Ischaemic colitis (IC) is a common condition with rising incidence, and in severe cases a high mortality rate. Its presentation, severity and disease behaviour can vary widely, and there exists significant heterogeneity in treatment strategies and resultant outcomes. In this article we explore practical challenges in the management of IC, and where available make evidence-based recommendations for its management based on a comprehensive review of available literature. An optimal approach to initial management requires early recognition of the diagnosis followed by prompt and appropriate investigation. Ideally, this should involve the input of both gastroenterology and surgery. CT with intravenous contrast is the imaging modality of choice. It can support clinical diagnosis, define the severity and distribution of ischaemia, and has prognostic value. In all but fulminant cases, this should be followed (within 48 hours) by lower gastrointestinal endoscopy to reach the distal-most extent of the disease, providing endoscopic (and histological) confirmation. The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation and antibiotics. Specific laboratory, radiological and endoscopic features are recognised to correlate with more severe disease, higher rates of surgical intervention and ultimately worse outcomes. These factors should be carefully considered when deciding on the need for and timing of surgical intervention.

Summary: Background: Immune checkpoint inhibitors have revolutionised cancer treatment, but at the cost of off‐target immune‐mediated organ damage. This includes checkpoint inhibitor‐induced enterocolitis which frequently requires hospitalisation and may be life‐threatening. Empiric treatment typically includes corticosteroids and infliximab, although no large‐scale studies have confirmed their effectiveness.Aim: To investigate the effectiveness of anti‐inflammatory therapy in checkpoint inhibitor‐induced enterocolitisMethods: We performed a systematic review and meta‐analysis of studies reporting clinical outcomes of checkpoint inhibitor‐induced enterocolitis in adult cancer patients treated with anti‐inflammatory agents. We searched Medline, EMBASE, and the Cochrane library through April and extracted the proportion of patients responding to anti‐inflammatory therapy. Variation in effect size was studied using a random‐effects meta‐regression analysis, with checkpoint inhibitor agent and tumour type as the variables.Results: Data were pooled from 1210 treated patients across 39 studies. Corticosteroids were effective in 59% (95% CI 54‐ 65) of patients, with response significantly more favourable in patients treated with anti‐PD‐1/L1 monotherapy, compared with anti‐CTLA‐4 containing regimens (78%, 95% CI 69‐85 vs 56 %, 95% CI 49‐63, P = 0.003), and more favourable in lung cancer patients compared with melanoma patients (88%, 95% CI 62‐97 vs 55%, 95% CI 47‐63, P = 0.04). Infliximab was effective in 81% (95% CI 73‐87) of patients, and vedolizumab in 85% (95% CI 60‐96).Conclusion: Corticosteroids, infliximab and vedolizumab, are effective in the treatment of checkpoint inhibitor‐induced enterocolitis. Checkpoint inhibitor regimen and cancer type were significant moderators in response to corticosteroid therapy.

The advent of monoclonal antibody therapies has revolutionised inflammatory bowel disease (IBD) treatment and delivered great benefits to patients. The optimal use of this class of drugs requires careful management and a clear understanding of their properties. In this review article, we consider how to maximise the benefit of our most novel biological agents, vedolizumab and ustekinumab. For each agent, we consider practical aspects including dose flexibility, evidence for use in combination with a conventional immunomodulator and the potential role of therapeutic drug monitoring. We also address positioning of the various mechanisms and agents in treatment algorithms as well as important aspects of managing patients receiving monoclonal antibodies, such as disease reassessment. Finally, we look ahead to the future of monoclonal antibodies, where not only have biosimilars increased the number of agents available but there are also a range of novel mechanisms currently in late phase clinical trials.

Objective To gain an understanding of the efficacy of vedolizumab in a ‘real-world’ setting. Design Retrospective cohort study using prospectively maintained clinical records. Setting Two UK tertiary inflammatory bowel disease (IBD) centres. Patients Patients with IBD commenced on vedolizumab at Guy's & St Thomas' and King's College Hospitals during November 2014–November 2015. Intervention Vedolizumab, a monoclonal antibody to α-4 β-7 integrins that selectively inhibit leucocyte migration into the gut. Main outcome measures Clinical disease activity was assessed at baseline, weeks 14 and 30 using Harvey–Bradshaw Index (HBI) for Crohn's disease (CD) and Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis (UC). Response was defined as HBI or SCCAI reduction ≥3. Remission was defined as HBI <5 or SCCAI <3. Continuous data are summarised as medians, followed by range. Results Fifty patients were included: 27 CD, 20 UC and 3 IBD-U (included in the UC group for analysis). At baseline visit, the median HBI was 8 (1–16) and SCCAI was 6 (0–15). At week 14, these values had fallen to 5 (0–15) (p=0.117) and 4 (0–10) (p=0.005), respectively. Additionally, week 30 data were available for 19 patients (9 CD, 10 UC). The clinical disease activity scores at that point were HBI 2 (0–7) (p=0.039) and SCCAI 2 (0–10) (p=0.023). At baseline, 37 (74%) of the 50 patients had clinically active disease. Of the patients with active disease, 22 (59%) responded and 14 (38%) achieved remission at week 14. Conclusions Our early experience with vedolizumab demonstrates a clear benefit in terms of disease control as well as a steroid-sparing effect in a cohort, which included patients with complex and previously refractory disease.

There are no universally accepted guidelines regarding surveillance of ulcerative colitis [UC] patients after restorative proctocolectomy and ileal pouch-anal anastomosis [IPAA]. There also exists a lack of validated quality assurance standards for performing pouchoscopy. To better understand IPAA surveillance practices in the face of this clinical equipoise, we carried out a retrospective cohort study at five inflammatory bowel disease [IBD] referral centres. Records of patients who underwent IPAA for UC or IBD unclassified [IBDU] were reviewed, and patients with <1-year follow-up after restoration of intestinal continuity were excluded. Criteria for determining the risk of pouch dysplasia formation were collected as well as the use of pouchoscopy, biopsies, and completeness of reports. We included 272 patients. Median duration of pouch follow-up was 10.5 [3.3-23.6] years; 95/272 [35%] had never undergone pouchoscopy for any indication; 191/272 [70%] had never undergone pouchoscopy with surveillance as the specific indication; and 3/26 [12%] high-risk patients had never undergone pouchoscopy. Two cases of adenocarcinoma were identified, occurring in the rectal cuff of low-risk patients. Patients under the care of surgeons appeared more likely to undergo surveillance, but rates of incomplete reporting were higher among surgeons [78%] than gastroenterologists [54%, p = 0.002]. We observed wide variation in surveillance of UC/IBDU-IPAA patients. In addition, the rate of neoplasia formation among 'low-risk' patients was higher than may have been expected. We therefore concur with previous recommendations that pouchoscopy be performed at 1 year postoperatively, to refine risk-stratification based on clinical factors alone. Reports should document findings in all regions of the pouch and biopsies should be taken.