Abstract Background Many patients with IBD believe diet affects the course of disease and is at least as important as medication in their IBD treatment. However, easy assessment of patients’ food intake and structured support of a healthy diet are lacking. The Eetscore is an online tool which assesses diet quality and subsequently gives personal dietary advice. We used the Eetscore to assess diet quality of IBD patients, evaluated if diet quality improved over time and studied correlations with quality of life (QoL) and clinical disease activity. Methods A prospective cohort study with adult IBD patients was performed. Participants completed the Eetscore, the short IBDQ and a clinical disease activity questionnaire (P-HBI or P-SCCAI) at baseline and after 1 month. The Eetscore is a validated web-based screening tool to assess diet quality based on 16 food components (e.g. meat, vegetables, fruit and fish). It consists of a short Food Frequency Questionnaire and is scored with the Dutch Healthy Diet 2015-index based on the Dutch dietary guidelines. The score of each component ranges from 0 to 10, resulting in a total score between 0 and 160. Higher scores indicate better adherence to Dutch dietary guidelines. The Eetscore subsequently provides personalised dietary advice based on the assessment. We assessed changes over time using paired samples t-tests or McNemar’s test and correlations using Pearson’s or Spearman’s correlation. Results We included 212 participants. At time of this preliminary analysis, 175 participants (60% female, 49% Crohn’s disease) completed baseline and 1-month assessments. Their median age was 49 years [IQR 32–58], BMI 25 kg/m2 [IQR 22–28] and disease duration 10 years [IQR 4–18]. At baseline, mean Eetscore was 98 ± 19, with highest median scores (≥8.5) on red meat, fat and oils, sweetened beverages, alcohol and salt intake, and lowest median scores (≤5) on nuts, legumes, processed meat and unhealthy choices (Figure 1). Diet quality increased with 5.6 points (95%CI 3.7–7.5) to a mean Eetscore of 103 ± 21 (p<0.001) after 1 month. QoL improved from 53 ± 10 to 55 ± 9 (∆2.0 (95%CI 1.2–2.8); p<0.001). The proportion of participants with clinically quiescent disease was comparable at both time points (71% vs 74%, p=0.29). Diet quality was not correlated with QoL or clinical disease activity. Conclusion This study suggests the Eetscore is a useful tool to monitor and support a healthy diet in IBD patients. Diet quality improved significantly following personalised dietary advice of the Eetscore. Short term results did not indicate a correlation between diet quality and QoL or clinical disease activity.

Abstract Background Active monitoring of IBD patients during intravenous (iv) biologic treatment is recommended but time-consuming and inconvenient for both patients and nurses. We developed a mobile application to promote self-management and monitor IBD patients cost-effectively during iv biologic treatment. We aimed to study the feasibility of the mobile application. Methods A prospective cohort study was performed in a secondary care centre with adult IBD patients treated with infliximab (iv) or vedolizumab (iv) for at least three months. The mobile application was used during four rounds of iv biologic treatment (figure 1). The application includes information modules and a personal interactive timeline with messages one week prior to iv biologic treatment (figure 1). Patients are asked to fill in a health check prior to each treatment to screen for contra-indications, such as respiratory infections or severe side-effects. Patients can also note any particularities or request contact with the IBD nurse. Blood tests are performed before every other infusion. Previously, patients were contacted by telephone prior to each biologic treatment by the IBD nurse. Using the application, patients are only personally contacted in case of abnormalities or upon request. Results Of 55 included patients, 52 patients completed the study. Mean age was 42 years (min 19 – max 68), 71% had Crohn’s disease, 76% had clinically quiescent disease, 85% used infliximab and 15% vedolizumab. Most patients used internet for over three years (98%) and their smartphone or tablet every day (98%). Compliance to health checks and blood tests was 67% during the 1st round of biologic treatment and 70%, 87% and 80% during the 2nd, 3rd and 4th round respectively. Patients used the application between median 6 (IQR 5 – 9) and 8 (IQR 5 – 11) times per round of biologic treatment. Patient satisfaction with the application was median 8 (VAS score, IQR 7 – 9). Prior to the 1st round of biologic treatment, all patients (100%) were contacted by telephone as in previous standard care. Using the application the number of patients requiring telephone contact decreased to 47%, 35% and 49% before the 2nd, 3rd and 4th round respectively. Patients remained equally satisfied with IBD care: median VAS score 8 (IQR 8 – 9) before and after implementation of the mobile application. The majority of patients (92%) wanted to continue using the application after the study ended. Figure 1: Study procedures Conclusion Monitoring of IBD patients treated with biologics using a mobile application is feasible. We saw a high compliance and satisfaction of patients, and reduction of health-care utilization. Almost all patients preferred using the application over previous standard care.

The duodenal-jejunal bypass liner (DJBL) is an endoscopic device designed to induce weight loss and improve glycemic control. The liner is licensed for a maximum implant duration of 12 months. It might be hypothesized that extension of the dwelling time results in added value. The goals of our study were to determine weight change, change in glycemic control, and safety in patients with an intended 24 months of DJBL dwelling time.

Alpha-1 antitrypsin (A1AT) is an acute-phase protein that is produced in liver cells. A1AT deficiency is a hereditary disease which is defined by the hepatic production of an abnormal protein that can not be released into the plasma. This leads to deficiency of plasma A1AT and subsequently to an impaired protection against proteases, resulting in pulmonary disease. Accumulation of the abnormal protein in hepatocytes can lead to liver damage. serum level measurement, phenotyping and liver biopsy can be used for establishing the diagnosis. Homozygous A1AT deficiency can cause neonatal hepatitis; in adults end-stage liver disease, cirrhosis and hepatocellular carcinoma can develop. There are strong arguments to consider heterozygous A1AT deficiency as an important co-factor in the aetiology of chronic liver disease. studies have shown that A1AT heterozygosity can be considered a modifier for hepatitis C virus, end-stage liver disease, cirrhosis and hepatocellular carcinoma. The accumulation of A1AT in the hepatocytes occurs more profoundly in a diseased liver, and as a consequence it affects the natural course of the liver disease. Therapeutic options include augmentation therapy (infusion of purified human plasma A1AT) in pulmonary disease; in end-stage liver disease liver transplantation is an option. for the future, other interventions such as gene therapy or strategies to inhibit polymerisation are promising. K E Y W o r d s Alpha-1-antitrypsin deficiency, hepatocellular carcinoma, heterozygosity, liver disease i N T r o d U C T i o N Alpha-1 antitrypsin (A1AT) is an acute-phase protein that is produced in liver cells. It is released into the plasma in response to an inflammatory stimulus. A1AT deficiency is a hereditary disease that is defined by the hepatic production of an abnormal protein that can not completely be released into the plasma. This leads to deficiency of plasma A1AT and subsequently to an impaired protection of the lungs against proteases. This results in pulmonary emphysema; hepatic accumulation of the abnormal protein can lead to chronic liver disease. This review gives an update of the present knowledge on partial A1AT deficiency in relation to various liver diseases. G E N E T i C s A N d ( P A T H o ) P H Y s i o l o G Y The A1AT molecule is a serum glycoprotein acting as an acute-phase protein. It is released during inflammatory processes from the hepatocyte, which results in increased plasma concentrations. The major physiological function © 2007 Van Zuiden Communications B.V. All rights reserved. r E V i E W Heterozygous alpha-1 antitrypsin deficiency as a co-factor in the development of chronic liver disease: a review K.F. Kok, P.J. Wahab, R.H.J. Houwen, J.P.H. Drenth, R.A. de Man, B. van Hoek, J.W.R. Meijer, F.L.A. Willekens, R.A. de Vries Departments of Hepato-Gastroenterology, Pathology and Clinical Chemistry, Rijnstate Hospital, Arnhem, the Netherlands, Department of Paediatric Gastroenterology, Wilhelmina Children’s Hospital/University Medical Centre Utrecht, the Netherlands, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands, Department of Hepato-Gastroenterology, Erasmus MC Rotterdam, the Netherlands, Department of Gastroenterology and Hepatology, Leiden University Medical Centre, the Netherlands, corresponding author (presently at ): e-mail: karinkok@hetnet.nl J.P.H. Drenth was not involved in the handling and review process of this paper.

Summary Naive and central memory T lymphocytes (TN and TCM) can infiltrate the inflamed gut mucosa in inflammatory bowel disease (IBD) patients. Homing of these subsets to the gut might be explained by ectopic formation of tertiary lymphoid organs (TLOs), containing high endothelial venules (HEVs). We aimed to evaluate the presence of HEVs and TLOs in inflamed intestinal mucosa of newly diagnosed, untreated IBD patients in relation to the presence of TN and TCM lymphocytes. IBD patients (n = 39) and healthy controls (n = 8) were included prospectively. Biopsy samples of inflamed and normal intestine, respectively, were analysed by immunohistochemistry for lymphocytes (CD3/CD20), blood vessels (CD31) and peripheral lymph node addressin (PNAd) expression (MECA-79). TN and TCM lymphocyte subsets were identified by flow cytometric immunophenotyping. A higher number of HEVs was found in the inflamed colon of patients with ulcerative colitis [median 3·05 HEV/mm2; interquartile range (IQR) = 0–6·39] and ileum of Crohn's disease patients (1·40; 0-4·34) compared to healthy controls (both 0; P = 0·033). A high density of colonic HEVs (HEVhigh) was associated with increased infiltration of TN and TCM in the inflamed gut (median 87%; IQR = 82–93% of T cell population), compared to HEVlow patients (58%; 38–81%; P = 0·003). The number of colonic follicles was higher in HEVhigh patients (median 0·54/mm2; IQR 0·28–0·84) compared to HEVlow patients (0·25/mm2; 0·08–0·45; P = 0·031) and controls (0·31/mm2; 0·23–0·45; P = 0·043). Increased homing of TN and TCM lymphocytes to inflamed gut tissue in IBD patients might be facilitated by ectopic formation of extrafollicular HEVs and TLOs in a subgroup of patients.

legend N2D N1D 2LPEG N2D vs. 2LPEG N1D vs. 2LPEG EFFICACY Primary analysis set, n1⁄4 275 Primary analysis set, n1⁄4 275 Primary analysis set, n1⁄4 272 Primary endpoint: Patients with successful overall bowel cleansing efficacy (HCS) [n] 253 (92.0%) 245 (89.1%) 238 (87.5%) -4.00%* [0.055] -6.91%* [0.328] Supportive secondary endpoint: Patients with successful overall bowel cleansing efficacy (BBPS) [n] 249 (90.5%) 243 (88.4%) 232 (85.3%) n.a. n.a. Primary endpoint: Excellent plus Good cleansing rate in colon ascendens (primary analysis set) [n] 87 (31.6%) 93 (33.8%) 41 (15.1%) 8.11%* [50.001] 10.32%* [50.001] Key secondary endpoint: Adenoma detection rate, colon ascendens 11.6% 11.6% 8.1% -4.80%; 12.00%** [0.106] -4.80%; 12.00%** [0.106] Key secondary endpoint: Adenoma detection rate, overall colon 26.6% 27.6% 26.8% -8.47%; 8.02%** [0.569] -7.65%; 9.11%** [0.455] Key secondary endpoint: Polyp detection rate, colon ascendens 23.3% 18.6% 16.2% -1.41%; 15.47%** [0.024] -6.12%; 10.82%** [0.268] Key secondary endpoint: Polyp detection rate, overall colon 44.0% 45.1% 44.5% -8.85%; 8.00%** [0.579] –7.78%; 9.09%** [0.478] Compliance rates (min 75% of both doses taken) [n] 235 (85.5%) 233 (84.7%) 245 (90.1%) n.a. n.a. SAFETY Safety set, n1⁄4 262 Safety set, n1⁄4 269 Safety set, n1⁄4 263 All treatment-emergent adverse events [n] 77 89 53 n.a. n.a. Patients with any related treatment-emergent adverse event [n] 30 (11.5%) 40 (14.9%) 20 (7.6%) n.a. n.a. *1⁄4 97.5% 1-sided CI; **1⁄4 95% 2-sided CI; n.a.1⁄4 not applicable. United European Gastroenterology Journal 4(5S) A219

Placement of the duodenal-jejunal bypass liner (DJBL) is a minimally invasive technique for the management of patients with type 2 diabetes mellitus and obesity. Acute pancreatitis was seen in 5 of 167 patients (3 %) in our series. It is suggested that acute pancreatitis in patients with the DJBL results from either direct blockage or edema of the major duodenal papilla, which may be caused by the following: migration of the anchor of the DJBL, accumulation of food debris between the liner and the duodenal wall, or reflux of duodenal contents into the pancreatic duct due to intraluminal hypertension caused by the liner. Early removal of the DJBL resulted in fast and complete recovery, whereas delayed diagnosis and removal led to severe, necrotizing acute pancreatitis.

AIM:To remove the migrated bands using a gastrointestinal endoscopic approach. Little is published on complications that can occur.METHODS:From June 2006 to June 2010, eight patients developed intragastric band migration. Two patients had received their AGB in a different hospital, the remaining six were operated by the same surgeon. In all patients gastrointestinal endoscopic removal of the band was attempted by two individual gastroenterologists. Clinical signs of band migration were: persisted nausea, abdominal pain, weight gain, recurrent infection of the port and tubing system and hematemesis.RESULTS:In four patients removal was performed without complications. In two patients extracting the cleaved gastric band into the stomach appeared impossible. The two remaining patients presented with acute hematemesis and melena. One of these patients was readmitted with hematemesis. The other patient started bleeding during the gastroscopy and was converted to a laparoscopy in which one of the branches of the left gastric artery was oversewn.CONCLUSION:Band migration after gastric banding can be life threatening. Gastrointestinal endoscopic removal is a feasible technique that holds the promise of fast reconvalescence.

Background and Aims To prospectively examine the feasibility and accuracy of Contrast Enhanced Ultrasound (CEUS) in the assessment of Crohn's disease (CD) activity in the terminal ileum in comparison to Magnetic Resonance Enterography (MRE), using endoscopy as a reference standard. Methods 105 consecutive patients with alleged clinically active CD were assessed by MRE and CEUS. CEUS of the terminal ileum was performed using an intravenous microbubble contrast enhancer. Accuracy values of CEUS and MRE for the presence of active terminal ileitis were evaluated using the Receiver Operating Characteristic method, using endoscopic findings as a reference standard. Sensitivity and specificity values of MRE and CEUS were compared by the McNemar test. Results CEUS was feasible in 98% of patients, MRE in all. Optimal diagnostic accuracy in CEUS was obtained at a peak intensity value of 10%, showing 100% sensitivity, 92% specificity and an accuracy of 99% in demonstrating ileal mucosal inflammation. For MRE, overall sensitivity, specificity and accuracy were, 87%, 100%, and 88%, respectively. CEUS and MRE were highly correlated in assessing length and wall thickness of the terminal ileum. CEUS identified 11 of 16 MRE-detected strictures, but no fistulae. Conclusion The accuracy of CEUS is comparable to that of MRE in the assessment of active, uncomplicated terminal ileal CD and therefore a valuable bedside alternative to MRE in the follow-up of these patients.

in acute lesions of inflammation including ulcerative colitis. Its role is not fully understood, especially its importance in wound and mucosal healing in inflammatory bowel disease [1,2]. Methods: We included 57 patients with moderate to severe ulcerative colitis from the University Hospital of North Norway. Patients were treated with infliximab to clinical and endoscopic remission defined by the ulcerative disease activity index as a score of 2 or less and with an endoscopic sub score of 0 or 1. Mucosal gene expression levels of IL-33 and tumour necrosis factor alpha (TNF-a) levels where determined in colon mucosal biopsies prior to infliximab therapy and at endoscopic remission using real-time PCR. Immunohistochemistry analysis was performed for IL-33 in 10 patients and 10 healthy controls. Results: No differences in IL-33 mucosal levels were found for the whole study population when comparing active disease with endoscopic remission, however a significant reduction of IL-33 was found in a subgroup of 17 patients (30%) who achieved normalisation of TNF-a expression (fold change 0.44, p value = 0.039). Infliximab therapy was stopped in 55 patients following endoscopic remission, at 1 year follow up 26 patients (47%) where still in disease remission. Immunohistochemistry showed IL-33 positive cells in the acute disease phase localised in the lamina propria, endothelial cells and also in basalcryptcells, the latter was not seen in endoscopic remission or in the healthy controls. Conclusions: Induction of endoscopic remission by infliximab in patients with ulcerative colitis significantly reduced the mucosal IL-33 levels only when TNF-a was normalised. Our data support the hypothesis of IL-33 as a pivotal mediator of inflammation in ulcerative colitis and is tightly associated to the mucosal expression of TNF-a.

The endoscopically placed duodenal–jejunal bypass liner (DJBL) or EndoBarrier gastrointestinal liner has been designed for the treatment of type 2 diabetes mellitus and simultaneous achievement of weight loss by obese patients. This study was performed to determine the safety, efficacy, and feasibility of delivering the DJBL with the patient under conscious sedation (CS). The primary end points of the study were safety and complications. The secondary end points were delivery time (min), amount of propofol (mg) used, and the total hospital stay (h).

BACKGROUND AND STUDY AIMS:Endoscopic implantation of a duodenal-jejunal bypass liner (DJBL) is a novel bariatric technique to induce weight loss and remission of type 2 diabetes mellitus. Placement of the DJBL mimics the bypass component of the Roux-en-Y gastric bypass (RYGB) procedure. In this observational study, we evaluated improvement of glycemic control and weight loss in the course of the treatment (0 - 24 weeks after DJBL implantation) and analyzed accompanying gut hormone responses. PATIENTS AND METHODS:12 obese individuals with type 2 diabetes were selected for DJBL implantation. Body weight, fat mass, and fasting plasma levels of glucose, insulin, C-peptide, and glycated hemoglobin (HbA1c), were analyzed at 0, 1, 4 and 24 weeks post-implant. Fasting ghrelin, gastric inhibitory peptide (GIP), and glucagon-like peptide (GLP-1) were determined at 0, 1 and 4 weeks post-implant. RESULTS:Besides significant weight loss, fat mass, fasting insulin, and homeostasis model assessment-estimated insulin resistance (HOMA-IR) index were also significantly decreased after DJBL implantation and a 42 % reduction was found in diabetes medication (P < 0.05). The fasting GLP-1 response in the first 4 weeks post-implant was significantly correlated with the fasting insulin and HOMA-IR response. Fasting ghrelin was found to be significantly elevated, in contrast to the decrease in ghrelin that is found after RYGB surgery. CONCLUSIONS:DJBL implantation provoked significant weight loss, a decrease in fat mass, and an early remission of type 2 diabetes, comparable to results seen after RYGB surgery. Gut hormone analyses revealed a potential role of fasting GLP-1 in early remission of type 2 diabetes. Interestingly, the DJBL-induced elevation of ghrelin contradicts the suggested role of reduced ghrelin levels after RYGB in improvement of glycemic control.

Background: Routine duodenal biopsies during upper gastrointestinal endoscopy (UGE) have been suggested to be useful in detecting coeliac disease (CD). However results from previous studies are not conclusive. The aim of this study is to investigate the diagnostic yield and cost-effectiveness of routine duodenal biopsy during UGE.Methods: In this retrospective single-centre study, we studied 6442 patients undergoing first-time UGE at the Rijnstate Hospital, Arnhem, the Netherlands, from January 2009 to December 2010. All UGE reports were analysed for indication, duodenal intubation, and endoscopic aspect of duodenal mucosa. Endomysium and tissue transglutaminase antibody titre, when present, were scored as positive or negative. CD was defined as Marsh 3a or higher. Costs of duodenal biopsies and pathology analysis were calculated. Comparisons were done with T-tests for continuous data and Chi-square tests for categorical data.Results: Forty-one patients had newly diagnosed CD; 34 of these 41 patients had definite indications for biopsy prior to UGE, e.g. positive serology or symptoms. Thus, routine duodenal biopsies identified seven patients as having CD, who otherwise would not have been biopsied. The number needed to biopsy was therefore 577, spending more than v 30,000 per case.Conclusions: We do not recommend routine duodenal biopsy to screen for coeliac disease because of the high number needed to biopsy as well as high costs.

index (BMI), serum resistin levels and IR values. Erythrocyte sedimentation rate and C-reactive protein levels were significantly higher in IBD patients (p < 0.0001). No statistically significant difference was noted between ulcerative colitis patients, Crohn’s disease patients and healthy subjects with respect to age, sex, BMI, serum resistin levels and IR values. Serum resistin levels were significantly higher in IBD patients who had received and/or were receiving steroids (n = 15) when compared to patients who did not receive steroid therapy (n = 27; p < 0.001). There was no difference between these two groups with respect to age, sex, BMI, fasting serum glucose levels and IR values. The disease activity of patients with ulcerative colitis and Crohn’s disease was evaluated according to Seo activity index and Crohn’s disease activity index, respectively. There was no significant difference between patients with mild disease activity (n = 30) and moderate disease activity (n = 12) with respect to sex, BMI and IR values. Patients with mild disease activity were significantly older (p < 0.05) and had significantly lower serum resistin levels (p < 0.05) compared to those with moderate disease activity. Conclusions: In our study, serum resistin levels which did not differ between IBD patients and healthy subjects, were elevated parallel to increasing disease activity. Higher serum resistin levels were also found in patients who received steroids owing to disease activation. IBD patients in remission did not display either increase in resistin levels or IR. Neither IBD patients in remission did not display either increase in resistin levels or IR.