Researchers have identified early molecular warning signs of inflammatory bowel disease that may appear before symptoms and remain active even when patients seem to be doing well.
The study, led by WEHI in partnership with the Royal Melbourne Hospital, uncovered a hidden defect in intestinal cells that can make them vulnerable to damage. The problem was still detectable in some patients whose disease appeared to be well controlled.
Published in Science, the findings may help explain why people with inflammatory bowel disease can experience sudden flare-ups even after reaching remission.
Key findings
WEHI researchers identified a ‘smoldering’ molecular defect in gut cells from people with inflammatory bowel disease.
The defect involves abnormal cell death and could be detected even in patients whose disease was under good control.
The work, carried out through a broad collaboration with the Royal Melbourne Hospital, could eventually lead to earlier prediction of flare-ups, more precise monitoring and treatment tailored more closely to individual patients.
A hidden problem in intestinal cells
Inflammatory bowel disease (IBD), which includes conditions such as Crohn’s disease and ulcerative colitis, is a chronic condition that affects around 180,000 Australians.
People with IBD can experience serious symptoms including rectal bleeding, abdominal pain, diarrhea, fatigue, and weight loss.
Modern therapies can help many patients achieve remission, but diagnosing and managing IBD remains challenging.
The disease often alternates between periods when symptoms are controlled and sudden flare-ups that can become severe enough to require hospital care.
Study co-author Dr. Andre Samson said the researchers discovered that intestinal cells could remain vulnerable even when patients felt well, and their disease appeared stable.
“Once you’ve got the diagnosis, IBD doesn’t go away. Even if you become symptom-free on the current treatments, we know there’s a likelihood you’re going to have a flare or relapse,” said Dr. Samson.
“What we found in patient samples was that intestinal cells are primed to die. Even in patients with essentially no symptoms, there’s still this persistent problem sitting there.”
Cell death may help drive IBD
The results challenge the assumption that cell death in IBD is simply damage caused by inflammation. Instead, the researchers say abnormal cell death may be involved in helping drive the disease itself.
The defect was already present during the earliest stages of disease activity, including in patients with clinically mild IBD. Detecting it required detailed molecular analysis.
Study co-author Professor James Murphy said the discovery revealed a ‘smoldering’ molecular problem and encouraged the researchers to focus more closely on what happens at the beginning of the disease process.
“Most people have been focusing on the major clinical problem, when someone comes to hospital with severe gut inflammation,” Prof Murphy, a WEHI deputy director and lab head, said.
“We’ve gone to the other end of the spectrum and looked at gut tissue that doesn’t have clear signs of active disease. What we’re finding is this molecular defect happening very early in disease progression – one of the first dominoes to fall.”
Human tissue reveals clues to future flare-ups
The research relied entirely on human tissue and patient-derived organoids.
Working with clinicians from the Royal Melbourne Hospital, the team collected around 900 biopsies from 80 people with and without IBD. Researchers used those samples to grow organoids, lab-grown tissues derived from patients, allowing them to investigate the disease directly in human cells.
Study co-author Professor Edwin Hawkins, head of the Colonial Foundation Diagnostics Center where samples were analyzed, said the size and nature of the patient group were important strengths of the research.
“While cell death has been implicated in IBD for a long time, how it arises in humans has remained unclear, probably because most studies rely on mouse models which often do not accurately mimic the human condition,” Prof Hawkins, a WEHI lab head, said.
“Our study is based on human tissue and patient biopsies.”
Researchers then tracked the patients for more than two years. They found that people showing stronger intestinal cell death signaling were also more likely to experience a relapse.
Toward earlier IBD detection
IBD can behave very differently from one person to another, making it difficult to know who will respond to a particular treatment or who is most likely to relapse.
Study co-author Dr. Jiyi Pang said the newly identified molecular signals could eventually help scientists develop more precise tools for monitoring patients and selecting treatments based on the biology of an individual’s disease.
“The causes of IBD are largely unknown and quite variable,” Dr. Pang said.
“Using mini-intestinal organoids grown in a dish and by working alongside a diverse team of researchers and clinicians, we uncovered the inflammatory signals responsible for this cell death response.”
“We now have the hallmarks of what underlies disease at the molecular level. The question is which of those are therapeutically actionable and whether they might help us to better match treatments to patients, based on how their disease behaves at a molecular level.”
More personalized treatment could follow
Study co-author Dr. Aysha Al-Ani cautioned that the findings are unlikely to produce a new diagnostic test or therapy immediately. However, they provide a foundation for future research into better forecasting tools and potential treatments.
“It opens new avenues for different prognostic tools, using more sophisticated and refined methods than are currently used clinically,” Dr. Al-Ani said.
“The ethos behind IBD therapy is to reduce the frequency and severity of flares, halting disease progression and improving patients’ lives. More sensitive molecular detection may help us keep patients in deep remission for longer and introduce new treatments.”
The research team included scientists and clinicians from the University of Melbourne, the Royal Melbourne Hospital, Royal Children’s Hospital, Monash Institute of Pharmaceutical Sciences, the Hudson Institute of Medical Research and Monash University.
This work is supported by the Kenneth Rainin Foundation, the National Health and Medical Research Council of Australia (NHMRC), the Australian Research Council, the Stafford Fox Medical Research Foundation, the Colonial Foundation, Crohn’s and Colitis Australia, and the Victorian State Government.
