BACKGROUND:The most common causes for ulcero-stricturing diseases of the ileo-cecal region and colon in Southeast Asia are Crohn's disease (CD) and gastrointestinal tuberculosis (GI TB). Diagnosing these conditions is challenging because they share several clinical, endoscopic, radiological and histological features on mucosal biopsies. Therefore, there is a need to standardize the sampling, processing and interpretation of mucosal biopsies to aid clinical decision-making. METHODS:Recognizing this challenge, core subject experts nominated by the Indian Association of Pathologists and Microbiologists (IAPM), the Indian Society of Gastroenterology (ISG) and the Colitis and Crohn's Foundation, India (CCFI), collaborated to formulate comprehensive recommendations for pathologists regarding optimal biopsy protocols, histological interpretation and reporting for differentiating CD from GI TB. A structured Delphi process was followed. RESULTS:The recommendations from the core domain expert groups were based on discussions, brainstorming sessions and extensive literature reviews conducted over three virtual group meetings, multiple online voting sessions and one physical meeting involving all experts. This document is expected to standardize the practice of luminal gastroenterology by providing a ready reference for budding specialists and pathologists, thereby promoting uniformity in practice. CONCLUSION:These multi-society, evidence-based and practically applicable recommendations developed by core subject experts aim to promote uniformity and confidence in pathology reports, facilitate timely patient management and prevent complications arising from erroneous treatment.

Intestinal ultrasound (IUS) has emerged as a promising bedside tool for evaluating disease activity in Crohn’s disease (CD), but real-world data using standardized ultrasound activity scores remain limited. In this cross-sectional observational study, patients with ileal, colonic or ileocolonic CD underwent IUS and ileocolonoscopy within a two-week interval. IUS findings were quantified using the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS). Endoscopic activity was assessed using the Simple Endoscopic Score for Crohn’s Disease (SES-CD). Diagnostic performance of IBUS-SAS for detecting endoscopic activity (SES-CD ≥ 3) was evaluated using receiver operating characteristic (ROC) analysis. Construct validity was assessed using Spearman correlation, discordance analyses and multi-variable logistic regression. Segment-level correlations and diagnostic accuracy were also examined. Forty patients (median age 41 years; 18 [45

Celiac disease (CD) risk conferred by HLA-DQ2 and DQ8 varies significantly across populations. In north India, where CD is as prevalent as in European populations, reports on the association of HLA-DQ2 and DQ8 with CD are limited. In a north Indian CD case-control cohort (459 CD and 450 controls), known CD-associated risk HLA-DQ alleles, HLA-DQA1*05:01/02:01/03:01 and HLA-DQB1*02/*03:02, were genotyped using SSP-PCR to uncover their frequency and association with CD. Published dense Illumina_Immunochip genotyping data of the study cohort were used to identify proxy-SNPs for HLA-DQ genotypes and their alleles. We also investigated the correlation between common CD phenotypes and DQ2/8 genotypes. Ninety-nine percent of the CD patients were found to carry HLA-DQ2.5, DQ2.2 or 8. HLA-DQA1*05:01 (OR = 5.86 [4.39-7.81], p < 0.0001) and HLA-DQB1*02 (OR = 16.61 [11.37-24.25], p < 0.0001) were identified as the strongest susceptibility alleles. HLA-DQ2.5 was present in 92% of patients and conferred the highest CD risk (OR = 29.01 [19.56-43.00], p < 0.00001), while DQ8 appeared protective (OR = 0.42 [0.25-0.70], p < 0.0001). HLA-DQ2.5/8 and HLA-DQ2.5/2.2 were found significantly associated with serum anti-tTG-IgA and skin conditions, respectively, among CD patients. rs1129740, rs9273012 and rs7744001 were identified as proxy-SNPs to efficiently predict the presence/absence of DQ2.5, DQ2.2, DQ8 and its alleles. This was the first well-powered study to evaluate the susceptibility of HLA-DQ in CD among the north Indian population. HLA-DQ2.5 showed a strong association with CD, conferring a higher disease risk, while DQ8 appeared protective, and the contribution of DQ2.2 was inconclusive. Three proxy-SNPs, rs1129740, rs9273012 and rs7744001, could be utilized to predict HLA-DQ genotypes as a cost-effective alternative for CD risk assessment.

Plasma exchange (PLEX) improves survival in acute liver failure (ALF); however, there is no study specifically analyzing its utility in hepatitis A virus-related ALF (HAV-ALF). A few reports suggest that ALF patients who are not on inotropes tolerate PLEX better. We aimed at comparing the efficacy of PLEX and of standard medical treatment (SMT) to treat HAV-ALF. We retrospectively compared consecutive HAV-ALF patients treated with PLEX (2018–2024) vs. SMT (2011–2024) at 13 centers across India. We compared in-hospital native liver survival in both groups. In the subset of patients not on inotropes, we compared survival and assessed predictors of poor outcome in PLEX and SMT groups. Eighty-four HAV-ALF patients in PLEX group (61 males; age = 23.5 [21–33] years, median [IQR]; King’s College Criteria [KCC] fulfilled = 22 patients, 26.2

Exclusive enteral nutrition (EEN) is an established induction therapy in pediatric Crohn’s disease (CD); however, its role in adults remains less well defined. A systematic search was performed through December 2025. Eligible studies included randomized controlled trials (RCTs) and non-randomized studies evaluating EEN in adults (≥ 18 years) with active CD. The primary outcome was clinical remission, defined by validated disease activity indices. Risk of bias was assessed using RoB 2 and the Newcastle–Ottawa Scale. Random-effects models were applied to estimate pooled remission rates and relative risks. Forty studies, comprising 2459 patients, were included. In 23 real-world cohort studies (n = 1269), the pooled clinical remission rate with EEN was 66

Background: In acute severe ulcerative colitis (ASUC), the combination of tofacitinib with intravenous corticosteroids (IVCS) has been shown to improve treatment response and reduce the need for rescue therapy, as demonstrated in the TACOS trial; however, the optimal dose of tofacitinib in ASUC remains poorly defined. Methods: This was a single-center, double-blind, randomized controlled trial. Adult patients with ASUC were randomized in a 1:1 ratio to receive either tofacitinib 20 mg/day (Group 1) or 30 mg/day (Group 2) along with IVCS (hydrocortisone, 100 mg IV every 6 hours). The primary endpoint was clinical response by day 7, defined as a reduction in the Lichtiger Colitis Activity Index by more than 3 points with an absolute score <10 for two consecutive days without the need for rescue therapy. The key secondary outcome was the cumulative probability of medical rescue therapy or post discharge escalation of therapy or colectomy within 90 days. Results: A total of 72 patients were randomized (36 per group). At day 7, clinical response was achieved in 33/36 (91.7%) patients in Group 1 and 31/36 (86.1%) in Group 2 (RR 1.06, 95% CI 0.90–1.25; p=0.46). The absolute difference in response rates was 5.6% (95% CI -9.98% to 21.34%). Rescue therapy was required in 3 patients in Group 1 (all received infliximab) and 5 patients in Group 2 (2 underwent colectomy and 3 received infliximab). Event-free survival at 90 days, defined as the absence of rescue therapy, treatment escalation, or colectomy, was similar between groups (83.3% vs 80.2%; log-rank p = 0.74). Adverse events were predominantly mild, with no reported venous thromboembolism or major adverse cardiovascular events. Conclusion: In this exploratory pilot trial, no statistically significant difference was observed with tofacitinib 30 mg/day compared with 20 mg/day when administered with IVCS. Given the limited sample size and exploratory design, larger adequately powered trials are required.

In acute severe ulcerative colitis (ASUC), early response patterns to intravenous corticosteroids (IVCS) during the first week may shape subsequent disease course. Characterizing these trajectories is crucial for guiding timely therapy and improving patient outcomes. We evaluated response patterns to IVCS in hospitalized patients with ASUC. Clinical response was categorized as complete response (CR), partial response (PR), or non-response (NR) on days 3, 5, and 7. Patients were followed up to day 90 for need for rescue therapy (RT), post-discharge escalation of therapy (EOT), and mortality. Seventy-nine patients were analyzed. By day 3, 12 (15%) achieved CR, 34 (43%) PR, and 33 (42%) NR. Among the 67 patients with PR or NR on day 3, 9 (13.4%) achieved CR by day 5 and 22 (32.8%) more by day 7. On day 7, CR, PR, and NR were observed in 42 (53%), 17 (21%), and 20 (25%) patients, respectively. Patients with CR on day 3 had a lower, but not statistically significant, likelihood of needing RT + EOT by day 90 compared to NR (29% vs. 47%; p = 0.15). However, by day 5, patients with CR or PR had significantly lower day 90 RT + EOT needs compared to NR (26% vs. 54%, p = 0.02; 23% vs. 54%, p = 0.03). By day 7, the day 90 probability of RT + EOT was higher in PR (45%) and NR (63%) versus CR (16%) (p = 0.001 and < 0.0001, respectively). Only a small proportion of patients with ASUC show CR at day 3; most are partial responders. Partial responders to IVCS at day 3 frequently achieve CR by day 5-7, and have relatively favorable short term disease course, highlighting the prognostic value of early response stratification.

BACKGROUND:Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), poses significant diagnostic challenges, particularly in South-East Asia, where its prevalence has risen sharply. Although endoscopic biopsies and histopathological evaluations are central to IBD management, inconsistencies in sampling, processing and reporting hinder accurate and reliable diagnosis. METHODS:To address these gaps, the Indian Association of Pathologists and Microbiologists (IAPM), the Indian Society of Gastroenterology (ISG) and the Colitis and Crohn's Foundation, India, (CCFI) collaborated to formulate comprehensive guidelines. Using a structured Delphi process and expert consensus, recommendations were developed to standardize biopsy protocols, histological evaluation and reporting of mucosal biopsies and tackling critical diagnostic challenges. RESULTS:The recommendations cover biopsy sampling, optimal processing, orientation, interpretation methods, histopathological algorithms, recommendations on histological scoring, follow-up biopsies and differentiation of IBD from its mimickers based on existing literature and expert's experience. Reporting formats were suggested to ensure uniformity in practice. CONCLUSION:These evidence-based, practical recommendations aim to enhance diagnostic precision, unify practices and improve patient outcomes in IBD care, providing pathologists in resource-diverse settings with a standardized approach to gastrointestinal mucosal biopsy evaluation.

INTRODUCTION:The coexistence of inflammatory bowel disease (IBD) and human immunodeficiency virus (HIV) represents a clinical paradox in which immune hyperactivity coexists with persistent immunodeficiency. Improved survival with antiretroviral therapy (ART) has led to increasing co-diagnoses, creating complex diagnostic and therapeutic challenges. AREAS COVERED:A comprehensive literature search of PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library from inception through December 2024 was conducted, supplemented by major gastroenterology and infectious disease conference proceedings through April 2025. This review synthesizes contemporary evidence on epidemiology, immunopathogenesis, clinical presentation, and management of IBD in people living with HIV. Key themes include immune reconstitution and Th17-cell depletion, diagnostic differentiation from infectious and noninfectious mimickers, underutilization of advanced IBD therapies despite emerging safety data, bidirectional interactions between intestinal inflammation and HIV viral dynamics, and clinically relevant ART - IBD interactions requiring multidisciplinary care. EXPERT OPINION:Accumulating evidence supports the safe and appropriate use of immune-modulating therapies in virologically suppressed HIV-positive patients with IBD, challenging historical risk-averse approaches. Optimal management requires precision-based strategy incorporating CD4+ cell thresholds, mucosal and inflammatory biomarkers, and individualized risk stratification. Future priorities include standardized diagnostic algorithms, longitudinal registries integrating immunological and virological parameters, and improved access to advanced therapies, moving beyond the traditional autoimmunity - immunodeficiency binary.

Inflammatory bowel disease (IBD) shares many clinical, endoscopic, and histologic aspects of enteritis and colitis of infectious etiologies, including bacteria, viruses, fungi, and parasites. Patients with infectious enteritis and colitis often have a history of consumption of unclean drinks or foods, especially in the epidemic or endemic area. Patients with acute episodes often present fever, abdominal pain, diarrhea, mucus, and bloody bowel movements. In most cases, infectious enteritis and colitis are self-limited, lasting several days to several weeks. Stool examination often shows red blood cells and white blood cells. However, stool microbiological examination, albeit useful, is only able to identify pathogen(s) in less than 50% of patients. During the acute phase of infectious enteritis or colitis, upper and lower endoscopy usually provide limited value in the diagnosis and differential diagnosis. However, the endoscopy is required, if the symptom persists beyond 4 weeks. Endoscopic features of infectious bowel diseases are mostly nonspecific. However, there are some characteristic endoscopic features in some infectious bowel diseases, such as intestinal tuberculosis. These agents may also cause superimposed or opportunistic infection to underlying IBDs.

The genetic component of ulcerative colitis (UC) remains largely unexplained in non-European populations. This study aimed to investigate the polygenic architecture of UC in an Indian population. Whole-exome sequencing was performed in 160 UC patients and 379 ethnically matched controls. Gene-based rare variant burden tests (SKAT-O, CMC) and exome-wide association testing of coding and noncoding common variants using allelic chi-square testing were performed. Burden analysis identified 85 previously unreported genes significantly enriched for rare variants in UC, of which 22 showed suggestive associations (P ≤ 5 × 10⁻³; odds ratio 2.6–10.9). These genes were primarily involved in epithelial integrity, immune signalling, DNA repair, and vesicle trafficking pathways. Exome-wide association analysis identified 55 common variants surpassing the Bonferroni-corrected significance threshold (P ≤ 5.57 × 10⁻⁷), mapping to 44 unreported and two known susceptibility genes, with most belonging to functional categories similar to those observed in the rare variant analysis. Logistic regression analysis showed that variants significant in the allelic test remained significant after adjustment for covariates. STRING network analysis revealed functional interactions between eight genes identified in this study and known inflammatory bowel disease–related genes. Sub-phenotype analysis further indicated genetic heterogeneity among clinically defined UC subgroups. This first exome-based study of Indian UC patients expands the genetic landscape of the disease and identifies population-specific associations that appear distinct from those reported in Western cohorts, suggesting potential differences in underlying disease mechanisms. Most identified genes map to disease-relevant pathways. However, given the modest sample size and limited statistical power, these findings should be considered exploratory and require further validation to clarify their contribution to UC pathogenesis. The study also underscores the importance of conducting genetic investigations in genetically diverse and understudied populations to improve the broader applicability of genetic findings.

The Mediterranean diet is a nutritional approach reported to be beneficial in various diseases. We performed a systematic review about its role in the treatment of inflammatory bowel disease (IBD). Electronic databases (PubMed, Embase and Scopus) were searched on 10th February 2025 to identify reports on the use of the Mediterranean diet in the treatment of IBD. We extracted data with respect to clinical response, remission and endoscopic and histological responses with the use of the Mediterranean diet in the treatment of IBD. Pooled clinical response rates and remission rates were calculated. Eight studies were eventually included. Seven studies involving 223 participants provided information about the induction of remission. The pooled clinical remission rate with Mediterranean diet was 0.62 (95

BACKGROUND:The aim of this study was to determine if Crohn's disease (CD) and ulcerative colitis (UC) manifest similarly in different parts of the world. METHODS:Investigators of cohort studies from around the world were contacted to provide the most recent data from their CD and UC cohorts. Each cohort provided summated and averaged data on pre-specified variables. The Montreal Classification was used for phenotype assessment. Age at diagnosis was stratified into less than 17 years, 17-39 years, and >39 years. Disease location for CD was stratified as ileum only, colon only, ileocolon, upper gastrointestinal and proximal small bowel disease, and perineal penetrating disease. Disease behavior for CD was stratified into inflammatory disease, stricturing disease, and penetrating disease. Location for UC was stratified into proctitis, left-sided colitis, and extensive including subtotal and pancolitis. Reports were classified geographically as Asia, Latin America, South Africa, and "Western" (ie, North America, Europe, and Oceania). These categories were collapsed to "Western" and "non-Western" for analyses. RESULTS:Data from 54 868 patients with IBD were included. For CD, data were available from nine Western cohorts, 12 Asian cohorts, three Latin American cohorts, and one African cohort. For UC, eight Western cohorts were compared with 11 Asian cohorts, three Latin cohorts, and one African cohort. The demographic and phenotypic distribution for CD and UC in comparisons between Western and non-Western countries were no different. Western cohorts had longer disease durations than non-Western cohorts. CONCLUSION:No significant differences were seen in any phenotypic data between the cohorts, suggesting that IBD is similar worldwide.

Functional dyspepsia (FD) is a common disorder with multi-factorial pathophysiology. It has two sub-types, post-prandial distress syndrome (PDS) and epigastric pain syndrome (EPS), which frequently overlap. Emerging evidence suggests that low-grade inflammation, particularly duodenal eosinophilia (DE), may play a pathogenic role in FD. However, Indian data on this subject remains scarce. This study aimed at evaluating the prevalence and clinical correlates of DE in patients with refractory FD. In this prospective, cross-sectional study, Rome- IV defined FD patients with refractory symptoms and normal esophagogastroduodenoscopy (EGD) were enrolled. Age and sex-matched non-dyspeptic controls with normal EGD were also recruited. Standardized duodenal biopsies from cases and controls were independently assessed by two blinded histopathologists for eosinophil counts and degranulation. Symptom profiles and health-related quality of life (HRQoL) were evaluated using validated questionnaires. Of 274 patients with refractory dyspepsia screened, 189 patients with normal EGD (mean age 41.4 ± 15.2 years; 54.5

Irritable bowel syndrome (IBS) is a common disorder with multi-factorial pathophysiology. Emerging evidence suggests a role of low-grade mucosal inflammation in IBS. Small intestinal bacterial overgrowth (SIBO), which has symptoms similar to IBS, may be misdiagnosed as IBS. Data on the prevalence of SIBO and elevated fecal calprotectin (FCP) levels in IBS patients remains sparse and conflicting. We aimed at determining the prevalence and clinical significance of SIBO and elevated FCP in patients with refractory IBS. This prospective cross-sectional study enrolled refractory IBS patients (Rome-IV criteria). SIBO was diagnosed using the glucose hydrogen breath test and FCP levels ≥ 50 μg/g were considered elevated. Clinical evaluation was performed using standardized questionnaires: IBS Symptom Severity Scale (IBS-SSS) and IBS Quality of Life (IBS-QoL). Of 209 patients screened, 148 with refractory IBS were enrolled (mean age 35.8 ± 11.9 years; 66.1

BACKGROUND AND AIM:Grounded theory develops theoretical frameworks from systematic analysis of patient experiences. Translational research converts findings into clinical tools. Despite dietary management being crucial in inflammatory bowel disease (IBD), no framework exists for understanding patients' dietary journey phases. We explored how IBD patients psychologically and socially experience dietary changes over time and developed a clinical assessment tool. METHODS:Using grounded theory methodology with translational tool development, we conducted semi-structured interviews with 25 adult IBD patients (21 ulcerative colitis, 4 Crohn's disease; mean age 38.6 years, 56% male) at a tertiary center in North India. A non-clinical researcher conducted interviews minimizing bias. Data were analyzed using constant comparative analysis with open, axial, and selective coding. Qualitative findings were systematically translated into the IBD Dietary Journey Assessment Tool (IDJAT). RESULTS:Three journey phases emerged: (1) medicalization (psychological reconceptualization of food's role)-the transformation of food from nourishment to medicine, with fear-based restrictions and medical dependence for dietary decisions; (2) life disruption and rebuilding-profound emotional and social upheaval requiring adaptation (a psychological adjustment process); (3) empowerment (psychological sense of control and mastery)-understanding triggers, self-management, and helping others. Patients progressed through phases via evolving information navigation and coping (non-linear progression, cycling during flares). The IDJAT comprises quick screening questions, phase identification scales, and phase-specific intervention guidelines. CONCLUSIONS:This grounded theory study provides the first framework for IBD dietary journey phases. The IDJAT enables clinicians to identify patients' phase and deliver appropriate support, transforming dietary care from generic advice to journey-informed, phase-matched care.

Perianal fistulizing Crohn’s disease (PFCD) presents significant challenges due to its complex nature and severe impact on patients’ quality of life. Several factors contribute to its complexity, including the anatomical intricacies, chronic and recurrent course, heightened risk of infection and the need for multifaceted treatment strategies. Recognizing these challenges, the Colitis and Crohn’s Foundation (India) (CCF[I]) deemed it essential to release a clinical guidance on PFCD. This update, developed through a structured literature review and national expert consensus meeting, integrates the latest research, standardizes treatment protocols, aims to improve patient outcomes and addresses persisting challenges, while also serving as a valuable educational resource for healthcare professionals.