Less invasive markers, new treatments, and recognition of demographic characteristics of the disease are the main focuses of IDOR’s Gastroenterology research. 

Inflammatory Bowel Diseases (IBD) are autoimmune diseases characterized by chronic inflammation in the gastrointestinal tract. The main symptoms include abdominal pain, cramps, diarrhea, rectal bleeding, urgency to evacuate, and fatigue. The disease can affect individuals of any gender or age, but it’s more commonly developed in the under-30 population. 

At IDOR, IBD motivates various research projects in the field of Gastroenterology, whether it be on finding disease markers, testing new medications, or defining its epidemiological distribution. Currently, there are no conclusive findings on the origin of IBD, but evidence suggests that genetic predispositions may trigger harmful immune reactions to the patients’ intestinal flora, also known as the intestinal microbiota. 

Searching for IBD blood markers 

Investigating IBD is the main research focus of Dr. Heitor Siffert de Souza, a scientist at IDOR and a faculty member of the Institute’s Ph.D. Program, as well as a researcher and professor at the Federal University of Rio de Janeiro (UFRJ). 

In one of his investigative lines, his goal is to find less invasive biomarkers for IBD and colorectal câncer by identifying these diseases through simple and non-invasive tests. According to the researcher, traditional procedures for diagnosing IBD – endoscopy and colonoscopy – usually require patient sedation, and besides being uncomfortable, these exams are less accessible due to their cost and complexity, which can hinder early disease diagnosis in poorer populations. 

In this research line, conducted by IDOR in partnership with the National Cancer Institute (Inca), the State University of Rio de Janeiro (UERJ), and UFRJ, Dr. Siffert de Souza collects blood samples from patients diagnosed with IBD to identify blood alterations that characterize the disease. The research, in the final stages of the collection process, includes samples from over 500 IBD patients that the doctor attends at the UFRJ’s University Hospital. He notes that many of his patients only seek medical attention when the disease is aggravated, and identifying the problem precociously through routine exams could be of great relevance to the entire population, especially the large portion that relies on the Unified Health System (SUS) of Brazil. 

Searching for demographic markers of IBD 

In addition to seeking predictors of IBD through small markers in the blood, Dr. Heitor Siffert de Souza also investigates the disease through large databases, mainly provided by DATASUS and IBGE (public data sources in Brazil), focusing on cases recorded in Brazil over the last 12 years. In this line, his interest is to identify the demographic patterns of the main populations affected by the disease. 

The doctor reports an increase in IBD cases in the world’s Western population, especially in large urban centers, but his focus is on studying Brazil and the irregular distribution of diagnoses in the country. “The mapping shows that IBD cases are reaching the interior of the country, not just in large cities, which shows that the disease is not only related to the pollution or industrialization of these places. We have fewer cases in the Amazon area than in the Southeast and South of the country, but the South is not highly populated, which also reveals that a high population density is not necessary for the problem to occur. The state of Espírito Santo has more cases than the state of Rio de Janeiro, which has a much larger population. It is interesting to study these geographical and social differences in Brazil itself,” shares the researcher, who believes that these data could be interesting for the development of personalized health interventions for different population groups. 

Standardized care for Early Diagnosis and treatment of IBD 

IBD is not only a research topic at IDOR but also an assistive focus for many of its researchers who work as doctors at Rede D’Or Hospitals. Among them is Dr. Antônio Carlos Moraes, a researcher at IDOR and head of the Internal Medicine Service at Copa D’Or Hospital in Rio de Janeiro. Moraes is the creator of  Gastro D’Or, an ambitious project for standardizing care in the company hospitals. The project has as one of its main objectives the early identification and treatment of gastrointestinal diseases. 

The gastroenterologist, also a full member of the Brazilian Federation of Gastroenterology, reports that one of Gastro D’Or’s lines of care is entirely dedicated to IBD, “The average time for IBD diagnosis is long, about three and a half years, and during this time, the patient usually has five visits to the emergency room. Our goal is to reduce these numbers,” he clarifies. 

The researcher details that Gastro D’Or has representatives in most Rede D’Or Hospitals, and the care protocol is standardized since the patient’s first consultation, where questions are asked to identify the possibility of developing IBD. This standardization also occurs through the training of emergency teams, that are taught to recognize characteristics that may be signs of the disease. All these symptoms are then evaluated and referred to a specialist, facilitating early diagnosis. 

The standardization of the protocol also includes exams: all diagnostic procedures, such as endoscopy, radiology, and pathological analysis, follow the same model in all hospitals. Doctors from different states are instructed to align the language in their reports, a direction that applies not only to gastroenterologists but also to radiologists and hepatologists. “There is no way to retrospectively look at a patient if the colleague from, for example, the state of Maranhão reports differently from the colleague from São Paulo State. Words and classifications must be the same in all hospitals so that we have standardized reports,” defends Moraes. 

Having implemented Gastro D’Or in April 2021, the researcher continues to lead the national initiative to this day, showing pride in his team’s results. “Gastro D’Or is already very mature and established at Rde D’Or. We have already accumulated over 500,000 consultations, 146,000 exams, and almost 4,000 surgeries. We still have monthly meetings where we discuss clinical cases with multidisciplinary teams,” he adds, revealing that the project plans to expand to even more Rede D’Or Hospitals in the coming years. 

The quality and standardization of procedures benefit patients not only in early diagnoses but also in the development of new therapies for IBD, which occurs through research conducted by IDOR in partnership with the pharmaceutical industry. Other studies on IBD can also be requested by Gastro D’Or members or by master’s and doctoral students at the Institute. “An example is the Tooth Fairy study, a research project where we aim to analyze the baby teeth of people with IBD. Baby teeth saved by mothers or patients themselves can be mineralogically evaluated, and we want to verify if in certain populations it is possible to identify the inflammatory profile already in childhood. The IDOR Research Ethics Committee validates the recruitment of patients in the D’Or Network for studies like this,” adds the researcher. 

The role of the microbiota in IBD 

While the care for patients with IBD appears well-structured, the understanding of the progressive increase of the disease still seems distant. For Dr. Heitor Siffert de Souza, this may indicate that there is no single cause for the problem, which may be the result of multifactorial changes in people’s environment and lifestyle. 

Although the scientist values and invests in the search for specific markers for the disease, he emphasizes that humans cannot be disconnected from the environment in which they live. “IBDs are complex diseases, they don’t have a single cause. They can be responses to environmental agents, such as food, lifestyle, pollution, etc. In this world of external agents, we also include the microbiota, which occupies the importance of a human organ, with essential functions in digestion, nutrient production, and control of pathogenic bacteria. We cannot live without it,” comments the researcher. 

Siffert believes in the scientific hypothesis that the microbiota reflects much of the environment in which we live and is also altered by it. Excessive use of antibiotics, contaminated soil, water pollution, and foods altered by hormones and pesticides may be causing changes in this microecosystem. “Do we want this story to end? Saying that we have to exercise, and avoid sugar, alcoholic beverages, and smoking is obvious, but not enough. We have to ask the right question: Why are we sedentary? Why don’t we have a balanced diet? Pollution and stress are all factors of a set. The intestine is an interesting organ because it is a great reflection of the environment,” explains the researcher, who understands the microbiota as an important reflection of the living conditions of the population and considers that containing IBD cases may go beyond medical care, requiring public policy interventions. 

In a third line of research, Siffert is also developing studies in partnership with IDOR’s Pediatrics area, where his goal is to investigate the development of the human microbiota since its fetal stage. “Fetuses have atrophic intestines and do not develop inflammation. As this intestine is exposed to the environment, it is populated by bacteria and begins to grow, increasing its regenerative potential but also increasing the army of inflammatory cells that will live there with trillions of bacteria, fungi, and even viruses in the microbiota. By the way, the largest army of immune cells in the body is in the intestine, not in the lymph nodes, nor the bone marrow, and I believe that immunology is very linked to the microbiota. So much so that treatments for IBD are based on immunosuppression. These diseases are also commonly characterized by dysbiosis, an imbalance in the microbiota that causes frequent inflammatory reactions,” bets the researcher. 

The investigation of emerging public health issues is a major hallmark of research at IDOR, which seeks to promote scientific advancement combined with an increase in the quality of life for the population. Including fronts that encompass clinical research, laboratory work, and demographic analyses, ongoing studies in the field of Gastroenterology at IDOR promise to provide relevant information for the understanding of IBD, contributing both to the international scientific community and to the foundation of specific interventions that can be addressed to heterogeneous epidemiological scenarios, just like the ones found in Brazil. 

Written by Maria Eduarda Ledo de Abreu.