Six patients (35%) received biologic therapy after surgery. First endoscopic surveillance was performed at a median 18 months. Modified Rutgeerts Score was 0 in 2 (12%), 1 in 9 (53%), 2a in 1 (6%), 2b in 4 (24%) and 3 in 1 (6%) of patients. One patient underwent further surgery for proximal stricture >5cm from the anastomosis. Median follow up was 98 months. Conclusion Mesenteric excision comparable to that of D2 lympadenectomy for colorectal cancer is safe. Furthermore, it may confer benefit with lower ePOR, compared to recent literature. Further research is needed to confirm the benefit of mesenteric excision in ileocaecal resection for Crohn’s Disease. References 1.Nardone OM, Calabrese G, Barberio B, et al. Rates of Endoscopic Recurrence In Postoperative Crohn’s Disease Based on Anastomotic Techniques: A Systematic Review And Meta-Analysis. Inflamm Bowel Dis. 2024;30(10):1877–87. 2.Brown SR. How can the surgeon reduce recurrence after surgery for ileocolic Crohn’s disease? Semin Colon Rectal Surg. 2023;34(4):100985.

Introduction Endoscopy other than essential or emergency cases was paused in March 2020 during the first wave of the Covid-19 pandemic leading to a significant backlog. In April 2020 the BSG issued new guidance for safe resumption of endoscopy services. Methods We here described how we managed the endoscopy backlog generated by the first wave of the Covid-19 pandemic in a Covid-minimised unit. We evaluated the impact of service suspension on backlog, recovery strategy, infection control policy, results of pre-procedure Covid-19 testing, and 7/14-day post-procedure Covid-19 symptom screening. Results 937 elective procedures were cancelled between 23 March and June 2020. A vetting tool linked to the booking system was used to categorise these as High-risk 2-week wait (n=57), Defer 3 months (n=439), Defer 6 months (n=300), Defer 12 months (n=9), Surveillance (n=45), Discharge back to referrer (n=87). Elective procedures restarted on 8 June 2020. Lists were initially booked with 50% reduction in volume compared to pre-Covid-19, to accommodate PPE, downtime and social distancing. We increased endoscopy administration from 2 to 5 staff, to implement 7-day pre-procedure ''SCOTS criteria' telephone screening, 3-day pre-procedure Covid-19 PCR testing, and 7/14-day post-procedure telephone follow-up. We introduced outpatient information leaflet and consent forms regarding Covid-19 risk. Inpatient endoscopy was carried out in the operating theatre until the end of August. On 17 July we removed downtime after lower GI endoscopy increasing capacity. Twice weekly evening lists resumed in August, with an extra evening list added in September. From 1 August until 10 October we used insourcing at weekend. We trialed outsourcing of 2 weekly lists for 4 weeks in August, but did not find this strategy effective. Additional Saturday and evening lists were performed by 6 endoscopists removed from the GIM rota. We were able to clear our waiting list by mid-October so that we could offer mutual aid to a neighboring hospital. Between June and November we performed endoscopy in 3,481 outpatients. Each patient had pre-endoscopy Covid-19 swab and 20 (0.57%) were positive. 23 out of 3,261 (0.71%) patients developed Covid-19 symptoms after 7 days and 29 (0.89%) after 14 days. Conclusions We demonstrated effective clearance of the endoscopy backlog in a Covid-19 safe environment over 4 months. Key interventions were advance vetting, increased administrative support, an endoscopy unit located in a separate building, quick implementation of infection control policies, insourcing and freeing of endoscopists from the GIM rota. Learning point was underestimating burnout of endoscopy nursing staff.

Ustekinumab is a recognised treatment for moderate-to-severe Crohn’s disease. We aimed to examine its effectiveness in an adult population in three London centres, and to identify patient, disease or drug-related factors associated with effectiveness. A retrospective observational study on adults with Crohn’s disease prescribed Ustekinumab between 2017 and 2019. The primary outcome was clinical response at Week 12. Other outcomes included clinical response at Week 52, clinical remission at Weeks 12 and 52, disease activity on biochemical markers (CRP and faecal calprotectin), endoscopic remission (resolution of ulceration at ileocolonoscopy) and fistula improvement or closure in a subset of patients with perianal fistulising disease. A total of 134 patients with a median follow-up of 12 months. Clinical response and remission rates were 58% and 46% at 12 weeks and 64% and 57.5% at 52 weeks respectively. Median HBI score reduced from 9 to 5 at 12 weeks and to 4 at 52 weeks. Concomitant reduction in C-reactive protein and calprotectin and endoscopic healing or improvement (52%). Twelve per cent experienced at least one adverse event, 22% discontinued Ustekinumab and 31% required rescue therapy. Rescue therapy with corticosteroids was independently associated with short time to treatment discontinuation. Clinical response and remission rates were comparable to other studies. Previous exposure to biologics and longer disease duration were associated with less favourable outcomes. Rescue therapy with corticosteroids was the only factor independently associated with treatment discontinuation. Future studies should examine outcomes of Ustekinumab prescribed early in the disease course.

Introduction: Following British Society Gastroenterology (BSG) recommendations in March 2020 [1], UK endoscopy other than essential or emergency cases was paused during the first wave of the Covid-19 pandemic. This led to a significant backlog of patients waiting for endoscopy. At the end of April 2020 the BSG issued new guidance for safe resumption of endoscopy services [2]. Aims & Methods: The aim of this study was to describe how we managed the endoscopy backlog generated by the first wave of the Covid-19 pandemic in a Covid-minimised unit utilising BSG guidance [2]. We evaluated the impact of service suspension on backlog;recovery strategy, infection control policy, results of pre-procedure Covid-19 testing, and 7/14-day post-procedure Covid-19 symptom screening. Results: 937 elective procedures were cancelled between 23 March and June 2020. A vetting tool linked to the booking system was used to categorise these as High-risk 2-week wait (n=57), Defer 3 months (n=439), Defer 6 months (n=300), Defer 12 months (n=9), Surveillance (n=45), Discharge back to referrer (n=87). Elective procedures restarted on 8 June 2020. A single endoscopy room operated for the first 3 days, 2 rooms until 22 June, and subsequently all 3 rooms. Lists were initially booked with 50% reduction in volume compared to pre-Covid-19, to accommodate requirements for PPE, downtime and social distancing. We increased endoscopy administration from 2 to 5 staff, to implement 7-day pre-procedure 'SCOTS criteria' telephone screening, 3-day preprocedure Covid-19 PCR testing, and 7/14-day post-procedure telephone follow-up. We introduced outpatient information leaflets and consent forms regarding risk of Covid-19. Inpatient endoscopy was carried out in the operating theatre rather than endoscopy unit until the end of August. On 17 July we removed the requirement for downtime after lower GI endoscopy (following clarification that this was not considered 'aerosol generating') and increased lower GI endoscopy volume accordingly. Twice weekly evening lists resumed in August. From 1 August until 10 October we utilised weekend insourcing delivered by an agency endoscopy team. We trialed outsourcing of 2 lists per week to an independent provider for 4 weeks in August, but did not find this strategy effective. In September we increased to 5 evening lists per week. Additional Saturday lists were performed by 6 endoscopists made available through removal from the general internal medicine (GIM) rota. Through these measures we were able to clear our waiting list by mid-October. In mid-November we offered mutual aid to a neighbouring hospital with 2 lists per week. Between June and November we performed endoscopy in 3,481 outpatients. Each patient had pre-endoscopy Covid-19 testing and 20 (0.57%) were positive. 3,261 patients were called at day 7 and 14 post-endoscopy: 23 (0.71%) patients developed symptoms compatible with Covid-19 after 7 days and 29 (0.89%) after 14 days. Conclusion: We demonstrate effective clearance of the endoscopy backlog in a Covid-19 safe environment over 4 months, which exceeded the expected pace of recovery [3]. The key interventions were advance vetting of procedures, increased administrative support, an endoscopy unit located in a separate building, quick implementation of infection control policies, insourcing and freeing of endoscopists from the GIM rota. Learning points were underestimating burnout of endoscopy nursing staff returning from redeployment and the decreased endoscopy demand due to reduced referrals and patients' fear of attending hospital.

Intro Ustekinumab is efficacious for treating moderate to severe Crohn’s disease (CD). We aim to study real world efficacy of ustekinumab for CD. Methods A retrospective observational study across 3 London Hospitals with 106 adults with CD started on ustekinumab between 2017–2019. Primary outcome was clinical response (3-point change in the Harvey-Bradshaw index) at week 12. A secondary outcome was time to treatment discontinuation (drug survival). Predictors of discontinuation were analysed using Cox regression and multivariable Cox regression for joint association. Results 47.2% were male; median age at time of ustekinumab induction was 35 years (range 20 – 69). 61.3% had ileocolonic disease. The majority (55.7%) had inflammatory phenotype. 47.2% were on concomitant immunomodulators during induction. Only 9.4% were biologic naïve. 41.5% had previous abdominal surgery. Median follow-up was 12 months (range 1 – 33). 58.9% had clinical response at 12 weeks. 72% (95% CI: 62% to 81%) and 67% (95% CI: 55% to 77%) remained on Ustekinumab after 1 and 2 years follow-up respectively. The association between various patient factors and time to discontinuation is shown in table 1. There were no associated factors with time to discontinuation. Maintenance frequency of 12 weeks was half as likely to be associated with discontinuation, but not statistically significant. Only 8/44 on 8-weekly maintenance frequency de-escalated to 12-weekly. Conclusion Only a third of CD patients discontinued ustekinumab at 2 years follow-up and 5% discontinued therapy between year 1 and 2 of treatment. This suggests clinical response within the first year of treatment is likely to be sustained for another year. None of the patient, disease or drug-related factors predicted drug discontinuation.

Background Management of pregnant women with inflammatory bowel disease (IBD) can be complex. Women often report getting conflicted information from different health care professionals and needing to attend too many hospital appointments. Following the success of other combined medical-obstetric clinics that were already running at Homerton hospital we set up a monthly IBD – obstetric clinic in January 2016. The aim of this study was to review the effect of this clinic on pregnancy outcomes. Method A retrospective review of patient records was performed to obtain patient demographics, medical, surgical and drug history, mode of delivery and birth weight from January 2016 to January 2018. Results A total of 45 pregnancies in 44 women were identified. 18 women have Crohn’s disease (CD) and 26 ulcerative colitis (UC). Most women were on some treatment with only 4 being on none. 21 women were on 5-ASA (oral, topical or both). 7 women were on thiopurines. 8 women were on biologics (Infliximab 3, adalimumab 4, vedolizumab 1). 5 women were on biologics and thiopurines (3 adalimumab, 2 infliximab). Biologics were stopped at 28 weeks in 6/8 women, 1 woman stopped at 20 weeks and in one case it was necessary to continue Adalimumab throughout the pregnancy. 2 patients needed treatment with prednisolone due to flare up during pregnancy. One woman was diagnosed with UC during pregnancy and required prednisolone. One woman with severe perianal CD needed surgical drainage during pregnancy. All pregnancies resulted in live births. Mean birth weight was 3203 g. 7 women had emergency caesarean section (CS), 9 women elective CS and 5 had instrumental deliveries. The commonest indications for elective CS were obstetric or maternal choice and emergency CS foetal distress or failure to progress. There were 5 preterm deliveries (<37 weeks), 4 spontaneous, 1 emergency. There was one birth with severe intrauterine growth retardation (IUGR) secondary to a large placental haemorrhage at the beginning of the pregnancy and 1 duodenal atresia. One woman on infliximab and azathioprine developed listeria sepsis 10 days after the last infliximab infusion at 28 weeks. This was identified and treated appropriately, the pregnancy continued to term with no foetal complications. Average number of clinic visits was 3. There were a total of 115 appointments with a rising trend as the clinic became established and better known to GPs and midwives. Conclusion This study showed that a combined IBD-obstetric clinic improves adherence to treatment and guidelines with good pregnancy outcomes. Patient feedback is that they value this combined approach both in terms of the medical/obstetric expertise and in terms of convenience.

Introduction Inflammatory bowel disease (IBD) is frequently treated with tumour necrosis factor-alpha inhibitors (anti-TNF). This is associated with an increased risk for reactivation tuberculosis (TB) in those with latent tuberculosis infection (LTBI), which preventive therapy can reduce by 74%.1The British Thoracic Society (BTS) guidelines include tables calculating the risk of developing TB and need for prophylaxis.2 Method We retrospectively reviewed clinic letters from 2010 to 2014 for IBD patients referred for anti-TNF screening at an East London hospital. Ethnicity, age, years in the UK, Tuberculin skin test (TST) result, interferon-gamma release assay (IGRA) result, and use of prophylaxis was recorded. Adjusted annual risk was calculated as per the BTS guidelines and patients labelled as “high risk” if prophylaxis was indicated. This was compared with the number that received prophylaxis after TB specialist assessment. Results Out of the 116 patients identified, 91% were prescribed immunosuppressants (e.g., prednisolone, azathioprine, mercaptopurine). 37 patients were classified “high risk” as per the BTS guidelines; however following TB specialist assessment only 9 patients received prophylaxis. 14 of the 116 patients demonstrated positive TST and/or IGRA, although none of the patients receiving anti-TNF therapy developed reactivation TB. 100% of Black African and Indian ethnicity were classified “high risk”, although at least 78% of people in these groups were UK residents for over 10 years. Conclusion The BTS guidelines did not accurately predict which patients would require preventive therapy in this cohort. Clinical assessment and immunological testing by a TB specialist reduced the number receiving preventive therapy, without increased rates of TB. Disclosure of interest None Declared. References Carmona L, Gomez-Reino JJ, Rodriguez-Valverde V et al. Effectiveness of recommendations to prevent reactivation of latent tuberculosis infection in patients treated with tumour necrosis factor antagonists. Arthritis Rheum 2005;52:1766–72 British Thoracic Society Standards of Care Committee. BTS recommendations for assessing risk and for managing Mycobacterium tuberculosisinfection and disease in patients due to start anti-TNF-alpha treatment. Thorax 2005;60:800–805

Introduction Inflammatory bowel disease (IBD) is frequently treated with tumour necrosis factor-alpha inhibitors (anti-TNF). This is associated with an increased risk for reactivation tuberculosis (TB) in those with latent tuberculosis infection (LTBI), which preventive therapy can reduce by 74%.1The British Thoracic Society (BTS) guidelines include tables calculating the risk of developing TB and need for prophylaxis.2 Method We retrospectively reviewed clinic letters from 2010 to 2014 for IBD patients referred for anti-TNF screening at an East London hospital. Ethnicity, age, years in the UK, Tuberculin skin test (TST) result, interferon-gamma release assay (IGRA) result, and use of prophylaxis was recorded. Adjusted annual risk was calculated as per the BTS guidelines and patients labelled as “high risk” if prophylaxis was indicated. This was compared with the number that received prophylaxis after TB specialist assessment. Results Out of the 116 patients identified, 91% were prescribed immunosuppressants (e.g., prednisolone, azathioprine, mercaptopurine). 37 patients were classified “high risk” as per the BTS guidelines; however following TB specialist assessment only 9 patients received prophylaxis. 14 of the 116 patients demonstrated positive TST and/or IGRA, although none of the patients receiving anti-TNF therapy developed reactivation TB. 100% of Black African and Indian ethnicity were classified “high risk”, although at least 78% of people in these groups were UK residents for over 10 years. Conclusion The BTS guidelines did not accurately predict which patients would require preventive therapy in this cohort. Clinical assessment and immunological testing by a TB specialist reduced the number receiving preventive therapy, without increased rates of TB. Disclosure of interest None Declared.Abstract PTH-060 Table 1 Table comparing BTS risk stratification with numbers treated for LTBI Ethnic group Number in group >10 years in UK (% group) BTS high risk (% group) TST positive (% group) IGRA positive (% group) Prophylaxis given (% group) Black African 13 13 (100%) 13 (100%) 0 (0%) 1 (8%) 1 (8%) Indian subcontinent 18 14 (78%) 18 (100%) 3 (17%) 2 (11%) 3 (17%) Caucasian 56 53 (95%) 2 (4%) 3 (5%) 2 (4%) 3 (5%) Other 29 21 (72%) 4 (14%) 4 (14%) 3 (10%) 2 (7%) Total 116 101 (87%) 37 (32%) 10 (9%) 8 (7%) 9 (8%) References Carmona L, Gomez-Reino JJ, Rodriguez-Valverde V et al. Effectiveness of recommendations to prevent reactivation of latent tuberculosis infection in patients treated with tumour necrosis factor antagonists. Arthritis Rheum 2005;52:1766–72 British Thoracic Society Standards of Care Committee. BTS recommendations for assessing risk and for managing Mycobacterium tuberculosisinfection and disease in patients due to start anti-TNF-alpha treatment. Thorax 2005;60:800–805

Systemic sclerosis is an autoimmune connective tissue disorder, which can be progressive with multisystem involvement. Guidance on the management of complications is based on a limited data set and practice amongst clinicians can vary. The UK Scleroderma study group set up several working groups to agree some consensus pathways for the management of specific complications. Approximately nine out of ten patients with systemic sclerosis will have involvement of the gastrointestinal system and in this review article we explore the management of these complications in a symptom-based approach. The algorithms are a useful tool for clinicians, which we hope, will be a point of reference and highlight the need for further research in these areas.

Irritable bowel syndrome is a common gastroenterological disorder characterized by abdominal pain, diarrhoea or constipation and bloating. The exact pathophysiology remains unknown but possible mechanisms involve altered gut motility, visceral hypersensitivity and exaggerated stress response. Treatment depends on the predominant symptoms. This article discusses the pathophysiology of IBS and the treatments available.

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