Background and Aims:The safety of gastrointestinal endoscopy in neutropenic patients remains unestablished. Gastrointestinal and infectious disease society guidelines indicate that infectious adverse events are increased after endoscopy in neutropenic patients. We performed a systematic review and meta-analysis to assess the safety of endoscopy in neutropenic patients. Methods:Cochrane Library, Embase, Google Scholar, MEDLINE, PubMed, Scopus, and Web of Science were searched through September 2025 for studies in neutropenic patients (absolute neutrophil count <1000 cells/μL) undergoing endoscopy with outcome data on infections, mortality, or fever. Conference abstracts from January 2017 to September 2025 were also searched. Two reviewers independently identified studies meeting inclusion criteria, performed data extraction, and assessed risk of bias. Coprimary outcomes were 30-day infection-related mortality and infectious adverse events within 7 days of endoscopy. Secondary outcomes were new bacteremia and new fever within 7 days of endoscopy. Random-effects meta-analyses were performed. Results:Six cohort studies met eligibility criteria (N = 1241 patients). Pooled incidence was 0.0% (95% confidence interval [CI] 0.00%-0.03%; I2 = 0.0%) for infection-related mortality and 7.3% (95% CI 0.00%-25.57%; I2 = 98.6%) for infectious adverse events, which consisted of bacteremia (2.4% [95% CI 0.03%-6.99%; I2 = 87.3%]) and new fever (4.8% [95% CI 0.00%-9.74%; I2 = 99%]). Preprocedural antibiotic use did not reduce infectious adverse events or bacteremia as compared to no antibiotic use: odds ratio = 2.97, 95% CI 0.47-18.67. Conclusion:Infection-related mortality within 30 days was 0% and infectious adverse events within 7 days occurred in 7.3% of neutropenic patients undergoing endoscopy. These findings suggest endoscopy maybe safely performed in appropriately selected neutropenic patients.

Immune checkpoint inhibitor-induced (CPI) enterocolitis is a frequent complication of cancer immunotherapy. This case details the treatment of CPI enterocolitis with risankizumab (anti-IL23) and the use of intestinal ultrasound (IUS) to noninvasively monitor treatment response. This report is clinically relevant given the frequency of CPI enterocolitis and the expanding applications of IUS.

This case demonstrates the utility of intestinal ultrasound in inflammatory bowel diseases outside of Crohn's disease and ulcerative colitis. We describe the utility of intestinal ultrasound in monitoring disease activity and treatment response in a patient with microscopic colitis.

Background: Pregnancy outcomes in patients with inflammatory bowel disease with quiescent disease are similar to those in the general population. Data from the Pregnancy Inflammatory bowel disease And Neonatal Outcomes registry have demonstrated the safety of antitumor necrosis factor (TNF) α agents and thiopurines in pregnancy. The objective of this study was to provide information from the Pregnancy Inflammatory bowel disease And Neonatal Outcomes registry on maternal and fetal outcomes in patients exposed to the newer biologics ustekinumab (UST) and vedolizumab (VDZ). Methods: In this multicenter prospective observational study, we included pregnant women with singleton pregnancies and a diagnosis of inflammatory bowel disease. Questionnaires were administered to women at study intake, each subsequent trimester, delivery, and 4, 9, and 12 months after birth. Bivariate analyses were used to determine the independent effects of specific drug classes on outcomes. The exposure cohorts were VDZ, UST, anti-TNF, immunomodulators, and combination with anti-TNF and immunomodulators. All were compared with no exposure and with biologics/immunomodulators. Results: There were 1,669 completed pregnancies with 1,610 live births. The maternal mean age was 32.1 (SD 4.6) years at delivery with 66 VDZ exposed and 47 UST exposed. Women on UST were more likely to have Crohn's disease. There was no increased risk of spontaneous abortion, small for gestational age, low birth weight, neonatal intensive care unit stay, congenital malformations, or intrauterine growth restriction with in utero VDZ or UST exposure. The rate of preterm birth was lower (0.0%) for the UST-exposed cohort when compared with other cohorts including VDZ (13.8%), anti-TNF (8.2%), combination therapy (14.2%), immunomodulators (12.3%), and unexposed (9.7%) ( P = 0.03). Rates of serious infections at birth, 4 months, and within the first 12 months of life were comparable among all cohorts. Nonserious infections were lower at 12 months in UST-exposed pregnancies. There was no increased risk signal for placental complications in the VDZ cohort. UST infant concentrations at birth were increased whereas VDZ concentrations were overall decreased compared with maternal serum drug concentration. DISCUSSION: This analysis of UST and VDZ exposure during pregnancy suggests no increase in complications compared with TNF, immunomodulators, and combination TNF/immunomodulators. No signal was found for increased placental events with either therapy. Continuation of UST and VDZ throughout pregnancy is recommended.

Abstract Background  Inflammatory bowel disease (IBD) is a chronic condition that requires close monitoring. Digital health virtual care platforms can enable self-monitoring and allow providers to remotely surveil patients and efficiently identify those with active disease. Objectives  The primary aim was to design and implement an IBD remote monitoring program, identify predictors of patient engagement, and determine who found the chat to be a valuable tool. Methods  We developed the IBD Virtual Care Chat, an electronic health record (EHR)-integrated chat to monitor electronic patient reported outcomes (ePROs), medication changes, and disease activity, and subsequently report concerning findings to providers via the EHR. All patients in the IBD practice over age 18 with a clinical encounter in the preceding 12 months were eligible to be enrolled. The primary aim was to identify predictors of patient engagement and determine who found the chat to be a valuable tool. Results  Between May 2021 and March 2022, 2,934 patients were enrolled. A total of 1,160 engaged at least once and 687 (23.4%) continually engaged, submitting at least three ePROs. Disease severity (based on Harvey–Bradshaw Index or Simple Clinical Colitis Activity Index) did not impact ePRO submissions. Patients were significantly more likely to be continually engaged if they self-reported the presence of extraintestinal manifestations (7%, 95% confidence interval: 0.01–0.14; p  = 0.04). Patient satisfaction remained moderately high with a median score of 8 (interquartile range: 5–10) on a scale of 1 (poor) to 10 (good). Conclusion  Our program demonstrates the potential for EHR-integrated digital health as part of routine IBD care to achieve sustained engagement with high patient satisfaction.

Background Upadacitinib is a selective Janus kinase inhibitor approved for the management of ulcerative colitis and is under evaluation for the management of Crohn’s disease [CD] in Phase 3 clinical trials. Aims Our goal was to describe our real-world experience with upadacitinib in CD. Methods This is a two-centre retrospective cohort study of adult patients with moderate to severe CD on upadacitinib. The primary outcome was clinical response and remission as determined by stool frequency and abdominal pain scores. Secondary endpoints included endoscopic response and remission as determined by change in Simple Endoscopic Score for CD. Outcomes were assessed at 3 months after starting upadacitinib and at the patient’s most recent follow-up. We further evaluated adverse events and dose-related response. Results A total of 45 CD patients received upadacitinib and were included in the safety analysis. Thirty-six patients received upadacitinib for CD, whereas nine received it for inflammatory arthritis [n = 8] or pyoderma [n = 1]. Thirty-three patients received upadacitinib for 3 months or longer and were included in the efficacy analysis. At the 3-month follow-up, 21 patients achieved clinical response [63.6%] and nine achieved clinical remission [27.2%]. At time of last follow-up, 23 patients had clinical response [69.7%], ten achieved clinical remission [30.3%] and four [28.6%] achieved endoscopic remission. Adverse events occurred in 12 patients [26.7%]. Two patients had a serious adverse event [4.5%] without associated mortality. Conclusion In this real-world cohort of highly refractory CD patients, upadacitinib was effective in inducing remission and had an acceptable safety profile.

The prevalence of inflammatory bowel disease is continuing to increase worldwide and is more commonly diagnosed in women of reproductive age. Individuals with Crohn's disease may have inaccurate perceptions regarding the rate of infertility, heritability, and the safety of taking therapies for Crohn's disease during pregnancy, all of which greatly affect their decisions surrounding family planning. Given this area of need for both patients and providers, in this article, we have included the latest evidence on the impact of Crohn's disease on fertility, heritability, pregnancy outcomes, and the safety of medications for Crohn's disease during pregnancy and lactation.

Inflammatory bowel disease (IBD) has an increasing prevalence worldwide, including young adults. Fertility and pregnancy safety are common topics of concern in this patient population. Maintaining fertility and achieving healthy maternal and fetal outcomes are dependent on disease severity. Steroid free remission for at least three months prior to conception increases the likelihood of sustained remission throughout pregnancy and decreases the risk of pregnancy related complications for both the mother and child. Data from large registries, including PIANO (Pregnancy in Inflammatory Bowel Disease and Neonatal Outcomes), has demonstrated that biologics and thiopurines are low risk during pre-conception, pregnancy, delivery, and lactation. Children with in utero or breastmilk exposure to these medications are not at increased risk of infection during their first year of life and achieve developmental milestones at a rate consistent with that of the general population. Methotrexate must be avoided due to the risk of teratogenicity. Data to support use of small molecule therapies during pregnancy and breastfeeding is lacking at this time.

To the editors, Although there are conflicting data on the increased risk of lymphoma in patients with inflammatory bowel disease (IBD), there are confirmed reports of small-bowel lymphoma masquerading as small-bowel Crohn disease (CD).1-3 Here we present 2 additional patients with small-bowel lymphoma initially thought to have CD. A male patient aged 68 years presented with a 1-year history of abdominal pain, bloating, diarrhea, and weight loss. Magnetic resonance enterography revealed thickening and hyperemia involving 25 cm of the terminal ileum (TI). Colonoscopy showed severe ileitis with numerous TI ulcers (Fig. 1A). Biopsies showed chronic focally active ileal inflammation. Infliximab was started for presumed CD. After induction, the patient had improvement in abdominal pain and diarrhea but continued to complain of early satiety and bloating. Six months later, repeat colonoscopy showed a moderately tight, nearly circumferential ulcerated TI stricture. Magnetic resonance enterography showed a thickened TI...

Background: Immune checkpoint inhibitors (ICIs) have transformed the management of advanced malignancies but are associated with diarrhea and colitis. The objective of our systematic review and meta-analysis was to determine the incidence and outcomes of ICI-associated diarrhea and colitis. Bibliographic databases were searched through August 13, 2019, for observational studies of ICI therapy reporting the incidence and/or treatment of diarrhea or colitis. The primary outcome was ICI-associated diarrhea and colitis. Meta-analyses were performed with random-effects models. Twenty-five studies (N=12,661) were included. All studies had a high risk of bias in at least 1 domain. The overall incidence of diarrhea/colitis was 12.8% [95% confidence interval (CI), 8.8-18.2, I (2)=96.5]. The incidence was lower in patients treated with anti-programmed cell death 1/programmed death-ligand 1 (4.1%, 95% CI, 2.6-6.5) than in those treated with anti-cytotoxic T-cell lymphocyte-associated antigen 4 (20.1%, 95% CI, 15.9-25.1). The remission of diarrhea and/or colitis was higher in patients treated with corticosteroids plus biologics (88.4%, 95% CI, 79.4-93.8) than in those treated with corticosteroids alone (58.3%, 95% CI, 49.3-66.7, Q=18.7, P<0.001). ICI were permanently discontinued in 48.1% of patients (95% CI, 17.8-79.1). ICI were restarted after temporary interruption in 48.6% of patients (95% CI, 18.2-79.4) of whom 17.0% (95% CI, 6.4-30.0) experienced recurrence. Real-world incidence of ICI-associated diarrhea/colitis exceeds 10%. These events lead to permanent ICI discontinuation in just over 50% of patients, while <20% have recurrence of symptoms if ICI are resumed. Further studies are needed to identify patients who would benefit from early treatment with biologics as well as appropriate patients to resume ICI therapy.

INTRODUCTION: Invasive mucormycosis is a rare, life-threatening infection that primarily affects immunocompromised hosts. Common sites of involvement include paranasal sinuses, lungs, and skin. Gastrointestinal (GI) involvement is seen in only 7% of cases. Most GI mucormycosis occurs in pediatric or low birth-weight infants; cases in adults are rare. Here we describe 10 patients with GI mucormycosis, their clinical outcomes and endoscopic and histologic findings. METHODS: GI mucormycosis cases were identified using a 30-year search of the pathology database at a single large academic center. The electronic medical record was used to record patient demographics, comorbidities, symptoms, treatments and outcomes. RESULTS: Ten adult patients with GI mucormycosis were identified (Table 1). Seven were male and six had a hematologic malignancy for which they received chemotherapy. Nine patients were immunocompromised by malignancy (6), diabetes (1), aplastic anemia (1) or HIV (1). Presenting symptoms were fever (4), abdominal pain (4), chest pain (2), dysphagia (2), nausea/vomiting (2), and diarrhea (1). Sites of involvement included the liver (2), esophagus (1), small intestine (2), stomach (1), and colon (1). The methods of diagnosis were endoscopy (2), surgical resection (1), liver biopsy (2) and autopsy (3). Endoscopic findings included erosive esophagitis with ulceration (1) and non-bleeding gastric ulcers (2). Eight patients had necrosis, abscess formation and extensive angio- and tissue invasion on pathology. One patient had small bowel perforation, one required surgical intervention and three required resections. Follow up data was available in 5 patients, 3 of whom died within 3 months of diagnosis and of the surviving 2, one developed esophageal stricture and one had hepatic involvement without long-term sequelae. CONCLUSION: Hematologic malignancy with chemotherapy use was the most common risk factor associated with GI mucormycosis. We observed a variety of presenting symptoms, of which the most common were fever and abdominal pain. While only 2 patients were diagnosed endoscopically, both had non-bleeding gastric ulcers and one also had esophageal ulceration. Two of 5 treated patients with follow up survived greater than 3 months. Conclusion: There is high mortality associated with GI mucormycosis and clinically significant long-term sequelae in patients that survive.Figure 1.: A. Endoscopic image of stomach. Gastric antral ulcer measuring 5 centimeters in size with adherent blood clot (Forrest classification IIB). There is no evidence of visible vessel or active bleeding seen. Figure 1B. Stomach, Periodic acid–Schiff with diastase, 400x: The gastric mucosal tissue is infiltrated by ribbon-like fungal hyphae highlighted darker pink by the stain. The broad branching hyphae depicted by arrow heads are noted infiltrating the mucosa. Figure 2A. Endoscopic image of esophagus. Circumferential, diffuse esophageal ulceration with no evidence of recent or active bleeding. Figure 2B. Esophagus, Grocott-Gomori's methenamine silver, 400x: The stain highlights infiltrating fungal hyphae dark brown black. The subepithelial stroma of the ulcer shows infiltrating broad pauciseptate ribbon like fungal hyphae depicted by short arrows.Table 1

Ustekinumab (UST) is an effective treatment for Crohn’s disease (CD). Here we present two cases of leukocytoclastic vasculitis (LCV) in CD patients after UST induction therapy with a review of the literature. Patient #1: A 26 year old woman with a 14 year history of Crohn’s ileocolitis. She was previously treated with 6-mercaptopurine, infliximab, and vedolizumab without durable response. She ultimately underwent a left hemicolectomy due to development of a sigmoid stricture and was started on UST postoperatively. Thirty-six days after her initial UST intravenous (IV) infusion of 390 milligrams (mg) she developed new partially blanching, erythematous, non-tender, non-pruritic macules and papules over the right medial thigh, which later evolved into palpable purpura involving both lower extremities (Figure 1A). She reported no gastrointestinal (GI) or other symptoms. White blood cell (WBC) count and metabolic panel were normal. Antinuclear antibody (ANA) titer was 1:80. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) were positive. C-reactive protein (CRP) was elevated to 41.5 mg/liter (L). One lesion was biopsied, and pathology findings were consistent with LCV (Figure 1B). She was started on colchicine 0.6 mg daily with improvement in her rash and has received her second dose of UST without further complications. Patient #2: A 29 year old woman with a 6 year history of Crohn’s ileocolitis. Her prior treatments include budesonide, mesalamine, and infliximab. While on infliximab, she developed jejunal and ileal ulcers on video capsule endoscopy. Infliximab was discontinued, and UST was started. Three months following initial IV induction therapy of UST, she developed pink purpuric papules and hemorrhagic vesicles involving her bilateral shins, dorsal feet, calves, and bilateral extensor forearms. The appearance of the rash was consistent with LCV (Figure 2). She was started on prednisone at 60 mg daily for 1 week with taper resulting in complete resolution of her rash. UST was continued with no recurrence. WBC count and metabolic panel were normal. ANCA was negative, and ANA titer was 1:80. CRP was elevated to 13.2 mg/L. Literature review revealed only one prior published case report of a patient with inflammatory bowel disease developing LCV after administration of UST. In this case, UST was discontinued since re-administration caused the rash to return. Here we have two patients who developed LCV soon after initiating UST therapy, although after treatment with prednisone/colchicine, there was no recurrence with continuing UST. It is possible to develop LCV in association with CD alone; however, these patients had longstanding disease without occurrence of LCV until being started on UST. Moreover, patient #1, was in remission from a Crohn’s disease standpoint at the time of UST initiation and onset of the rash.

INTRODUCTION: The ratio of blood urea nitrogen (BUN) to creatinine can be used as a surrogate for identifying sources of upper gastrointestinal bleed (UGIB). The proposed mechanism of this “accelerated azotemia” is brisk bleeding above the ligament of Treitz, followed by blood protein breakdown and absorption in the upper GI tract in the setting of hypovolemia and subsequent kidney hypoperfusion. Several ratios have been described in the literature, with variable sensitivities and specificities, but there is no consensus on the ideal ratio for recognizing an UGIB. Our study seeks to expand upon a prior research study done at our institution to determine the sensitivity, specificity, and positive predictive value (PPV) of gradated BUN/creatinine ratios (20:1 to 100:1) in identifying an UGIB. METHODS: 1,194 patients were identified between 2008 and 2016 using “Looking Glass Clinical Analytics” TM . Inclusion criteria were patients admitted with hematochezia, melena, or hematemesis, with a decrease in hemoglobin (Hb) of >1 g/dL from baseline. Patients with chronic kidney disease stage 3 or greater were excluded. Demographic data and source of bleeding were collected. Hb, BUN, and creatinine values were collected at baseline, day 1, and day 2 of admission. Sensitivity, specificity, and PPV were calculated for each ratio. A receiver operating characteristic (ROC) curve was created for day 1 and 2 of admission. RESULTS: 604 patients had GI bleeding confirmed by endoscopy. Average age was 67 years, 50% (n = 302) were female, and 76% (n = 459) were Black or Hispanic. 62% (n = 375) had a confirmed UGIB source. Median change in Hb from baseline was 3.0 g/dL. For a BUN/creatinine ratio of ≥20:1 on day 1, specificity was 66.67%, sensitivity was 73.32%, and PPV was 78.16%. Values for day 1 and 2 of hospital admission are listed in Tables 1 and 2. ROC curve on day 1 (Figure 1) had an area of under the curve of 0.68 (CI = 0.64-0.73). CONCLUSION: A BUN/creatinine ratio of ≥30:1 has a PPV of 84% and may be ideal for identifying an UGIB. Interestingly, as the ratio increases above 30:1, the PPV plateaus and the likelihood of UGIB does not increase further. The specificity of UGIB at 30:1 is high at 85%. The ROC curve shows that the BUN/creatinine ratio is an accurate test for predicting an UGIB. This indicates that in clinical practice, a patient presenting with GI bleeding and a drop in hemoglobin ≥1 g/dL associated with an “accelerated azotemia” of ≥30:1 should first undergo upper endoscopy to localize a bleeding source.