This transcript has been edited for clarity.
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Welcome to part 3 — the finale, if you will — of my video series highlighting the best research from Digestive Disease Week (DDW) 2024, which was held this year in Washington, DC.
In part 1 and part 2 of this series, I focused largely on studies related to endoscopy and inflammatory bowel disease (IBD), respectively. In this last overview, I've identified seven noteworthy abstracts and presentations that touch on a wide-ranging number of topics, but which are nonetheless unified by their attention-grabbing findings.
A Disconcerting Rise in Colorectal Cancer Among the Young
The first study of interest provides some very alarming results about colorectal cancer in younger patients.[1] Researchers used a 20-year database from the Centers for Disease Control and Prevention, which captured nearly 3 million cases of colorectal cancer, virtually all such diagnoses reported in the United States during this time.
The increase in colorectal cancer in patients under 45 was significant. Between 1999 and 2020, the incidence of colorectal cancer increased by 333% in teens aged 15-19, 185% in those aged 20-24, and 45% in those aged 40-44. This latter group had the highest incident rate, at 21.2 per 100,000 individuals in 2020.
These results mean that colon cancer is not, and should not, be considered a disease restricted to the older population. Younger age is not a protector against this disease.
It's important that the public is aware of this. The signs and symptoms of colorectal cancer in the younger population, particularly bleeding, should be a discriminant alarm sign that requires further evaluation.
Imaging Studies Shed Light on Brain-Gut Axis in Inflammatory and Functional Disease
A couple of studies caught my eye that dealt with newer imaging techniques — specifically, functional MRI — in the assessment of the brain-gut axis.
The first such study[2] analyzed differences in brain gray-matter volume and functional connectivity between patients with active and inactive Crohn's disease, as well as healthy controls. The researchers observed demonstrable differences between patients whose Crohn's disease was in remission vs those with active disease and healthy controls.
Along the same lines, the second study[3] looked at the brain morphology of a subset of patients with IBD, although notably, patients with functional dyspepsia and irritable bowel syndrome were also included. Researchers again identified significant differences in brain morphology and connectivity, this time depending on whether patients had functional diseases or inflammatory diseases.
Collectively, these newer imaging assessments of the gut-brain axis provide valuable insights into neurologic involvement in these conditions. For functional diseases, we can see evident changes in the brain. This means that when patients come to us with symptoms of these diseases, we can unironically say, it really is all in your head, as well as in your gut, where we see biologic changes as well.
Serious Adverse Events Take a Considerable Psychosocial Toll on Endoscopists
One noteworthy study identified a key unmet need that we're almost entirely overlooking in the field of gastroenterology. This came from the team of investigators behind the INNOCENT Study,[4] who studied the psychological impacts of severe adverse events (SAEs) on endoscopists.
We know that complications can occur during these procedures under normal circumstances, but by nature, they're more likely to occur with interventional endoscopy.
Investigators surveyed 195 interventional endoscopists about the psychological impact they experienced following an SAE. Approximately 73% said they felt psychologically impacted by SAEs. The most frequent impactful SAEs were perforation and death. Endoscopists performing 500-1000 procedures annually were more likely to report experiencing nightmares or physical reactions after SAEs.
Participating gastroenterologists were also asked whether their centers provided support programs following SAEs. This led to a very alarming finding: Out of all these centers, seven had such a support program, but 120 did not.
I view this as a call to action. Centers need to be evaluating this now, in order to promote the mental health and well-being of the physicians who perform these critically needed procedures.
Adrenal Insufficiency in IBD
In a very provocative study,[5] investigators performed a systematic literature review and subsequent meta-analysis of findings in patients with IBD treated with oral steroids or rectal steroids. They assessed the hypothalamic-pituitary-adrenal axis leading to adrenal insufficiency, as measured by cortisol levels or adrenocorticotropic hormone stimulation tests, in pediatric and adult populations. They found no significant difference in adrenal insufficiency based on oral formulation or age. The prevalence of adrenal insufficiency was 46.9% with oral steroids, 31.2% with budesonide, and 5.3% with rectal steroids.
These results indicate that when administering glucocorticoid treatments, we need to be acutely attuned to the fact that adrenal insufficiency occurs in 1 in 3 patients on oral treatments.
Even though this is less common with rectal steroids, we still need to be educated enough about the risk for adrenal insufficiency to mitigate and treat it, when appropriate.
Wearable Tech for Monitoring IBD
Another study I wanted to highlight involves monitoring IBD using wearable technology, which assesses sweat as a biofluid for sampling inflammatory markers and cytokines.[6] The feasibility of using this device was tested in adult patients with an IBD-related hospital admission, who were compared against a cohort of healthy subjects. Data obtained from the wearable device was uploaded via Bluetooth to a cloud server. Investigators then drew daily blood to identify serum levels of tumor necrosis factor (TNF) alpha.
There was a striking, significant difference in sweat TNF-alpha measurements between those with active IBD and healthy controls (P < .0001). These results suggest that we may soon be able to use a wearable device to assess disease activity, specifically for cytokine expression in IBD.
Platelet-Rich Stroma for Treatment-Refractory Perianal Fistulizing Crohn's Disease
Our final study[7] was conducted in a group of adult patients with treatment-refractory perianal fistulizing Crohn's disease. All patients were treated with a platelet-rich stroma (PRS) solution, a combination of stromal vascular fraction and platelet-rich plasma. PRS is obtained via autologous procurement. The stromal vascular fraction can come from adipose or from bone marrow, although there's certainly an abundance of adipose tissue to harvest. All patients underwent fistula curettage, closure of the internal fistula opening, and PRS injection. The majority of patients (68%) were also on biologics.
Investigators in the Netherlands had previously published 1-year data from this pilot study in 2023. This long-term study extended that follow-up period to a mean of 3.7 years. At final follow-up, complete closure was reached in 88% of patients. I've never seen a complete closure rate like that before. In addition, complete radiologic closure was achieved in 75% and partial clinical closure in 100%.
This is an extremely exciting technology. Future randomized research is warranted to look at this and potentially further expand the understanding of how it can be a demonstrably efficacious treatment for a very complex patient population.
This concludes my highlights from DDW 2024. I'm Dr David Johnson. Thanks again for listening.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.
COMMENTARY
7 Studies Likely to Reshape GI Care in the Years Ahead
Digestive Disease Week (DDW) 2024 Highlights: Part 3
David A. Johnson, MD
DISCLOSURES
| June 07, 2024This transcript has been edited for clarity.
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Welcome to part 3 — the finale, if you will — of my video series highlighting the best research from Digestive Disease Week (DDW) 2024, which was held this year in Washington, DC.
In part 1 and part 2 of this series, I focused largely on studies related to endoscopy and inflammatory bowel disease (IBD), respectively. In this last overview, I've identified seven noteworthy abstracts and presentations that touch on a wide-ranging number of topics, but which are nonetheless unified by their attention-grabbing findings.
A Disconcerting Rise in Colorectal Cancer Among the Young
The first study of interest provides some very alarming results about colorectal cancer in younger patients.[1] Researchers used a 20-year database from the Centers for Disease Control and Prevention, which captured nearly 3 million cases of colorectal cancer, virtually all such diagnoses reported in the United States during this time.
The increase in colorectal cancer in patients under 45 was significant. Between 1999 and 2020, the incidence of colorectal cancer increased by 333% in teens aged 15-19, 185% in those aged 20-24, and 45% in those aged 40-44. This latter group had the highest incident rate, at 21.2 per 100,000 individuals in 2020.
These results mean that colon cancer is not, and should not, be considered a disease restricted to the older population. Younger age is not a protector against this disease.
It's important that the public is aware of this. The signs and symptoms of colorectal cancer in the younger population, particularly bleeding, should be a discriminant alarm sign that requires further evaluation.
Imaging Studies Shed Light on Brain-Gut Axis in Inflammatory and Functional Disease
A couple of studies caught my eye that dealt with newer imaging techniques — specifically, functional MRI — in the assessment of the brain-gut axis.
The first such study[2] analyzed differences in brain gray-matter volume and functional connectivity between patients with active and inactive Crohn's disease, as well as healthy controls. The researchers observed demonstrable differences between patients whose Crohn's disease was in remission vs those with active disease and healthy controls.
Along the same lines, the second study[3] looked at the brain morphology of a subset of patients with IBD, although notably, patients with functional dyspepsia and irritable bowel syndrome were also included. Researchers again identified significant differences in brain morphology and connectivity, this time depending on whether patients had functional diseases or inflammatory diseases.
Collectively, these newer imaging assessments of the gut-brain axis provide valuable insights into neurologic involvement in these conditions. For functional diseases, we can see evident changes in the brain. This means that when patients come to us with symptoms of these diseases, we can unironically say, it really is all in your head, as well as in your gut, where we see biologic changes as well.
Serious Adverse Events Take a Considerable Psychosocial Toll on Endoscopists
One noteworthy study identified a key unmet need that we're almost entirely overlooking in the field of gastroenterology. This came from the team of investigators behind the INNOCENT Study,[4] who studied the psychological impacts of severe adverse events (SAEs) on endoscopists.
We know that complications can occur during these procedures under normal circumstances, but by nature, they're more likely to occur with interventional endoscopy.
Investigators surveyed 195 interventional endoscopists about the psychological impact they experienced following an SAE. Approximately 73% said they felt psychologically impacted by SAEs. The most frequent impactful SAEs were perforation and death. Endoscopists performing 500-1000 procedures annually were more likely to report experiencing nightmares or physical reactions after SAEs.
Participating gastroenterologists were also asked whether their centers provided support programs following SAEs. This led to a very alarming finding: Out of all these centers, seven had such a support program, but 120 did not.
I view this as a call to action. Centers need to be evaluating this now, in order to promote the mental health and well-being of the physicians who perform these critically needed procedures.
Adrenal Insufficiency in IBD
In a very provocative study,[5] investigators performed a systematic literature review and subsequent meta-analysis of findings in patients with IBD treated with oral steroids or rectal steroids. They assessed the hypothalamic-pituitary-adrenal axis leading to adrenal insufficiency, as measured by cortisol levels or adrenocorticotropic hormone stimulation tests, in pediatric and adult populations. They found no significant difference in adrenal insufficiency based on oral formulation or age. The prevalence of adrenal insufficiency was 46.9% with oral steroids, 31.2% with budesonide, and 5.3% with rectal steroids.
These results indicate that when administering glucocorticoid treatments, we need to be acutely attuned to the fact that adrenal insufficiency occurs in 1 in 3 patients on oral treatments.
Even though this is less common with rectal steroids, we still need to be educated enough about the risk for adrenal insufficiency to mitigate and treat it, when appropriate.
Wearable Tech for Monitoring IBD
Another study I wanted to highlight involves monitoring IBD using wearable technology, which assesses sweat as a biofluid for sampling inflammatory markers and cytokines.[6] The feasibility of using this device was tested in adult patients with an IBD-related hospital admission, who were compared against a cohort of healthy subjects. Data obtained from the wearable device was uploaded via Bluetooth to a cloud server. Investigators then drew daily blood to identify serum levels of tumor necrosis factor (TNF) alpha.
There was a striking, significant difference in sweat TNF-alpha measurements between those with active IBD and healthy controls (P < .0001). These results suggest that we may soon be able to use a wearable device to assess disease activity, specifically for cytokine expression in IBD.
Platelet-Rich Stroma for Treatment-Refractory Perianal Fistulizing Crohn's Disease
Our final study[7] was conducted in a group of adult patients with treatment-refractory perianal fistulizing Crohn's disease. All patients were treated with a platelet-rich stroma (PRS) solution, a combination of stromal vascular fraction and platelet-rich plasma. PRS is obtained via autologous procurement. The stromal vascular fraction can come from adipose or from bone marrow, although there's certainly an abundance of adipose tissue to harvest. All patients underwent fistula curettage, closure of the internal fistula opening, and PRS injection. The majority of patients (68%) were also on biologics.
Investigators in the Netherlands had previously published 1-year data from this pilot study in 2023. This long-term study extended that follow-up period to a mean of 3.7 years. At final follow-up, complete closure was reached in 88% of patients. I've never seen a complete closure rate like that before. In addition, complete radiologic closure was achieved in 75% and partial clinical closure in 100%.
This is an extremely exciting technology. Future randomized research is warranted to look at this and potentially further expand the understanding of how it can be a demonstrably efficacious treatment for a very complex patient population.
This concludes my highlights from DDW 2024. I'm Dr David Johnson. Thanks again for listening.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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