Patients undergoing ileal pouch-anal anastomosis (IPAA) for inflammatory bowel disease (IBD) may experience post-operative inflammation of the ileal pouch (pouchitis) or rectal cuff (cuffitis). Post-operative pelvic floor dysfunction has previously been associated with inflammatory pouch outcomes. Furthermore, our recent pilot study identified an association between abnormal pre-operative anorectal manometry (ARM) and post-operative pouch ulceration and cuffitis; however, we did not adjust for covariates due to sample size and did not assess composite outcomes of pouch inflammation. In this expanded study, we aimed to further assess whether pre-operative pelvic floor dysfunction defined by abnormal anal sphincter function on ARM is associated with post-operative pouch and cuff inflammation. This historical cohort study assessed IBD patients who underwent pre-operative ARM with completion of their IPAA surgical series January 2009 - December 2024. Patients were divided into two groups—normal versus abnormal pelvic floor function—based on ARM prior to completion of IPAA surgical series. The two primary outcomes were a composite outcome of endoscopic inflammatory pouch diseases (EIPD) and an outcome of rectal cuffitis after the peri-operative period. Secondary outcomes included individual components of the composite primary outcome. Multivariable logistic regression was used to assess primary outcomes (EIPD and cuffitis) while controlling for covariates. A total of 179 patients were included in this study, 46 (25.7%) in the abnormal ARM group and 133 (74.3%) in the normal ARM group. Cohorts had similar demographic and pre-operative characteristics except for gender; there was a higher proportion of females in the abnormal ARM group (63.0% versus 45.1%; p = 0.036). Median follow-up time after IPAA was 2.88 years for the abnormal ARM group and 3.61 years for the normal ARM group (p = 0.347). In total, 72 (40.2%) patients developed cuffitis and 61 (34.1%) developed EIPD. In multivariable regression, patients with abnormal ARM had a higher risk of cuffitis (OR 2.17; 95% CI 1.05-4.35; p = 0.037; Table 1) but not EIPD (p = 0.427). Secondary outcomes were similar between groups apart from diffuse pouch inflammation, which was more common in patients with abnormal ARM (p = 0.024; Table 2). Abnormal pre-operative ARM was associated with post-operative cuffitis in IPAA patients after adjusting for potential confounders, which aligns with results from our pilot study. However, there was no significant association with EIPD. ARM prior to completion of IPAA surgical series could potentially be utilized to predict some inflammatory complications in select patients, but the specific associations between pre-operative ARM and endoscopic outcomes as well as the underlying mechanisms merit further investigation.

BACKGROUND:Patients undergoing ileal pouch-anal anastomosis (IPAA) for inflammatory bowel disease (IBD) commonly experience postoperative inflammatory complications, including pouchitis and cuffitis. While pelvic floor dysfunction has been associated with these complications, the predictive value of preoperative anorectal manometry (ARM) remains unclear. We evaluated the association between abnormal preoperative ARM and postoperative inflammatory outcomes in IPAA patients. METHODS:In this historical cohort study we assessed IPAA patients who underwent preoperative ARM with ileostomy closure during the period from January 2009 to December 2024. Patients were divided into 2 groups-normal vs abnormal pelvic floor function-based on ARM. Primary outcomes were a composite measure of endoscopic inflammatory pouch disease (EIPD) and endoscopic evidence of rectal cuffitis after the perioperative period. Secondary outcomes included individual components of the composite primary outcome. Multivariable logistic regression was used to assess associations while controlling for covariates. RESULTS:We included 179 patients in this study, 46 (25.7%) with abnormal ARM and 133 (74.3%) with normal ARM. In multivariable regression, abnormal ARM was associated with modestly increased odds of cuffitis (odds ratio [OR], 2.136; 95% CI, 1.050-4.345; P = .037) but was not associated with EIPD (OR, 1.490; 95% CI, 0.710-3.104; P = .287). Secondary outcomes were similar between groups, except for diffuse pouch inflammation, which was more frequently observed among patients with abnormal ARM (P = .024). CONCLUSIONS:Abnormal preoperative ARM was associated with increased odds of postoperative cuffitis but not composite endoscopic pouch inflammation in IPAA patients. Given the modest effect size and limited precision, these findings warrant confirmation in larger, prospective studies.

Despite advances in therapeutic strategies, postoperative recurrence (POR) of Crohn’s disease (CD) remains common, underscoring the importance of vigilant and accurate surveillance. Colonoscopy is the gold standard to assess for POR, but it is invasive and can be poorly tolerated by patients. Intestinal ultrasound (IUS) has emerged as a reliable, noninvasive modality for monitoring CD at the point of care and has excellent accuracy for evaluation of POR. However, visualization of the ileocolic anastomosis with IUS can be challenging. This review provides practical guidance for identifying the ileocolic anastomosis and its key sonographic landmarks. It also outlines techniques for assessing the anastomosis with grayscale IUS and discusses strategies for integrating IUS into routine postoperative surveillance of CD.

Crohn’s disease (CD) frequently progresses to stricturing complications. Anti-stricture therapies are lacking, and anti-inflammatory therapies are hence the mainstay of medical treatment. However, data on the efficacy of vedolizumab in stricturing CD are not available. We therefore aimed to assess outcomes of vedolizumab in this setting. We evaluated adult patients who received vedolizumab within 6 months of imaging-confirmed symptomatic ileal stricturing CD (CONSTRICT criteria) in a multicenter observational cohort study. Images were centrally read by an expert radiologist with experience in IBD imaging. Outcomes were rates of intervention (composite endpoint for endoscopic balloon dilation (EBD) or surgery during follow-up), EBD, surgery, obstructive symptoms, and vedolizumab persistence. Forty-four patients were included (61

BACKGROUND AND AIMS:Neoplasia of the pouch or rectal cuff is a rare cause of pouch failure in patients with an ileal pouch-anal anastomosis. Cuff inflammation has been suggested to convey a higher neoplasia risk but has not been thoroughly investigated. This study evaluated whether endoscopic inflammation of the rectal cuff conveys increased risk of subsequent neoplasia development. METHODS:This was a 2-institution case-control study of inflammatory bowel disease patients who developed neoplasia of the rectal cuff or ileal pouch and patients without neoplasia. Cases were matched to controls in a 1:4 ratio. Neoplasia was defined as dysplasia or adenocarcinoma, and cuff inflammation was defined as endoscopic evidence of erythema, edema, and/or ulcerations. A subanalysis assessed whether persistent inflammation conveys a higher neoplasia risk than resolved cuff inflammation. RESULTS:Forty-six cases of neoplasia were matched to 184 controls. Rectal cuff dysplasia (n = 23) was most common, followed by pouch dysplasia, cuff cancer, pouch cancer, and neoplasia involving both sites. Patients with cuff inflammation on initial pouchoscopy (adjusted odds ratio [aOR] = 2.82; 95% CI, 1.24-7.74; P = .013) had a higher risk of developing neoplasia. Compared to controls, patients with persistent cuff inflammation had a higher risk of neoplasia development (aOR = 3.70; 95% CI, 1.37-9.97; P = .010), but this trend was not observed in patients with inflammation on only one pouchoscopy. CONCLUSIONS:Patients with inflammation of the rectal cuff on initial pouchoscopy are at higher risk of subsequent neoplasia development, and this risk appears highest in patients with persistent inflammation.

BACKGROUND:Transmural healing (TMH) indicates resolution of inflammation in all bowel wall layers and is an emerging therapeutic target in Crohn's disease (CD). Standardized sonographic criteria for TMH and early improvement, termed Transmural Response (TMR), have not been established. This systematic review synthesizes published definitions to provide an up-to-date overview of the current evidence base for intestinal ultrasound (IUS)-based assessment in CD. METHODS:This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comprehensive searches of databases identified full-text articles that pre-specified TMH, TMR or normal/abnormal bowel on trans-abdominal IUS in pediatric or adult participants with CD. Definitions were summarized descriptively. RESULTS:Eighty-three full-text studies (8033 patients) met eligibility criteria; 39 (47%) defined TMH and 22 (27%) defined TMR. TMH definitions most often included bowel-wall thickness (BWT) ≤ 3mm (31/39, 79%), absent or minimal Doppler flow (25/39, 64%), and preserved bowel wall stratification (10/39, 26%). All TMR definitions required BWT reduction, but thresholds varied (absolute ≥ 1 mm or relative ≥ 25% in 16/22, 73%). Nine studies (9/22, 41%) also required Doppler flow improvement and 4/22 (18%) included additional criteria. Pediatric-specific criteria were reported in 2 TMH and one TMR studies, extrapolating from adult BWT values. Heterogeneity precluded quantitative pooling. CONCLUSIONS:Standardized IUS definitions of TMH and TMR in CD are lacking. Consistent, validated criteria are essential to enable reproducible ultrasound endpoints, support treat-to-target strategies, and facilitate incorporation of IUS into CD clinical trials and routine care.

Patients with Crohn's disease can have isolated or co-existent upper gastrointestinal involvement, but this is an understudied clinical manifestation. There are neither standardised definitions nor diagnostic or management recommendations to help to guide clinical practice. Therefore, we conducted a RAND/University of California Los Angeles appropriateness study on the definition, diagnosis, management, and appropriate outcomes of upper gastrointestinal Crohn's disease (UGICD). An international expert panel of 30 gastroenterologists and pathologists and two patient representatives were recruited. Following a previously published systematic review, 1061 candidate items were grouped into questions and evaluated for appropriateness. Two modified Delphi rounds of voting with an interposed moderated group discussion were performed. The expert panel defined UGICD as disease occurring in the oesophagus, stomach, and/or duodenum (proximal to the ligament of Treitz) that can occur at any time during the disease course. Upper endoscopy is appropriate only in patients with newly diagnosed or existing Crohn's disease with suspicion for upper gastrointestinal involvement (eg, upper gastrointestinal symptoms or the presence of anaemia). Management of UGICD should be determined on a case-by-case basis and factors, such as disease location and symptomatic, endoscopic, and imaging severity, should guide medical, endoscopic, and surgical intervention. Both clinical and endoscopic response and remission are appropriate treatment targets for routine clinical practice; there is uncertainty about the value of histological outcomes in UGICD.

Traditionally, perianal skin tag excision has been contraindicated in patients with Crohn’s disease (CD) owing to risk of non-healing wounds. We aimed to conduct a systematic review of the literature with meta-analysis, including our institutional data, on outcomes after perianal skin tag excision in patients with CD. We hypothesized that perianal skin tag excision in CD would be associated with non-healing wounds. A literature search was conducted using the MEDLINE, PubMed, Embase and Cochrane Library databases for patients with CD who underwent perianal skin tag excision or limited excisional hemorrhoidectomy. Studies reporting only on patients with ulcerative colitis or on non-operative intervention on perianal disease were excluded. For our institutional series, a retrospective review of adults with CD between 2012 and 2024 who underwent skin tag excision in isolation or with limited excisional hemorrhoidectomy was conducted. A meta-analysis on rate of complete wound healing was conducting across all relevant studies, using a generalized linear mixed model. Twelve retrospective studies fitting inclusion criteria were identified in the literature (Table 1). All identified studies were either retrospective cohort studies (N = 7) or case series (N = 5). Nine studies reported on operative intervention and postoperative outcomes, including rate of complete wound healing. The remaining three studies reported either on natural history of perianal CD focusing on risk factors (N = 2), or histologic analysis of excisional perianal specimens in CD (N = 1). At our institution, forty-five (100%) patients with CD underwent excision of skin tags; either in isolation (62%) or with limited excisional hemorrhoidectomy (44%). Long-term complications were observed in nine (20%) patients overall; long-term complication rate was higher in patients with prior perianal surgery for CD (40% vs 10%, p = 0.04). Complete wound healing was observed in 41 patients (91.1%) in our institutional series. Meta-analysis on complete wound healing (10 studies, pooled N = 249), showed a pooled likelihood of wound healing of 97% (95% confidence interval 84-100%, prediction interval 27-100%). A forest plot was generated (Figure 1), which demonstrated moderate heterogeneity across studies (I2 = 30%). Perianal skin tag excision in carefully selected patients with CD resulted in wound healing in most patients, and can be considered for lifestyle-limiting symptoms. In our data, history of prior surgery for perianal Crohn’s disease was associated with a higher rate of long-term complications. Conflict of interest: Dr. Unal, Ece: No conflict of interest Kc, Devesh: No conflict of interest Silva, Nicholas: No conflict of interest Nero, Neil: No conflict of interest Tang, Li: No conflict of interest Lavryk, Olga: No conflict of interest Kanters, Arielle: No conflict of interest Spivak, Anna: No conflict of interest Lipman, Jeremy: No conflict of interest Fulmer, Clifton: No conflict of interest Falloon, Katherine: No conflict of interest Qazi, Taha: No conflict of interest Cohen, Benjamin: Abbvie - consulting and speaking ALPCO - consulting J & J Innovative Medicine - consulting Takeda - consulting and speaking Emmes Biopharma Services LLC - DSMB Pfizer - consulting Holubar, Stefan: Grant: Surgical Research Network Grant American Society of Colon & Rectal Surgeons Grant Personal Fees: Shionogi, Takeda, Guidepoint

BACKGROUND:Pouch-related fistulas occur in 5% to 12% of patients with ileal pouch-anal anastomosis. Although cryptoglandular and Crohn-related fistulas are commonly treated with endorectal advancement flaps, the use of pouch-advancement flaps has not been previously reported in isolation. Our aim was to evaluate the outcomes of pouch-advancement flaps in the management of pouch-related fistulas and compare the outcomes of pouch-vaginal and pouch-perineal fistulas. METHODS:We retrospectively reviewed all patients with ileal pouch-anal anastomosis who underwent pouch-advancement flap surgery at our center. Our primary endpoint was sustained fistula healing after pouch-advancement flap surgery without the need for additional surgery at any time during long-term follow-up. RESULTS:Thirty patients met our inclusion criteria: 14 (46.7%) presented with pouch-perineal fistula, 14 (46.7%) with pouch-vaginal fistula, and 2 (6.6%) with both. Multibranched complex fistulas were diagnosed in 6 patients (20%). In 9 patients (30%), the pouch-advancement flap was protected with diverting loop ileostomy. After a median follow-up period of 25.7 months (range 4.8-43.1 months), the pouch-advancement flap was initially successful in 19 patients (63%), with no difference between pouch-perineal and pouch-vaginal fistulas (P = 1.0). After the initial healing, 14 of 19 patients (73.7% or 46% overall) had sustained healing, while 5 of 19 (26.3%) had fistula recurrence. Fecal diversion and other fistula characteristics were not associated with pouch-advancement flap healing (P = 1.0). CONCLUSIONS:Pouch-advancement flaps were initially successful in two thirds, with a recurrence rate after initial healing of 26.3%, regardless of whether they were pouch-perineal or pouch-vaginal. The role of fecal diversion before pouch advancement flap remains unclear, and larger, multicentric collaborative studies are needed to clarify its role.

Fibrostenosis is a serious complication of eosinophilic oesophagitis, but there is a lack of consensus regarding its definition and assessment. This poses a barrier in clinical care and research. To perform a systematic review to examine existing definitions and diagnostic methods of detection regarding fibrostenosis in eosinophilic oesophagitis. We searched MEDLINE, Cochrane Library, EMBASE, Scopus, and Web of Science and included studies of paediatric and adult eosinophilic oesophagitis patients with fibrostenosis based on endoscopy, imaging, histopathology, functional studies, and biomarkers. We excluded studies with <10 patients. We chose fibrostenosis as the umbrella term, encompassing all definitions. We identified 230 studies. The four categories of fibrostenosis definitions were: (1) structural findings (stricture, rings, and/or narrowings) ( n =204, 88.7%), (2) histology ( n =85, 37.0%), (3) functional (functional lumen imaging probe) ( n =15, 6.5%), and (4) biomarkers ( n =7, 3.0%). Multiple definitions were used in 78 studies. Methods used to detect structural fibrostenosis included Eosinophilic Oesophagitis Endoscopic Reference Score fibrostenotic components, luminal diameter (endoscopy or imaging), need for dilation, and endoscopist or radiologist global impression. Methods used to detect histologic fibrostenosis included Eosinophilic Oesophagitis Histologic Scoring System lamina propria fibrosis, pathologist global impression, and basal zone hyperplasia. Methods used to detect functional fibrostenosis included distensibility and compliance. Significant variability exists in definitions and diagnostic methods of detection regarding fibrostenosis in eosinophilic oesophagitis. Lack of agreement hampers progress in further investigating this complication. Development of consensus criteria is necessary to provide clarity for clinical care and research.

Inflammatory bowel disease (IBD) associated-erythema nodosum (EN) is one of the most common cutaneous manifestations of IBD, and significantly affects patients’ health care related quality of life. However, despite its frequency, there is still limited data regarding diagnosis in an IBD patient population. This systematic review aimed to summarize current diagnostic approaches to IBD-EN, with the goal of facilitating the development of standardized diagnostic methods and patient-reported outcomes specific to this condition. A literature search was conducted in collaboration with a medical librarian. Consensus or classification criteria, case series, cross sectional and cohort studies as well as randomized controlled trials related to diagnosis of IBD-EN were included. Studies that incorporated patient data were required to meet additional inclusion criteria, including a confirmed diagnosis of IBD along with clinical or subclinical IBD-EN. A total of 77 studies were eligible for analysis. Sixty-six studies provided prevalence data in undifferentiated subsets of IBD patients. The average prevalence of EN across the studies was 5.17% (0.2-30%) with a median of 3.45% (IQR 1.69%-7.10%). Seventy studies provided specifics regarding means of diagnosis. These included (with some overlap) use of ICD code (12), researcher review of medical records (62), physician reported diagnoses (28 in total, 13 diagnosed by gastroenterology, 15 by dermatology, and 2 in conjunction with rheumatology), and physical exam findings (10, including physical characteristics and / or location). The remaining 7 studies made no comment about methodology or specialty of provider that diagnosed EN. Due to the large heterogeneity in the available data a meta-analysis was not feasible. This systematic review reveals significant variability in the approaches to diagnosing IBD-EN in the literature. The wide range of prevalence estimates, along with inconsistent diagnostic methodologies—ranging from the use of ICD codes to diagnosis by specialists such as gastroenterologists and dermatologists—highlights the lack of standardization and evidenced based approaches to management. Until a standardized, evidence-based diagnostic and therapeutic framework is established, a multi-disciplinary approach that incorporates both clinical expertise and consistent diagnostic criteria should be prioritized to improve identification and management of IBD-EN. Figure 1 PRISMA flow diagram for evaluated studies. Figure 2 Prevalence data for included IBD-EN studies.