This case demonstrates the utility of intestinal ultrasound in inflammatory bowel diseases outside of Crohn’s disease and ulcerative colitis. We describe the utility of intestinal ultrasound in monitoring disease activity and treatment response in a patient with microscopic colitis.

Chronic inflammatory bowel diseases, such as Crohn\'s disease and ulcerative colitis, present diagnostic challenges due to their complex and heterogeneous nature. While histology remains fundamental for accurate diagnosis, a multidisciplinary approach incorporating clinical, endoscopic, and imaging modalities is increasingly recognized as essential for comprehensive evaluation. This article delves into the importance of integrating various diagnostic techniques in the assessment of IBD. Colonoscopy and histology, with its ability to directly visualize the intestinal mucosa, play a central role in the diagnostic process. However, histological analysis alone may not suffice, necessitating the inclusion of advanced imaging techniques, such as magnetic resonance enterography (MRE), computed tomography enterography (CTE), and intestinal ultrasound (IUS). These techniques provide valuable insights into the disease\'s extent, severity, and complications, and should be used in conjunction with biochemical parameters. These modalities complement traditional endoscopic and histological findings, offering a more holistic understanding of the disease process. A multidisciplinary approach that incorporates clinical, endoscopic, histological, serological, and imaging assessments enables clinicians to achieve a more accurate and timely diagnosis of IBD. Moreover, this integrated approach facilitates personalized treatment strategies tailored to individual patient needs, ultimately improving clinical outcomes and quality of life for those affected by chronic inflammatory bowel diseases.

OBJECTIVE: Intestinal ultrasound has become a crucial tool for assessing inflammation in patients with inflammatory bowel disease, prompting a surge in demand for trained sonographers. While educational programs exist, the length of training needed to reach proficiency in correctly classifying inflammation remains unclear. Our study addresses this gap partly by exploring the learning curves associated with the deliberate practice of sonographic disease assessment, focusing on the key disease activity parameters of bowel wall thickness, bowel wall stratification, color Doppler signal, and inflammatory fat.
METHODS: Twenty-one novices and six certified intestinal ultrasound practitioners engaged in an 80-case deliberate practice online training program. A panel of three experts independently graded ultrasound images representing various degrees of disease activity and agreed upon a consensus score. We used statistical analyses, including mixed-effects regression models, to evaluate learning trajectories. Pass/fail thresholds distinguishing novices from certified practitioners were determined through contrasting-groups analyses.
RESULTS: Novices showed significant improvement in interpreting bowel wall thickness, surpassing the pass/fail threshold, and reached mastery level by case 80. For color Doppler signal and inflammatory fat, novices surpassed the pass/fail threshold but did not achieve mastery. Novices did not improve in assessing bowel wall stratification.
CONCLUSIONS: We found considerable individual and group-level differences in learning curves supporting the concept of competency-based training for assessing bowel wall thickness, color Doppler signal and inflammatory fat. However, despite practice over 80 cases, novices did not improve in their interpretation of bowel wall stratification, suggesting that a different approach is needed for this parameter.

BACKGROUND: The development of noninvasive markers to assess mucosal healing in ulcerative colitis (UC) is essential in the treat-to-target era. The aim of this study was to evaluate the performance of intestinal ultrasound (IUS), fecal calprotectin (FC), and their combination to assess mucosal healing in UC patients.
METHODS: All consecutive patients between January 2021 and September 2022 with UC who underwent a complete colonoscopy and IUS and/or an FC test within 4 weeks were included in a prospective cohort. Bowel wall thickness (BWT) and the color Doppler signal (CDS) were assessed for each segment. Endoscopic mucosal healing was defined by a Mayo score of 0 to 1.
RESULTS: A total of 61 patients were included, of whom 79% showed endoscopic healing (26 Mayo 0 and 11 Mayo 1). Among the patients, 16 (27.6%) of 58 had a BWT <3 mm, and 41 (70.7%) of 58 had no CDS. The sensitivity, specificity, positive predictive value, and negative predictive value of a BWT <3 mm to predict endoscopic mucosal healing were 37%, 77%, 72%, and 44%, respectively. The association of FC <150 µg/g, a BWT <3 mm, and a CDS = 0 increased the specificity and positive predictive value (sensitivity 33%, specificity 94%, positive predictive value 89%, negative predictive value 48%). The combination of a normal IUS, no rectal bleeding, and an FC <172 µg/g identified all patients with mucosal healing.
CONCLUSIONS: The combination of IUS and FC is effective in identifying mucosal healing in UC. Noninvasive evaluation of mucosal healing is possible for most UC patients.
Intestinal ultrasound and fecal calprotectin are efficient noninvasive tools to identify patients with ulcerative colitis (UC) who achieved endoscopic mucosal healing. The combination of intestinal ultrasound and fecal calprotectin is effective to identify mucosal healing in UC in most patients with UC.

METHODS: In the past 3 years, the use of intestinal ultrasound (IUS) for monitoring inflammatory bowel disease in clinical practice has grown substantially in the United States. This American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) aims to review the available evidence and guidance regarding the role of intestinal ultrasound in inflammatory bowel disease care.
METHODS: This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important and recently published studies in this field, and it reflects the experiences of the multidisciplinary group of authors composed of adult and pediatric gastroenterologists.

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There is a large pool of ideas in both mainstream and non-mainstream medicine on how diet can be manipulated in order to treat or prevent illnesses. Despite this, our understanding of how specific changes in diet influence the structure and function of the gastrointestinal tract is limited. This review aims to describe two areas that might provide key information on the integrity and function of the gastrointestinal tract. First, demystifying the \"leaky gut syndrome\" requires rational application and interpretation of tests of intestinal barrier function. Multiple ways of measuring barrier function have been described, but the inherent difficulties in translation from animal studies to humans have created misinterpretations and misconceptions. The intrinsic nature of intestinal barrier function is dynamic. This is seldom considered in studies of intestinal barrier assessment. To adequately understand the effects of dietary interventions on intestinal barrier function, background barrier function in different regions of the gut and the dynamic responses to stressors (such as psychological stress) should be assessed as a minimum. Second, intestinal ultrasound, which is now established in the assessment and monitoring of inflammatory bowel disease, has hitherto been poorly evaluated in assessing real-time intestinal function and novel aspects of structure in patients with disorders of gut-brain interaction. In conclusion, a more complete functional and structural profile that these investigations enable should permit a greater understanding of the effects of dietary manipulation on the gastrointestinal tract and provide clinically relevant information that, amongst other advantages, might permit opportunities for personalized health care delivery.

OBJECTIVE: Reliable and easily accessible objective markers of disease activity to predict long-term treatment outcomes in severe ulcerative colitis (UC) are missing. We aimed to investigate if intestinal ultrasound (IUS) might predict long-term outcomes in hospitalized patients with severe UC treated with intravenous corticosteroids.
METHODS: Hospitalized patients with severe UC and IUS inflammation (bowel wall thickness (BWT)>3.0mm) starting IV corticosteroids were recruited at three university hospitals in Denmark. IUS was performed before treatment, 48±24 hours (h), 6±1 days, and 3 months after treatment initiation. Time until colectomy or need for new interventions was registered together with Mayo score at 3 months and partial Mayo score (pMayo) at 12-months. Follow-up time was 12 months.
RESULTS: Fifty-six patients were included in the final analysis. Forty-five (80%) patients needed intervention, including 9 colectomies, during the 12-month follow-up. After 48±24h: No patient with a BWT<3mm needed a colectomy, p=0.04. BWT≥4mm showed an increased risk of colectomy (odds ratio 9.5 (95%CI 1.5-186), p=0.03), while a BWT≥3mm showed an increased risk of intervention (3.6 (1.1-12.5), p=0.03). A BWT≥4mm resulted in a significantly shorter time until both colectomy, p=0.03, and treatment intensification (mean days 75 (95%CI24-127) vs. 176 (119-233), p=0.005. However, neither IUS parameters nor pMayo score, CRP, hemoglobin, or p-albumin could predict remission at 3- and 12-months.
CONCLUSIONS: BWT assessed at 48h post intravenous corticosteroid initiation in patients hospitalized with severe UC may identify patients with an increased risk of short- and long-term colectomy and predict a more aggressive short-term disease course.

UNASSIGNED: The increasing adoption of intestinal ultrasound (IUS) for monitoring inflammatory bowel diseases (IBD) by IBD providers has uncovered new challenges regarding standardized image interpretation and limitations as a research tool. Artificial intelligence approaches can help address these challenges. We aim to determine the feasibility of radiomic analysis of IUS images and to determine if a radiomics-based classification model can accurately differentiate between normal and abnormal IUS images. We will also compare the radiomic-based model\'s performance to a convolutional neural network (CNN)-based classification model to understand which method is more effective for extracting meaningful information from IUS images.
UNASSIGNED: Retrospectively analyzing IUS images obtained during routine outpatient visits, we developed and tested radiomic-based and CNN-based models to distinguish between normal and abnormal images, with abnormal images defined as bowel wall thickness > 3 mm or bowel hyperemia with modified Limberg score ≥ 1 (both are surrogate markers for inflammation). Model performances were measured by area under the receiver operator curve (AUC).
UNASSIGNED: For this feasibility study, 125 images (33% abnormal) were analyzed. A radiomic-based model using XG boost yielded the best classifier model with average test AUC 0.98%, 93.8% sensitivity, 93.8% specificity, and 93.7% accuracy. The CNN-based classification model yielded an average testing AUC of 0.75.
UNASSIGNED: Radiomic analysis of IUS images is feasible, and a radiomic-based classification model could accurately differentiate abnormal from normal images. Our findings establish methods to facilitate future radiomic-based IUS studies that can help standardize image interpretation and expand IUS research capabilities.

UNASSIGNED: Real-world data on tofacitinib\'s effectiveness is limited and mainly retrospective or registry-based. We elected to conduct a pragmatic prospective study to assess the efficacy of tofacitinib for moderate to severe ulcerative colitis (UC), aiming to evaluate the ability of intestinal ultrasound (IUS) to discriminate responders vs. non-responders in real-time.
UNASSIGNED: This pragmatic prospective clinical study included consecutive adult patients starting tofacitinib treatment for active moderate to severe UC. Patients were evaluated at baseline and after 8 weeks of tofacitinib (clinical, biomarker, endoscopy, and IUS). The primary outcome was clinical response defined by a decrease in the full Mayo score (fMS) of ≥3 at week 8. Next, we explored ultrasonographic parameters in the sigmoid colon as potential real-time classifiers to differentiate between responders and non-responders at week 8.
UNASSIGNED: Overall, 30 adult patients started tofacitinib; the median age was 26.3 years (IQR 22.5-39.8), and 50% were female. Most patients (86.6%) had left-sided or extensive colitis, 96.7% had previously failed biologic therapy, and 60% (18/30) were on oral corticosteroids at the start of tofacitinib. At week 8, clinical response (a decrease in the fMS ≥ 3) and remission (fMS ≤ 2) rates were 40% (12/30) and 20% (6/30), respectively. Biomarker response (FC < 250µg/g) and biomarker normalization (FC ≤ 100µg/g) were achieved in 47.6% (10/21) and 38.1% (8/21) of patients, respectively. Endoscopic healing (endoscopic Mayo sub-score [EMS] ≤ 1) was achieved in 33.3% (10/30) of patients. Sigmoid bowel wall normalization as assessed by IUS (sBWT ≤ 3) was achieved in 18.2% (4/22). The best sBWT cut-off at week 8 to accurately classify endoscopic healing vs. no healing was a sBWT of 3.6 mm (AUC of 0.952 [95% CI: 0.868-1.036], p < 0.001).
UNASSIGNED: In this real-world pragmatic prospective study, tofacitinib was an effective treatment for moderate to severe UC, and IUS at week 8 accurately discriminated treatment response from non-response.