Severe Consequences of Pediatric Perianal Crohn’s Disease

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A Strom et al. Clin Gastroenterol Hepatol 2026; 24: 1960-1969. Perianal Disease in Pediatric-Onset Crohn’s Disease: Incidence, Disease Course, and Long-Term Outcomes

Methods: In this nationwide Danish registry, a pediatric-onset CD cohort from 1980 to 2022 was identified. Outcomes for patients with and without perianal disease were examined.

Key findings:

  • There were 2356 patients with pediatric-onset CD, of whom 769 (32.6%) developed perianal CD. The cumulative incidence of perianal CD was 14.0%, 21.1%, and 28.1% after 1, 5, and 10 years.  After 30 years, the incidence rate was 45.2%.
  • A stoma was required in 308 (40.1%) and 147 (9.3%) patients with and without perianal disease, respectively (aHR, 2.8).
Probability of Major Abdominal Surgery in Patients with and without Perianal Disease
  • When comparing patients with/without perianal disease, the aHR for major abdominal surgery, cancer, and mortality were 1.5, 0.8, and 1.5 , respectively.
Probability of Mortality in Patients with and without Perianal Disease
  • When comparing patients with/without perianal disease, the aHR for mortality was 1.5. Of mortalities, 35 had perianal disease (4.6%; mortality rate, 2.2/1000 person-years) and 33 did not (2.1%; mortality rate, 1.4/1000 person-years). However, the confidence interval was 0.9-2.7) indicating the precision of this finding is low.

Discussion: “In our study, patients without perianal disease were diagnosed with CD more frequently in recent decades than patients with perianal disease. The differences in distribution of CD diagnosis over calendar years may be due to shorter follow-up among patients diagnosed with CD in recent decades, improved treatment delaying disease progression, and increased detection of milder CD phenotypes over time.”

My take: This study reinforces and quantitates the view that having perianal Crohn’s disease portends an increased risk for severe complications. With improving treatments, perhaps the outcomes will be more favorable now and in decades hence.

Related blog posts:

The True Price of Drugs: A Look at Denver’s Self-Funded Plan

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This is a recent X posting online by Mark Cuban:

The city of Denver makes it’s PBM [pharmacy benefit manager] contract available online. So I grabbed it and had Claude look at it and answer a simple question “Where are they getting ripped off”

Then I asked for a simplified version of the above :

Here it is in plain English. Denver hired UnitedHealthcare to run its employee health plan. Denver pays the actual medical and drug bills itself — United just processes them. That’s what “self-funded” means. The problem is that Denver can’t see what it’s actually paying for drugs.

  1. United buys the drug for one price and charges Denver a different price. It keeps the difference. Say the pharmacy gets paid $40 for a prescription. United bills Denver $100. United keeps $60. Denver never sees the $40. The contract says this out loud in three different places — it’s not hidden, it’s just written in language nobody reads. There’s no cap on how big that gap can be.
  2. Drug companies pay rebates. United keeps all of them and hands Denver a flat number instead. United collects rebate checks from drug manufacturers. Instead of passing those through, it promises Denver a fixed amount per brand prescription (about $740 in 2023). If the actual rebate was $1,500, United keeps the extra $760. The contract literally says any rebates above the fixed amount belong to United. Denver has no right to know what the real number was.
  3. United decides which drugs are “specialty” — and specialty drugs are where the money is. The contract defines a specialty drug as, essentially, “whatever United’s own specialty pharmacy sells.” United also reserves the right to reclassify drugs whenever it wants. Once a drug is labeled specialty and filled at United’s own pharmacy, it drops out of the normal price guarantees entirely. So the most expensive drugs are the least protected.
  4. The most expensive drugs of all — the ones given in a doctor’s office or infusion center — have no price guarantee at all. The contract flatly excludes them. Cancer drugs, infusions, injections administered by a provider. Zero pricing protection.
  5. Denver can’t shop around, and it can’t leave without a penalty. Denver isn’t allowed to negotiate directly with any drug manufacturer. It must use United’s mail-order pharmacy exclusively. And if Denver hires an outside vendor that steers employees to cheaper drugs or cheaper pharmacies, United can cancel all the pricing guarantees. If Denver ends the drug program early, United keeps every rebate it owes.
  6. Denver can’t audit its way out of this. Denver is allowed one audit a year, capped at 300 prescriptions, using a random sample United has to approve. No auditors paid on commission. No computer-based searches for errors. You cannot find a pricing problem across hundreds of thousands of claims by randomly checking 300 of them. The audit rules exist to make sure nothing gets found.

The bottom line for an HR person: the drug program looks free. There’s no fee for it anywhere in the contract. That’s the tell. United isn’t working for free — it’s getting paid out of the drug prices, and the contract is built so Denver can’t measure how much.

Related blog posts:

Isle of Palms, SC

Use of Proton Pump Inhibitors in Infants

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M Lassalle, et al. The Journal of Pediatrics: Clinical Practice 2026; 21: 200214. Open Access! Use of Proton Pump Inhibitors in Infants: Nationwide Cohort Study Based on the French EPI-MERES Register

Methods: This studied children born between 2010 and 2021 using the French National Health Data System registry (EPI-MERES). PPI use was identified through prescriptions before age 1 year.

Key findings:

  • There were 703,891 PPI users among the 8,222,100 children included.
  • The incidence of PPI use was 54.4 per 100 person-years among children with hospital-diagnosed gastroesophageal reflux disease (GERD) (+ 33.6% between 2010 and 2021), and 7.9 per 100 person-years in those without (+ 63.6%).
  • PPI use was associated with extreme prematurity (aOR=1.91), digestive diseases (aOR=5.60), respiratory diseases, aOR, 2.73, neurological diseases (aOR=1.59), and with high maternal socioeconomic level (first quintile of deprivation index [least deprived] vs fifth quintile [most deprived] (aOR=1.80)
  • The median age at initiation of PPI treatment decreased over time, supporting the idea that PPI use may have become more commonplace.

Discussion:

  • The presence of underlying diseases may increase the use of PPIs as it is “consistent with the hypothesis that more frequent interactions with the healthcare system may be closely associated” increased prescriptions of PPIs.
  • Potential adverse PPI effects: “Early life PPI exposure has been associated with an increased risk of respiratory and gastrointestinal infections. [Also, there are] associations with immune-mediated diseases potentially mediated by microbiome alterations, including asthma,25,26 allergic disorders,26,27 and inflammatory bowel disease.28“
  • “PPI use in children aged <1 year may be appropriate, especially for esophagitis,1 but is not needed if the symptoms do not interfere with growth and development,1 and there is no evidence supporting empirical PPI therapy for diagnosing GERD in infants.1“

My take: This study shows that PPI use before age 1 has increased sharply in France since 2010. This coincides with high usage in infants elsewhere despite lack of proven efficacy. However, a recent study from Boston showed a declining trajectory of PPI use (see related posts). This indicates that a consistent message that most infants should not be treated with PPIs may be effective.

Related blog posts:


Transnasal/Transoral Endoscopy May Be Better Suited For Adults

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V Patel et al. JPGN Rep. 2026; 1-6. doi:10.1002/jpr3.70220. Open Access! Use of single-use ultra-slim endoscopes for evaluation of pediatric esophageal varices: A pilot feasibility study

*Two of the study authors have financial ties to the manufacturer of the ultra-slim endoscopes.

Methods: Ten pediatric subjects (including one that was 2.9 years of age) with suspected or known esophageal varices (EV) underwent surveillance endoscopy using the ultra-slim endoscope (transoral or transnasal endosocpy [TNE]) followed by the standard gastroscope under sedation. Esophageal findings were analyzed using images from both procedures by two independent endoscopists. 

Key findings:

  • EV were identified in 8/10 subjects (Grade I (4), Grade II (3), and Grade II/III (1))
  • Endoscopic grading matched between both endoscopes in 7/8 (87.5%) cases
  • Three subjects required endoscopic intervention with either sclerotherapy (n = 1) or band ligation (n = 2)
  • Limitation: High risk stigmata of recent bleeding such as red wale signs or fibrin plugs were not assessed and documented in this study. These features are important for risk stratification; thus, understanding whether the ultra-slim endoscope reliably identifies these stigmata is needed

In the discussion, the authors note that “our study demonstrates the potential for considering TNE for EV evaluation in a lower cost, lower acuity setting.” In my view, this is a flawed argument, particularly in pediatrics.

  1. For varices, many of the children need therapeutic endoscopic intervention. Thus, outside of a study design, this requires an additional procedure (and additional cost).
  2. In pediatric gastroenterology, most clinicians do their endoscopic procedures in a hospital-based setting and/or in affiliation with hospitals. While this can provide additional safety for risky procedures, this drives up costs. In fact, this study which promotes TNE for cost savings does not report the anticipated costs. However, in a previous study, the cost of TNE exceeded that of a standard endoscopy (including anesthesia) in an endoscopy center. Though, the cost of TNE was less than a standard hospital-based endoscopy (Related blog post: Transnasal Endoscopy in Unsedated Children to Monitor Eosinophilic Esophagitis).

My take: This technology would be better suited for adults with eosphageal conditions. First of all, most adult GI physicians are not employed by hospitals. Thus, there is a much greater likelihood of cost savings. Secondly, avoiding an additional day missing work is usually a bigger factor for adult patients. However, if there is a need for preauthorization for reimbursement of the procedure, this could negate this potential benefit as well.

Related blog posts:

Beached Fishing Boats by Jules Achille Noel, The Art Institute of Chicago

Discordant Clostridiodes difficile Testing In Patients with Inflammatory Bowel Disease

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P Ramakrishan et al. Inflamm Bowel Dis 2026; 32: 1313–1320. Discordant Clostridioides difficile testing as a predictor of inflammatory bowel disease therapy escalation

Background: “In the general population, individuals with discordant tests (PCR+/TOX−) have similar outcomes to PCR− individuals, suggesting that this group represents individuals colonized with C. difficile.[14]”

Methods: In this retrospective study (n=117), outcomes assessed included CDI-directed therapy or escalation of IBD treatment.

Key findings:

  • 79% (93/117) were PCR+/TOX− and 21% (24/117) were PCR+/TOX+
  • PCR+/TOX+ patients had significantly higher CRP (98 vs 6 mg/L, P = .005)
  • PCR+/TOX− patients had more severe underlying IBD and higher rates of steroid use (48% vs 21%, P = .02) and were significantly more likely to require IBD therapy escalation (54% vs 25%, P = .004). Multivariable analysis showed PCR+/TOX− status (odds ratio [OR], 3.2) was a significant predictor of IBD treatment escalation. Antibiotic use did not significantly alter the need for escalation among PCR+/TOX−  patients.

Discussion:

  • “Most IBD patients who are PCR+/TOX−  are colonized with C. difficile, and IBD treatment could be considered rather than delaying for CDI therapy.”

My take: In patients with IBD, PCR-positivity for C diff is frequently a false positive due to high rates of colonization in this population. Patients who have their infection confirmed with an immunoassay are much more likely to respond to C diff therapy.

Related blog posts:

Resources:

National Civil Rights Museum in Atlanta, GA. One of the powerful exhibits is a Woolworth lunch counter replica with headphones.  With your eyes closed, the exhibit challenges you to keep your hands on the counter as one receives menacing threats like ‘Boy, I’m going to kill you.’ 

Nutrition Therapy for Intensive Care Patients

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JJ Patel, SA McClave. NEJM 2026; 395: 162-174. Nutrition Therapy in Critically Ill Adults

Key points: (for adults)

  • Early enteral nutrition preserves gut integrity and supports the microbiome, so it is the preferred approach, although contemporary randomized, controlled trials show that early short-term parenteral nutrition is safe when enteral nutrition is contraindicated.
  • Providing full-dose nutrition early may lead to more metabolic and gastrointestinal complications than restrictive or trophic feeding.
  • High-dose protein (>2.0 g per kilogram of body weight per day) offers no outcome benefit over standard dosing (≤1.2 g per kilogram per day) and may be harmful in patients with acute kidney injury.
  • Adverse events with enteral feeding (often called enteral feeding intolerance) are common during critical illness, and the safe delivery of nutrition requires gradual advancement, strategies for prevention of refeeding syndrome, glycemic control (glucose level, <180 mg per deciliter), and avoidance of routine gastric residual volume monitoring.

TIMING, ROUTE AND DOSE OF NUTRITION:

  • “The receipt of nothing by mouth…impairs gut health by reducing epithelial-cell proliferation, increasing apoptosis, and disrupting mucosal integrity, enteral nutrition supports gut function by enhancing tight-junction protein expression, reducing enterocyte apoptosis, preserving villous and crypt architecture, maintaining Paneth-cell function, supporting gut-associated lymphoid tissue, and helping to sustain commensal microbiota.11,12 The collective evidence from 21 randomized, controlled trials has shown that early enteral nutrition, initiated within the first 24 to 36 hours after ICU admission, leads to better outcomes than delayed delivery or no provision of enteral nutrition.13” [if no contraindications]
  • “The CALORIES and NUTRIREA-2 trials randomly assigned critically ill adults to receive early enteral nutrition or early short-term parenteral nutrition, and the results showed no between-group differences in 30-day and 28-day mortality, respectively”
  • “Thirteen randomized, controlled trials questioned the practice of providing full-dose nutrition during the acute phase of critical illness and compared restrictive strategies — such as hypocaloric feeding, permissive underfeeding, and trophic feeding (Table 2) — with full-dose regimens.18–22,36–43 Nine trials showed no significant between-group differences in mortality.18,19,21,37–41,43 Four trials showed that restrictive-dose enteral nutrition led to better outcomes, including reductions in mortality and duration of mechanical ventilation and earlier time-to-readiness for ICU discharge, than full-dose nutrition.20,22,36,42 …Early aggressive full-dose nutrition may cause net harm by increasing the risk of bowel ischemia, refeeding syndrome, overfeeding (exogenous nutrients combined with hepatic gluconeogenesis), suppression of autophagy, increased demand on dysfunctional mitochondria, delivery of excessive fluid volume, and gastrointestinal adverse effects.28“

HIGH PROTEIN NUTRITION:

Several large well-designed studies have looked at higher protein dosing, including the EFFORT Protein Trial, the PRECISE trial and the TARGET Protein trial. Even in patients with preexisting malnutrition which was assciated wiht higher mortality, provision of high protein did not modify this outcome. “These findings were supported by two meta-analyses that showed that a high dose of protein did not lead to better outcomes in critically ill adults than a lower dose.56,57 Moreover, a high dose of protein may be harmful in patients with severe illness and acute kidney injury.”

GASTRIC RESIDUALS:

” A meta-analysis of seven trials (involving 1240 patients) indicated that not monitoring gastric residual volume reduced unnecessary feeding interruptions and showed no between-group differences in the incidence of ventilator-associated pneumonia, the length of ICU stay, or mortality.67 Current evidence does not support the use of gastric residual volume monitoring to reduce the risk of aspiration or pneumonia in ICU patients. Gastric residual volume monitoring may hinder enteral nutrition delivery… Routine monitoring of gastric residual volume — as a marker of adverse events with enteral feeding — should be strongly discouraged.”

Figure 2. Conceptual model of evolution of physiological responses and nutrition strategy across phases of critical illness.

Long Term Outcomes:

“Over the past four decades, survival from critical illness has improved but is marred by substantial loss of lean body mass, which is a major long-term consequence for survivors.4 Loss of lean body mass contributes to acquired muscle weakness and functional disability, which can persist for up to 5 years after the initial ICU admission.74 In healthy persons, resistance exercise combined with protein supplementation has been shown to elicit a greater anabolic response than protein supplementation alone.75“

My take: While this article is geared towards adult patients, my expectation is that the recommendations are largely applicable to pediatric patients. However, there is much more data in adults and pediatric care needs to be adjusted based on size.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

The Politicization of Science and Outcomes for Health Care

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Yesterday’s blog post highlighted how the current policies are leading to a brain drain, undermining economic advangages and harming our ability to improve outcomes for patients.

Today’s post summarizes a recent editorial by the NEJM editors (NEJM 2026; 395: 187-188. The OMB and the Politicization of Science) that drills down on three specific proposals by the OMD to change research policy.

An excerpt:

“For decades, the Soviet Union promoted the unorthodox views of Trofim Lysenko, an agronomist who used his close ties to the political leadership to spread misinformation denying Mendelian genetics. What followed was a disaster: many years of poor harvests based on unsupported science and suppression of the teaching and practice of modern genetics throughout the Soviet bloc. A similar threat now hangs over U.S. science…

The rule changes that the White House Office of Management and Budget (OMB) recently proposed to the Health and Human Services (HHS) grant process would drastically change this process. There are too many objectionable aspects of these proposals to discuss here. But three are particularly striking. Political appointees would be able to make funding decisions and could ignore the advice of independent scientists. They could also stop funding midway through the promised grant period. And they would institute new rules, including rules severely limiting foreign interactions…

Expert, independent peer review of grant applications is essential for directing NIH dollars to research that has the greatest potential for advancing science and improving health. Selecting the most promising research is an enormously complex and challenging undertaking…

The OMB proposal to permit political appointees to discontinue funding of ongoing grants at any time, without cause, would have serious adverse consequences for the research enterprise and for patients…the gold standard of evidence is the randomized, controlled trial (RCT). The RCT’s methods minimize the influence of bias and preconceived notions. However, this type of trial often takes years to conduct…If a decision to stop funding the trial occurred at year 4 for political rather than scientific reasons, what would happen to patients who were enrolled in the study at that time? How would longer-term safety and efficacy observations be made?…Can physician–investigators ethically enroll a patient in a trial if ongoing funding for the trial is uncertain?

There would be substantial adverse effects on researchers as well as patients. Why would a basic science investigator start a line of investigation that might take years to complete if the funding for it could be cut at any moment, without cause?…A corrosive consequence of such an arbitrary funding process would be the diminishment of the U.S. workforce of clinical and basic science investigators — and it would ultimately harm biomedical innovation and cutting-edge patient care…

The proposed rules would also severely limit foreign research partnerships, requiring political approval of international collaborations…Broad global collaboration has led to…studies [which] can be completed years earlier than they would be otherwise, at a fraction of the cost, bringing earlier and greater benefits to all affected people, including people in the United States. Aren’t we better off addressing Ebola, tuberculosis, or screwworm before they spread to additional communities?” 

My take: Allowing politicians to arbitrarily choose which research to fund rather than those with the greatest merit will lead to a poor harvest of scientific advances for all of us. This would, however, enable a select few to benefit from their corrupt connections to steer more money into their greedy pockets.

Boardwalk at Arablia Mountain Trail

Scientific Excellence Leaving U.S.

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Numerous articles have documented the abrupt changes to research funding by this administration.

I will focus on the first article but the others provide additional insight into this issue.

An excerpt:

Omar Yaghi, an immigrant to the United States who shared last year’s Nobel Prize in Chemistry, has left his faculty post at the University of California, Berkeley, for one in China, where he will lead an institute using artificial intelligence to accelerate the discovery of new materials…

Last year, three of America’s six winners of science Nobels were born outside the country. In this century, overall, the émigré fraction for U.S. Nobels in physics, chemistry and medicine now stands at 40 percent…

Last year, before flying to Stockholm to receive his Nobel Prize, Dr. Yaghi in an interview with The New York Times voiced concern about Mr. Trump’s immigration policies, saying that they endanger the nation’s system of universities, companies and governments that promote scientific excellence…

My take: The arbitrary cuts and policy shifts have undermined an engine for American prosperity, stalled the development of medications for numerous disorders, imperiled thousands of patients enrolled in clinical trials. and resulted inthe loss of enormous scientific/medical talent.

Related blog posts:

Confusing Guidance and “Conditional” Recommendations for Probiotic Use in Pediatric Irritable Bowel Syndrome and Functional Abdominal Pain

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R Francavilla et al. J Pediatr Gastroenterol Nutr. 2026;83:3–6. Open Access! From evidence to advice: How uncertainty shapes probiotic guidance in pediatric irritable bowel syndrome

Key points:

  • “Recent guidance documents of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) on probiotic use in pediatric irritable bowel syndrome (IBS) do not simply converge toward a shared recommendation.1–3 Rather, they illustrate an evolution in how scientific uncertainty is operationalized in clinical advice. “
  • “The ESPGHAN Position Paper Probiotics for the Management of Pediatric Gastrointestinal Disorders represents the most structured approach among the three documents, treating probiotics as strain-specific interventions evaluated against predefined clinical outcomes.1 In functional abdominal pain disorders, healthcare professionals may recommend Limosilactobacillus reuteri DSM 17938 to reduce pain intensity, while in pediatric IBS Lactobacillus rhamnosus GG may be recommended to reduce pain frequency and intensity. These recommendations are accompanied by explicit dosing ranges, defined clinical targets, and formal appraisal of evidence certainty (moderate) and strength of recommendation (weak).”
  • “The joint ESPGHAN/NASPGHAN guideline on treatment of IBS and functional abdominal pain—not otherwise specified in children aged 4–18 years represents a shift in emphasis.2 L. rhamnosus GG is conditionally suggested as a therapeutic option for pediatric IBS, supported by moderate overall certainty of evidence and a small, reported effect size. Multistrain probiotics and synbiotics are likewise framed as options that may be suggested, but with low certainty of evidence. In contrast to earlier ESPGHAN position papers, the guideline does not specify detailed dosing regimens, treatment duration, or stopping rules.”
  • “This reframing extends further in the European and North American guidance addressing IBS and functional abdominal pain in childhood.3 …Within this framework, probiotics are positioned less as therapies to be prescribed and more as adjunctive measures to be discussed with families, including in primary care settings.”

Conclusions from authors: “At a policy level, conditional recommendations do not operate in a neutral context…Probiotics are widely available, variably regulated, and commonly perceived as harmless. In pediatric IBS, where symptoms are chronic, placebo responsiveness is high, and pharmacological options are limited, conditional guidance may be interpreted as tacit approval for routine use, regardless of modest effect sizes…their use may drift from deliberate intervention toward habitual supplementation.”

My take: I rarely recommend probiotics for pediatric IBS. Even simple dietary changes are much more likley to be beneficial. In addition, there is a concern about the lack of quality control in the production of probiotics.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Guidelines for Hirschsprung’s Disease

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D Rossi et al. J Pediatr Gastroenterol Nutr. 2026;83:185–207. Open Access! Updated European Reference Network for rare Inherited and Congenital Digestive and Gastrointestinal Anomalies guidelines for the management of rectosigmoid Hirschsprung’s disease 2025

These guidelines cover recommendations for diagnosis, pre- and postoperative care, poor functional outcomes, long-term follow-up, and Hirschsprung’s-associated enterocolitis.

Some specific recommendations:

Diagnosis:

Preoperative Care:

  • Routine screening for all patients with rectosigmoid Hirschsprung’s disease (HSCR))with ultrasound for congenital anomalies of kidney and urinary tract (CAKUT) and systematic assessment of nutritional status.

Operative Care:

Hirschsprung’s-Associated Enterocolitis:

  • Table 9 provides extensive advice for bowel management strategies/evaluation in children with fecal incontinence.
  • Table 11 discussed genetic testing, noting that RET gene should be considered. Genetic counseling is recommended in those patients with a family history of Hirschsprung’s disease.

My take: This article provides good advice for optimizing care for patients with Hirschsprung’s disease.

Related blog posts:

Diagrams of 3 common pull-through operations for Hirschsprung disease.
From left to right: full-thickness rectosigmoid dissection (Swenson), a recto-rectal pouch procedure (Duhamel), and an endorectal dissection (Soave). JPGN 2023; 76(4):533-546.