DOP126ECCO Topical Review on IBD-like patterns of drug colitis with practical guidance and a focus on immune checkpoint inhibitors

Abstract Background Drug-induced colitis (DIC) represents a heterogeneous and diagnostically challenging group of gastrointestinal mucosal injuries. The clinical, endoscopic, and histological manifestations of DIC often overlap with other pathologies, including IBD. Given the increasing recognition of immune checkpoint inhibitor (ICI)–associated colitis and the absence of standardised diagnostic or therapeutic algorithms, ECCO convened a multidisciplinary panel to review the features of DIC, with specific focus on ICI-induced disease. Methods A panel of gastroenterologists, histopathologists, and oncologists systematically reviewed literature identified through Medline, PubMed, EMBASE, and Scopus. Evidence was synthesised to develop ECCO Current Practice Positions addressing diagnostic principles, pathological patterns, therapeutic strategies, and ICI-specific considerations. Practice positions were refined and approved through structured group consensus. Results Twenty-three practice positions were formulated and agreed upon (Table 1). DIC may present with multiple histological patterns—including IBD-like or chronic colitis, acute colitis, microscopic colitis, ischaemic-type injury, and mixed features—few of which are specific. Close communication between clinicians and pathologists is essential to integrate clinical context and optimise diagnosis. For ICI-induced colitis, assessment should include CTCAE-based symptom grading, stool analysis for infection and calprotectin, endoscopy with biopsy, and imaging when indicated. Corticosteroids remain the mainstay of therapy; mild or microscopic forms may respond to budesonide or beclomethasone. Steroid-refractory or -dependent cases should escalate quickly to infliximab or vedolizumab, while surgery is reserved for refractory or complicated disease. Nutritional optimisation is recommended, and antimotility agents should be avoided in severe colitis. Rechallenge with ICIs can be considered following multidisciplinary evaluation, with strategy adaptation based on prior severity and treatment class. Patients with IBD receiving ICIs require careful baseline assessment and control of intestinal inflammation before treatment initiation. Conclusion DIC encompasses diverse clinicopathological entities requiring multidisciplinary evaluation and integrated diagnostic strategies. These ECCO Current Practice Positions provide a structured framework for diagnosis, pathology reporting, and treatment—particularly in the setting of ICI-induced colitis. Conflict of interest: Verstockt, Bram: - Research support from AbbVie, Biora Therapeutics, Celltrion, Landos, Pfizer, Sanofi, Sossei Heptares/Nxera and Takeda. - Speaker’s fees from Abbvie, Agomab, Alfasigma, Biogen, Bristol Myers Squibb, Celltrion, Eli Lily, Falk, Ferring, Galapagos, Materia Prima, Johnson and Johnson, Pfizer, Sandoz, Takeda, Tillots Pharma, Truvion and Viatris. - Consultancy fees from Abbvie, Alfasigma, Alimentiv, Anaptys Bio, Applied Strategic, Astrazeneca, Atheneum, BenevolentAI, Biora Therapeutics, Boxer Capital, Bristol Myers Squibb, Domain Therapeutics, Eli Lily, Galapagos, Guidepont, Landos, Merck, Mirador Therapeutics, Mylan, Nxera, Inotrem, Ipsos, Johnson and Johnson, Pfizer, Sandoz, Sanofi, Santa Ana Bio, Sapphire Therapeutics, Sosei Heptares, Takeda, Tillots Pharma and Viatris. - Stock options Vagustim and Thethis Pharma. Dragoni, Gabriele: Grant: ECCO Grant 2020 ECCO/AOCC Travel Grant 2021 ECCO IIS Registry Grant 2023 ECCO/IBUS Research Grant 2023 Personal Fees: - Speaker’s fees from: 2020: Novartis 2022: Janssen 2023: Alfasigma, Janssen, Pfizer, and Takeda 2024: Ferring, Johnson & Johnson, Eli Lilly, Pfizer, and Takeda 2025: Abbvie, Alfasigma, Ferring, Eli Lilly, LionHealth, Pfizer, Takeda - Advisory board fees from: 2023: Celltrion Healthcare and Pfizer 2024: AbbVie 2025: AbbVie, Johnson & Johnson Borralho Nunes, Paula: Personal Fees: MSD Burisch, Johan: Grant: Johnson & Johnson, MSD, Takeda, Tillots Pharma, BMS, Novo Nordisk Personal Fees: Celgene, MSD, Pfizer, AbbVie, Takeda, Tillots Pharma, Samsung Bioepis, BMS, Pharmacosmos, Galapagos, Zealand Pharma, Orion Pharma, Ferring, Johnson & Johnson Carbonnel, Franck: Grant: Alpha Wassermann, Nestlé, Mayoly Spindler Personal Fees: Abbvie, Arena, Biogen, Celltrion, Enterome, Ferring, Janssen, MaaT Pharma, Nestlé, Nordic Pharma, Pierre Fabre, Pharmacosmos, Roche, Takeda, Tillotts, Viatris Dekervel, Jeroen: Grants/Research Support: AstraZeneca, Bayer, Roche Speakers Bureau/Honoraria: Amgen, Astellas, AstraZeneca, Bayer, BeOne, BMS, Eisai, Ipsen, Lilly, MediMix, Merck, MSD, Roche, Servier Consulting Fees: AbbVie, Astellas, AstraZeneca, Bayer, BeOne, BMS, Eisai, Medtalks, MSD, Need Inc., Novartis, Incyte, Ipsen, Roche Travel grants: Amgen, AstraZeneca, Ipsen, Servier, Roche Driessen, Ann: No conflict of interest Ordás Jiménez, Ingrid: I have received financial support for travel and educational activities, and have served as a speaker or advisory board member for the following companies AbbVie, MSD, Pfizer, Takeda, Janssen, Kern Pharma, Chiesi, Falk Pharma, and Faes Farma. I have also received research funding from AbbVie, Faes Farma, and Takeda. Powell, Nick: Grant: Takeda, BMS, Pfizer, Astra-Zeneca Personal Fees: Abbvie, Abivax, Allergan, Astra-Zeneca, Bristol-Myers Squibb, Celgene, Celltrion, Dr Falk Pharma UK Ltd, Ferring, Galapagos, GSK, Janssen, MSD, Roche, Pfizer, Sobi, Takeda, Tillotts Rosini, Francesca: No conflicts Sleiman, Joseph: None Solitano, Virginia: Speaker’s fees from Pfizer, Takeda, Giuliani, Tillotts Pharma consulting fees from J & J travel grant from Abbvie van Schaik, Fiona: FDM van Schaik has received consultancy fees from Takeda, Galapagos and AbbVie, speaker’s honoraria from Galapagos, Lilly, AbbVie and Janssen-Cilag B.V., hospitality fees from Ferring and dr. Falk Farma and an unrestricted research grant from Takeda. Queiroz, Natalia: Personal Fees: NSFQ has served as a speaker and advisory board member of Janssen, Takeda and Abbvie. Feakins, Roger M.: Personal Fees: Payments received from AbbVie, Takeda, Bristol Myers Squibb, Decibio and Janssen in the past 5 years, or payments pending from Jazz and EliLilly in the next year, for lectures and consultations. Fees regularly from Alimentiv Clinical Trials for clinical trial work. Regular fees for reporting work for private sector pathology laboratory in London, UK (Unilabs).