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Background Perianal disease is a disabling complication of Crohn’s disease (CD). In this study, we aimed to explore the incidence of fistulising perianal CD (PCD) and its association with treatment pattern and disease outcomes, within the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45,074). We also aimed to differentiate simple from complicated PCD. Methods The current analysis was performed on data from the two largest Health Maintenance Organisations (HMOs), covering 75% of the Israeli population. First, we developed and validated algorithms to identify fistulising PCD patients and differentiate simple from complex disease, by establishing two reference cohorts of true positive PCD patients (TP, patients with perianal abscess/fistula) classified into simple or complicated PCD, and true negatives (TN) of CD patients without perianal disease (validated by chart reviews). We then applied the algorithms on the complete epiIIRN IBD cohort. Random charts were reviewed to validate again PCD diagnosis. Results The chosen algorithm included patients with at least one perianal-related diagnosis, procedure or surgery (sensitivity/specificity 75%/96% for identifying PCD, and 70%/79% for differentiating complicated vs. simple PCD). Of the total 26,440 CD patients, 4237 (16%) had fistulising PCD, of whom 1004 (4% of the total) had complicated PCD. Those with complicated PCD were diagnosed with IBD at a younger age than simple PCD and non-PCD (29.2 ± 13.6 vs. 32.2 ± 16 and 32.8 ± 16.7 years, respectively) (p < 0.001). PCD patients were treated more often with biologics (32% in non-PCD compared with 47% in simple PCD and 70% in complicated PCD, p = 0.01), steroids (74%, 78% and 83%, respectively; p < 0.001) and immunomodulators (56%, 64% and 67%, respectively; p < 0.001). Despite this, PCD patients had more hospitalisations (median 0 (IQR 0–2), 5 (2–11) and 13 (7–22) in non PCD, simple PCD and complicated PCD, respectively, p < 0.001), more colon surgery (5%, 18% and 52% in non PCD, respectively, p < 0.001) and higher mortality compared with CD patients without perianal disease (p < 0.001). Conclusion Conclusion: Despite the higher utilisation of immunomodulators and biologics, patients with PCD are at higher risk of hospitalisation and surgical resection, higher need for steroids and higher mortality. PCD is a strong predictor of disease course and thus should prompt early intensified treatment and close monitoring. This study was supported by a grant from the Leona M. and Harry B. Helmsley Charitable Trust.

Background Bowel ultrasonography (BUS) for imaging of inflammatory bowel disease (IBD) is increasingly recognised as a prominent non-invasive tool to supplement, and in some cases replace traditional endoscopic and imaging modalities, with high sensitivity and specificity. The increasing number of gastroenterologists trained to perform BUS has transformed BUS into a bedside tool to guide routine clinical decision making and accurately monitor response to treatment. However, this process is still in its infancy in paediatric IBD. We present here data on the first 2 years of implementation of BUS performed by a paediatric gastroenterologist (RLT) at the paediatric IBD centre at Shaare Zedek Medical Center in Jerusalem. We aim to describe trends, results and clinical implications of the US studies performed during this period. Methods The electronic medical record system was searched for all BUS studies performed on IBD patients by RLT as part of his weekly IBD clinic between 2017–2019. Studies performed on other caregivers’ patients were excluded to ensure uniform documentation and nomenclature. Findings were classified as normal (wall thickness Results A total of 83 bedside BUS studies were performed on 55 IBD patients (42 with Crohn’s – CD) during the study period, with a mean age of 15.1 ± 3.7 years. Thirty-four had one study (23 with CD), 15 had two (13 with CD) and 6 had three or more (all with CD). Overall, 32 studies were normal, 20 showed mild findings and 30 showed significant inflammation. Four studies found stenosis and one showed an abscess. Follow-up studies of initially active disease showed 10/16 (63%) with improvement, including 9/16 (56%) with sonographic remission. 22/83 (27%) studies were felt upon review to have had a direct impact on clinical decision-making. These included decisions not to switch therapy due to normal BUS despite symptoms, admission due to discovery of an abscess, decision to escalate therapy due to lack of sonographic improvement, and decision to continue adalimumab in the presence of a stricture due to favourable prognostic characteristics as per the CREOLE study. Conclusion Bedside BUS is a practical and useful tool that can be integrated into a paediatric IBD clinic, with the ability to provide relevant information in real-time and thus impact on day-to-day patient management.

Background Up to 25% of patients with ulcerative colitis (UC) may undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis may occur in 50–70% of patients, and ~30% may develop chronic pouchitis (CP) or Crohn’s-like disease of the pouch (CLDP). We aimed to identify predictors for the development of CP or CLDP during a long follow-up period. Methods Patients followed prospectively at the pouch clinic at Rabin Medical Center, were cross-referenced with data from the validated epiIIRN cohort which includes all IBD patients in Israel (n = 45 074). All patients had at least one year of follow-up since ileal continuity (i.e., ileostomy closure after pouch formation). CP was defined as an active flare of pouchitis for >4 weeks and being treated with antibiotics or anti-inflammatory therapy, or >4 episodes of acute pouchitis/year. CLDP was defined as having one or more of the following: pouch-related fistula (>1 year after ileostomy closure), inflammation of the afferent limb, or fibrostenotic disease of the pouch. For the analysis, the cohort was further categorised into favourable pouch outcomes (sustained normal pouch, acute pouchitis) vs. unfavourable pouch outcomes (CP, CLDP or pouch failure). Logistic regression included gender, age, previous therapies, disease duration before pouch surgery, surgical technique and number of previous non-IBD related abdominal operations. Results We included 182 patients (55% females; median age at IPAA: 32 years (IQR 23–45); median disease duration until pouch surgery 6 years (3–11); two-staged surgery 69%). The median follow up time was 14 years (IQR 7–22). Before surgery, 37% of patients had been exposed to immunomodulators (either thiopurines or methotrexate), 24% were exposed to anti-TNF therapy and 5% were previously treated with vedolizumab. An unfavourable pouch phenotype was noted in 48% of patients. On multivariate logistic regression, anti-TNF therapy and older age at pouch surgery were associated with decreased odds of an unfavourable pouch outcome (OR 0.3 95% CI 0.11–0.69, p = 0.007 and OR 0.96 95% CI 0.93–0.98, p = 0.005, respectively). Conclusion Therapy of UC with an anti-TNF and older age were associated with a favourable pouch outcome. These may be surrogates for patients with longer follow up as well as indication for IPAA. Such factors should be taken into consideration in clinical decision making.