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.

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.

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.

Patel, Pulkit Jayeshbhai MD; Desai, Devendra DNB; Dharap, Vikram DNB; Hodgar, Digvijay DNB Author Information

Chronic liver diseases (CLD) may progress to cirrhosis, decompensation and death. An intervening insult may lead to acute decompensation (AD); patients with AD may fulfil criteria for acute-on-chronic liver failure (AD–ACLF). While the outcome of ACLF and priority for liver transplantation have been studied, data on outcome in a non-transplant setting is sparse. We evaluated three international consensus criteria for definition of ACLF to determine the number of patients satisfying these definitions and their accuracy in predicting mortality and compare mortality in a non-transplant setting. Total 341 consecutive patients with CLD of any etiology were enrolled and followed up. All significant clinical events and changes in laboratory data were noted to classify patients into no AD, AD-ACLF and AD-non-ACLF. Total 150 (44

In inflammatory bowel disease (IBD), a flare can be due to natural history of disease or due to gastrointestinal infection. Infection is conventionally diagnosed by stool microscopy and culture. Stool multiplex polymerase chain reaction (PCR) assay or Biofire® FilmArray® GI Panel is a sensitive and rapid test for detecting infection, but is expensive; its impact on management and cost-effectiveness has not been studied in IBD. To compare stool PCR assay and conventional tests during IBD flare for detection of infection, impact of detection on treatment and cost-effectiveness of the tests. Sixty-five patients with IBD flare underwent conventional stool tests (microscopy, culture and Clostridioides difficile toxin assay) and stool PCR assay simultaneously. We prospectively enrolled 65 consecutive patients presenting with disease flare: ulcerative colitis (58 patients, 28 women, mean age 41.1 years) and Crohn’s disease (seven patients; three women; mean age 36.1). Stool PCR detected organisms in 36 (55.4

Background/AimsSarcopenia is implicated in inflammatory bowel disease (IBD) complications and surgical outcomes. This study aimed to investigate the prevalence and follow-up of sarcopenia in patients with IBD. MethodsConsecutive consenting patients with IBD aged > 18 years were included. Patients with associated sarcopenic diseases were excluded. All had measurements of anthropometry, body mass index (BMI), mid-arm muscle circumference, muscle strength, physical performance, and muscle mass (on computed tomography scan). They were followed up for up to 12 months, and incidence of flares, fractures, and surgery was noted. ResultsOf 157 patients screened, 35 refused participation; 5 with associated sarcopenic diseases were excluded. Of 117 patients (median age, 41 years; interquartile range, 18–81 years; 65 men), 73 had ulcerative colitis, 42 Crohn's disease, and 2 IBD-unclassified. Forty (34.2%) had probable sarcopenia; 47 (40.2%) had sarcopenia (29 ulcerative colitis and 18 Crohn's disease) including 10 (8.5%) with severe sarcopenia. Ten (21.3%) were in disease remission. Of factors associated with sarcopenia in univariate analysis, only BMI was significant in multivariate analysis. Ninety-nine patients followed up for a median of 7 months (interquartile range, 2–12 months). Freedom from flares was 5.3% in patients with sarcopenia and 46.1% in those without (P= 0.004). Three patients (1 with sarcopenia, 2 without) required surgery. ConclusionsSarcopenia was present in 40% of patients with IBD; one-fifth of these had severe sarcopenia. One-fifth were in remission. Low BMI correlated with sarcopenia. More patients with sarcopenia had disease flare. Screening for sarcopenia should be considered in patients with IBD.

Introduction: Wearables are electronic devices worn on the body to collect health data. These devices, like smartwatches and patches, use sensors to gather information on various health parameters. This review highlights the current use and the potential benefit of wearable technology in patients with inflammatory bowel disease (IBD). Areas covered: In this review, we explore the current use of wearable technology in healthcare and the studies applying this technology in patients with IBD. We also discuss the limitations of using digital health data in general and wearable technology in particular in the current clinical paradigm and predict a path forward in how to rationally and effectively apply this technology to improve the care of patients with IBD. A comprehensive search of all suitable studies was conducted using the databases of PubMed, MEDLINE, Embase, and Scopus from inception to August 2024. Expert opinion: Currently, wearable technology is applied to the monitoring of IBD and prediction of flares using devices and sensors. Future applications include early disease detection using biosensors, advanced data collection through ingestible devices, gut microbiome monitoring, and integration with machine learning. These advancements promise to revolutionize disease management, including IBD, by enabling early diagnosis, personalized treatment, and improved patient outcomes.

BACKGROUND & AIMS:Primary sclerosing cholangitis (PSC) frequently coexists with inflammatory bowel disease (IBD). PSC is a progressive disease that may lead to end-stage liver failure requiring liver transplantation (LT). Although PSC-IBD has been extensively studied in Western populations, data from Asia remain limited. We conducted an international multicenter study across Asia to investigate the prevalence of PSC in IBD patients and evaluate its impact on clinical outcomes. METHODS:This retrospective cohort study included patients with IBD from 25 hospitals in 6 Asian countries. The primary endpoint was the prevalence of PSC in patients with IBD. The secondary endpoints included the incidence of colorectal neoplasia and IBD-related surgery following IBD diagnosis, and the occurrence of cholangiocarcinoma, LT, and death after PSC diagnosis among patients with PSC-IBD. Temporal trends were assessed across 5 diagnostic eras of PSC. RESULTS:Among 51,314 patients with IBD, 474 had PSC (0.92%), with a prevalence of 1.4% in ulcerative colitis and 0.13% in Crohn's disease. Among 375 Asian patients with PSC-IBD, 9.1% developed colorectal neoplasia, 7.2% developed cholangiocarcinoma, 24% underwent LT, and 16% died. In more recent diagnostic eras, patients presented with fewer symptoms, lower alkaline phosphatase levels, and better liver function scores. The use of magnetic resonance cholangiopancreatography has increased over time. Symptomatic PSC and low serum albumin were significantly associated with a shorter time to LT, which was significantly longer in recent eras (P = .016). CONCLUSIONS:PSC is less prevalent among Asian patients with IBD than in Western populations. The increased use of magnetic resonance cholangiopancreatography may enable earlier detection, contributing to milder disease severity and improved clinical outcomes in recent years. umin.ac.jp, Number UMIN000054487.

Azathioprine (AZA)-induced pancreatitis is a significant adverse event affecting patients with inflammatory bowel disease (IBD). A genetic association with HLA-DRB1*07 and HLA-DQA1*02 alleles polymorphisms has been reported, but its prevalence and impact on Asian patients with IBD remain unclear. A retrospective review of a prospectively maintained database of patients with IBD was done from January 2005 till December 2024. Patients who developed pancreatitis were tested for HLA association with HLA class II-DRB1*07 and HLA-DQA1*02 alleles. Duration of AZA, dose of AZA and other risk factors such as smoking, alcohol intake, steroid administration, previous history of pancreatitis and any other risk factors for pancreatitis were noted. These patients were compared with a matched control group of non-IBD patients undergoing human leukocyte antigen (HLA) typing for other indications. Of 1751 patients with IBD, 441 (25.1

Thiopurine methyltransferase (TPMT) enzyme plays a key role in the metabolism of the thiopurine drugs that are used for the treatment of inflammatory diseases. Mutations in the TPMT gene cause abnormal metabolism, resulting in toxicity; therefore, TPMT genetic analysis has been recommended for effective dose management. We retrospectively analysed data to determine the distribution of TPMT genotypes in a western Indian population. TPMT genotyping test was performed on 1000 patients with different inflammatory conditions between January 2009 and October 2023. The common TPMT genotypes *2, *3A, *3B and *3C were detected by amplification refractory mutation system - polymerase chain reaction (ARMS-PCR) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques. TPMT mutants were detected in 36 (3.6%) patients, of whom 14 (39%) had TPMT*1/*3A, 19 (53%) had TPMT*1/*3C, two (5.5%) had TPMT*1/*3B, and one (2.8%) had TPMT*3B/*3B alleles; mutant allele frequencies were 0.7% for *3A, 0.2% for *3B and 1.65% for *3C. A sub-group analysis explained thiopurine toxicity in only 33% patients by TPMT gene polymorphism whereas in 67% the toxicity remained unexplained. The low prevalence of TPMT mutants (3.6%) along with unexplained thiopurine toxicity suggest that TPMT genotyping solely might be clinically less relevant in patients of Indian origin, underscoring the role of other genetic factors that may be involved in thiopurine toxicity in these patients.

The global burden of inflammatory bowel diseases (IBD) is estimated at 4.9 million and the global prevalence exceeds 0.3%. Multiple newer therapeutic agents have broadened the options for the therapy of IBD in the last three decades. Thiopurines, however, have retained their place as maintenance therapy in IBD, especially in resource-constrained setting. But thiopurines have narrow therapeutic range, often needing discontinuation due to side effects or lack of efficacy. Biologic agents revolutionized the treatment of IBD, but the efficacy is lost in 50% of patient after one year. These outcomes are often due to inadequate drug concentrations that may lead to the development of antibodies as well as pharmacodynamic failure. Therapeutic drug monitoring (TDM) was proposed to reduce loss of response and to optimize the therapy in patients on thiopurine and biologic therapy. TDM is based on exposure-response relationship, suggesting a positive correlation between elevated serum anti-TNF concentrations and favorable therapeutic outcomes. TDM has multiple facets. This article discusses the benefits, evidence and limitations of TDM. The practical use of TDM in clinical practice is highlighted. Newer developments in the field and their relevance in practice are discussed.

The lack of clear definition and classification for "moderate ulcerative colitis (UC)" creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

The use of proton-pump inhibitors (PPI) is linked with infrequent but serious adverse events, including acute kidney injury, chronic kidney disease (CKD) and progression of CKD. Data on renal safety in routine use of PPI are more relevant to clinical practice. We studied whether such use of PPI is associated with renal dysfunction. Patients taking PPI for at least six weeks had serum creatinine tested pre (n = 200) and post (n = 180) recruitment. These patients were then advised to follow-up: those taking PPI for at least 90 days in the next six months (n = 77) and at least another 90 days in the following six months (n = 50), had serum creatinine tested at such follow-up. Renal dysfunction was defined as any increase in serum creatinine level above baseline. The 200 patients recruited had mean age 39.6 (SD 9.2) years. Ninety-eight (49

Rising number of inflammatory bowel disease (IBD) cases in developing countries necessitate clear guidance for clinicians for the appropriate use of advanced therapies. An expert consensus document was generated to guide the usage of tofacitinib, a Janus kinase inhibitor, in ulcerative colitis. Tofacitinib is a useful agent for the induction and maintenance of remission in ulcerative colitis. It can be used in the setting of biological failure or even steroid-dependent and thiopurine refractory disease. Typically, the induction dose is 10 mg BD orally. Usually, clinical response is evident within eight weeks of therapy. In those with clinical response, the dose can be reduced from 10 mg BD to 5 mg BD. Tofacitinib should be avoided or used cautiously in the elderly, patients with cardiovascular co-morbidity, uncontrolled cardiac risk factors, previous thrombotic episodes and those at high risk for venous thrombosis or previous malignancy. Baseline evaluation should include testing for and management of hepatitis B infection and latent tuberculosis. Where feasible, it is prudent to ensure complete adult vaccination, including Herpes zoster, before starting tofacitinib. The use of tofacitinib may be associated with an increased risk of infections such as herpes zoster and tuberculosis reactivation. Maternal exposure to tofacitinib should be avoided during pre-conception, pregnancy, and lactation. There is emerging evidence of tofacitinib in acute severe colitis, although the exact positioning (first-line with steroids or second-line) is uncertain.

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disease of unknown etiology, involving complex interactions between the gut microbiome and host immune response. The microbial dysbiosis is well documented in IBD and significantly influences the host metabolic pathways. Thus, a metabolomic fingerprint resulting from the influence of gut dysbiosis in IBD could aid in assessing the disease activity. PubMed, Medline, Science Direct, and Web of Science were searched for studies exploring the association between microbiome and metabolome in IBD patients in the last 5 years. Additionally, references of cited original articles and reviews were further assessed for relevant work. We provide a literature overview of the recent metabolomic studies performed on patients with IBD. The findings report alterations in the metabolite levels of these patients. We also discuss the gut dysbiosis observed in IBD and its influence on host metabolic pathways such as lipids, amino acids, short-chain fatty acids, and others. IBD, being a chronic idiopathic disease, requires routine monitoring. The available non-invasive markers have their limitations. The metabolite changes account for both dysbiosis and its influence on the host's immune response and metabolism. A metabolome approach would thus facilitate the identification of surrogate metabolite markers reflecting the disease activity.

Background/Aims: Primary sclerosing cholangitis (PSC) represents the most common hepatobiliary extraintestinal manifestation of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD). Limited data exist on PSC in patients with IBD from India. We aimed to assess the prevalence and disease spectrum of PSC in Indian patients with IBD. Methods: Database of IBD patients at 5 tertiary care IBD centers in India were analyzed retrospectively. Data were extracted and the prevalence of PSC-IBD was calculated. Results: Forty-eight patients out of 12,216 patients with IBD (9,231 UC, 2,939 CD, and 46 IBD unclassified) were identified to have PSC, resulting in a prevalence of 0.39%. The UC to CD ratio was 7:1. Male sex and pancolitis (UC) or colonic CD were more commonly associated with PSC-IBD. The diagnosis of IBD preceded the diagnosis of PSC in most of the patients. Majority of the patients were symptomatic for liver disease at diagnosis. Eight patients (16.66%) developed cirrhosis, 5 patients (10.41%), all UC, developed malignancies (3 colorectal cancer [6.25%] and 2 cholangiocarcinoma [4.16%]), and 3 patients died (2 decompensated liver disease [4.16%] and 1 cholangiocarcinoma [2.08%]) on follow-up. None of the patients mandated surgical therapy for IBD. Conclusions: Concomitant PSC in patients with IBD is uncommon in India and is associated with lower rates of development of malignancies.