How Effective Is Treatment of Eosinophilic Esophagitis In Patients with Rumination Syndrome?

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D Yang et al. J Pediatr Gastroenterol Nutr. 2026;83:374–380. Rumination syndrome and eosinophilic esophagitis in children: Defining the relationship

Methods: This was a retrospective cohort study of children with RS and EoE evaluated at our institution from 2016 to 2023.

Key findings:

  • In this cohort with rumination syndrome, 22 of 230 had EoE. This is a significantly greater prevalence of EoE (10%) among children with RS than in the general population (0.1%).
  • Among those diagnosed with EoE first (70%), RS diagnosis occurred after a median of 15.4 months.
  • EoE treatment led to mucosal remission in 73% and improved dysphagia in 41%, but 86% continued to experience regurgitation.
  • RS treatment, including behavioral therapy and baclofen, improved or resolved regurgitation in 64%.
Improvement in Regurgitation to EoE vs RS ‐based treatments among patients with RS and EoE.
EoE, eosinophilic esophagitis;RS, rumination syndrome

Limitations: retrospective design and potential referral/selection bias in a tertiary care population (specialized center for rumination).

My take: In patients with both EoE and RS, regurgitation continued in 86% of patients who achieved EoE remission. Especially in those without dysphagia, most will need treatment of RS in additon to EoE. In addition, earlier treatment of RS may improve outcomes.

Related blog posts:

Balanced Fluid (like Lactated Ringer’s) vs Saline in Pediatric Sepsis

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  • Balamuth F, Weiss SL, Long E, et al. N Engl J Med 2026;395:870-881. Balanced fluid or 0.9% saline in children treated for septic shock. 

Key finding: No significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline.

  • MF O’Connor, J Bubeck-Wardenburg. N Engl J Med 2026;395:921-922. Commentary: Fluid Resuscitation in Patients with Sepsis — For Whom the Balance Tolls

From the commentary:

“Balamuth and colleagues report the findings of the Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS), a large, international, pediatric trial evaluating whether treatment with balanced crystalloid fluid (lactated Ringer’s solution, Plasma-Lyte, or Hartmann’s solution according to clinician discretion) is associated with better kidney-function outcomes than therapy with normal saline in patients with sepsis..

Evaluating more than 8000 children who were well matched with respect to the severity of sepsis at initial presentation, the current trial showed that the nature of fluid administered did not significantly affect patient outcomes…This finding contrasts with those of SMART and the SALT-ED trial as well as those of two other trials…6,7 

As appropriately recognized by Balamuth et al., less-severe illness in the participants in the present trial may have limited the ability of the trial to detect an influence of fluid composition on clinical outcome. Taken together, both adult and pediatric studies suggest that the clinical benefit of balanced-fluid administration correlates directly with the degree of cellular homeostatic disruption in patients with sepsis…

It is important to consider that harm has not been associated with the administration of balanced fluids in any clinical study. With the notable exception of patients with intracranial hypertension, the prudent approach may be to use balanced fluids as standard care in patients with sepsis.”

My take: For most children with sepsis, the outcomes are likely to be similar between those receiving balanced fluids and saline. However, sicker patients, which may be difficult to discern initially, may benefit from balanced fluids.

Related blog posts:

Congratulations to NASPGHAN’S NEWLY ELECTED LEADERS:

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 Tricky Problem of IBD with IBS-like symptoms

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Ma C, Ford A, Hashash J et al. Gastroenterology, 2026; 171, 504-520. Open Access! Recommendations for the Evaluation and Management of Inflammatory Bowel Disease With Irritable Bowel Syndrome–Like Symptoms: A Joint Rome Foundation and International Organization for the Study of IBD (IOIBD) Consensus

Background:

  • “A substantial proportion of persons with inflammatory bowel disease (IBD) in remission continue to experience abdominal pain, altered bowel habits, and bloating that resemble irritable bowel syndrome (IBS). Lack of standardized definitions and evidence-based management strategies leads to diagnostic ambiguity and potentially unnecessary escalation of IBD therapy. A joint Rome Foundation/International Organization for the Study of Inflammatory Bowel Disease Working Team developed consensus recommendations on nomenclature, evaluation, and treatment of IBD with IBS-like symptoms.”
  • “A meta-analysis of 27 studies demonstrated that 1 in 3 individuals with IBD reported
    coexisting IBS, although estimates were heterogeneous and few studies objectively excluded active disease (11.2% to 63.6%).[1] Among those with endoscopic or histologic
    remission, 1 in 4 reported IBS-like symptoms.”

Methods: A multidisciplinary international panel applied a modified RAND/UCLA Appropriateness Method and determined recommendations for evaluation and management of these patients.

Terminology:

  • “The preferred term was “IBD with IBS-like symptoms,” defined as abdominal pain, bowel habit change, and/or bloating not explained by active inflammation or structural disease.”

Pathophysiology:

Evaluation to determine whether GI symptoms are related to IBD or are related to IBS-like symptoms

Key points:

  • “An FC [fecal calprotectin] below 150 μg/g is considered normal, but persons with IBD with ongoing symptoms may require endoscopic evaluation even with a normal FC, especially in the setting of small bowel involvement or after surgery in CD.”
  • “In clinical care, the diagnosis of IBD with IBS-like symptoms can be supported using the Rome Clinical Diagnostic Criteria (having symptoms sufficiently bothersome to seek health care for at least the prior 8 weeks or when other conditions have been excluded).”
  • Dietary treatments of IBS symptoms were recommended including psyllium and a trial of a low FODMAP diet.
  • Medication treatments of IBS symptoms were recommended including TCAs, SSRIs, SNRIs, antidiarrheals (e.g. loperamide), antispasmotics, peppermint oil, osmotic laxatives, 5-HT4 receptor agonists and secretagogues (e.g. linaclotide).
  • Behavior therapies including GI-focused cognitive behavioral therapy and gut-directed hypnotherapy were recommended
Treatment algorithm

My take: Overall, this expert panel endorsed a broad-range of current IBS treatments for patients with well-controlled IBD experiencing ongoing GI distress. This paper focuses attention to this difficult clinical problem in which many patients, historically, have received escalating IBD therapy rather than IBS therapies. Part of the problem is that it is difficult to be certain that a patient’s IBD is well-controlled and that there are no structural problems (e.g. strictures). In addition, many patients have very mild findings and it can be hard to know if these findings are enough to account for the symptoms. The opposite problem can also occur in which patients have very active IBD yet have few clinical complaints.

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.

Outcomes in a Large PSC-IBD Cohort

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Methods: This population-based study, using an administrative database that covered >99% of 15 million residents, identified 476 incident patients with PSC-IBD. Patients were identified between 2002-2018 with followup through 2021. Median age at PSC diagnosis was 36 years and for IBD 34 years. 73% were diagnosed with IBD and had a median time to PSC diagnosis of 3.2 years. In the 27% with an initial diagnosis of PSC, the median time to IBD diagnosis was 0.9 years. The background comparator group consisted of 54,591 individuals diagnosed with IBD alone.

Key findings:

  • 54% probability of remaining event-free at 10 years. 
  • There were 98 (21%) deaths and 80 (17%) who underwent liver transplant.
  • There were 36 (7.5%) hepatopancreatobiliary cancers (HPBCa) in this cohort
  • A diagnosis of HPBCa was associated with higher progression rates to liver transplant (TIR 20.9) and mortality (TIR 75.0).
  • PSC–IBD patients had approximately 300-fold higher HPBCa and 4-fold higher CRC rates than IBD alone, underscoring their comparative substantial cancer burden.
  • Mortality occurred more frequently post-colectomy (TIR 3.08) and post-cholecystectomy (TIR 3.85) relative to event-free PSC–IBD, but there were no differences in post-surgery incidence of cancer or transplant.

My take: This provides more granular data on the likely outcomes in individuals with PSC-IBD. Identifying individuals who are likely to develop a complicated course is not currently feasible. Current strategies rely on ongoing surveillance.

Related blog posts:

This image captures Kirkjufell Mountain and the Kirkjufellsfoss waterfall in western Iceland. It was a filming location for Game of Thrones, where it was referred to as “Arrowhead Mountain”.

Survival Advantage of Living Donor Liver Transplantation in Large Pediatric Cohort

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Yodoshi, T., Kuenzig, M. E., Tang, F., Kajiwara Saito, M., Zizzo, A., Ng, V. L., & Benchimol, E. I. Liver Transplantation 2026, 32(9), 1273–1284. Donor type, social deprivation, and long‑term outcomes in pediatric liver transplantation: A 30‑year population‑based cohort.

Background: Living donor liver transplantation (LDLT) reduces wait‑list mortality in children; this can be due to shorter waiting times, minimal cold ischemia, and healthier donor organs. However, its long‑term advantages over deceased donor liver transplantation (DDLT) and how socioeconomic context shapes outcomes in a universal healthcare system (Canada) remain uncertain. Families with socioeconomic disadvantages may have significant barriers to accessing living donor liver transplantation (LDLT). In additon, caregiver resources, neighborhood deprivation, and health literacy may negatively impact post-transplant outcomes.

Methods: From 1991 to 2021, clinical data was linked to provincial health administrative data, yielding 449 recipients who underwent their first transplant. There were 189 LDLT and 260 deceased donor liver transplantation (DDLT).

Key findings:

  •  LDLT recipients had superior patient and graft survival. DDLT was associated with a higher risk of mortality [adjusted hazard ratio (aHR) 2.1], graft failure (aHR 2.1), and chronic kidney disease (adjusted subdistribution HR 5.3), compared with LDLT.
  • The absolute survival advantage of 10-15% at 10 years persisted into the third decade.
  • LDLT outcomes were less impacted by the socioeconomic disadvantages, with recipients showing comparable outcomes regardless of their SES.
  • The overall incidence of de novo cancer was low (2-3% at 10 years post-LT; most of these cancers were due to PTLD.
  • Limitations: The survival advantage could be in part due to selection bias. Patients with more urgent conditions like PALF were more likely to be DDLT recipients. In addiiton, this study did not adjust severity of illness at time of transplantation.

My take: LDLT is underutilized. More use of LDLT will result in better outcomes.

Related blog posts:

Neurocognitive Deficits in 30% of Short Bowel Cohort

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RAL Duister, LE Vlug et al. J Pediatr Gastroenterol Nutr. 2026;83:404–411. Open Access! Cognitive assessment in children with intestinal failure on and weaned off parenteral nutrition

This multicenter international cross-sectional study of children with IF (n=50) examined neurocognitive outcomes (2019-2024); all children were currently receiving home PN or having a history of home PN-dependency.

Key findings:

  • The most common underlying condition was necrotizing enterocolitis (28%); other etiologies included intestinal atresia (20%), midgut volvulus (10%), and intestinal pseudo-obstruction (12%)
  • 21/50 children (42%) received home parenteral nutrition (PN); median PN-duration was 26.8 (7.5–66.5) months
  • Median IQ score was 92.0 (74.3–101.0); 15 children (30%) had very/extremely low IQ (</= 79), both significantly different from the normal population (p < 0.001)

My take: This study provides a good estimate of the percentage of children with intestinal failure/short bowel syndrome with significant neurocognitive impairment: about 30%. The likelihood would be higher in those with proven neurological insults.

Related blog posts:

Seljalandsfoss with a 200 foot watefall cascade. Iceland

Dr. Barbara McElhanon: Update on Autism and GI Manifestations

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Recently, Dr. Barbara McElhanon gave our group a terrific update on the GI Manifestations Associated with Autism. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

  • Even with the early descriptions of autism, dating back to Les Kanner in 1943, gastrointestinal complaints like feeding difficulties/peculiar diets were recognized.
In a 1971 study, Barry Goodwin reported that seven of the 15 autistic children he had randomly selected from a local community for his study had chronic diarrhea. He found that placing these children on a gluten-free diet improved GI symptoms, as well as abnormal EEG findings.
  • Some studies have found an increase in some autistic behaviors (greater impairment in sleep, communication sensory processing and repetitive behaviors) in those with coexisting/worse gastrointestinal symptoms.
Patients with ASD had much more frequent GI complaints than the control group from this recent prospective longitudinal study at UC Davis looking at almost 500 kids
More than 50% of participants with ASD had GI symptoms at all time points
  • More than 1000 genes have been associated with developing autism.  About 90% of these genes have expression outside the central nervous system including the enteric nervous system.
There are some genes that are implicated in both autism risk and known GI problems. There is elevated serotonin in these patients which plays an important role in both the central and enteric nervous systems.
  • No unique microbiome has been identified as being associated with autism.  Fecal microbial transplantation (FMT) studies included an open label study suggesting an improvement in gastrointestinal symptoms and mood.  However, a randomized study with oral FMT found no changes except some improvement in socialization.
  • For now, FMT is not an established therapy for autism and probiotics are not recommended.
  • Dr. McElhanon notes that dietary restrictions are not recommended for autism.  Children with autism often have a restricted diet at baseline and further restrictions can increase the likelihood of feeding disorders like ARFID.
  • Dr. McElhanon notes that this administration has made several recommendations regarding autism; this has increased awareness and attention to children with autism.  However, at this time, the Marcus Center does not recommend the use of Leucovorin. The studies that have purported to show benefit were small studies with varying doses.  This medication has had an increase in usage due to the increased awareness. 
  • With regard to acetaminophen, recent large studies have shown that it is safe to use and has not increased the risk of autism after use by pregnant women.
  • Due to atypical diets, vitamin/nutrient deficiencies are not rare in children with autism and dietary restrictions.  Disorders like scurvy (Vitamin C deficiency) need to be considered in this population.  Vitamin supplements (eg. NanoVM which is tasteless) are important to prevent these deficiencies.
  • For clinical care, Dr. McElhanon prefers to get a good history before delving into the potentially extensive testing that families may bring.  Also, additional time for the visit and to discuss treatment are needed.  In children with autism, due to difficulty administering medications and diet, it can take longer to figure out the right option.
  • More research on optimal treatment is ongoing.

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.

Elegant Study: Childhood Exposure to a Sibling with Crohn’s Disease and Disease Susceptibility

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R Chen et al. Gut. Epub ahead of print, August 31, 2026. doi:10.1136/
gutjnl-2026-339257. Childhood exposure to a sibling with Crohn’s disease alters gut microbiome and Crohn’s disease susceptibility

Thanks to Mike Hart for sharing this reference. This study is worth reading in its entirety due to the combination of experiments. This is a fairly long post to summarize the most important findings.

Background:

“In a study of 2756 Dutch families, gut microbiome composition and function were more alike between siblings than between parent-offspring pairs or spouses…These findings suggest that increased disease susceptibility among siblings of individuals with CD may be mediated by their shared gut microbiome.”

Methods:

  1. The authors used the prospective Genetic Environmental Microbial (GEM) Project and the nationwide South Korean database to assess the association between childhood exposure to affected siblings and CD onset (n=3126). This was validated in the South Korean dataset.
  2. A T-cell transfer model of colitis in germ-free mice was conducted to investigate the effects of stool from childhood-exposed (n=4) versus adult-exposed (n=4) siblings.
  3. An integrative risk model combining faecal calprotectin (FCP) and microbial enterotypes was trained and internally validated within the GEM cohort.

Key findings:

  • “In the GEM cohort, childhood exposure to an affected sibling was associated with a fourfold higher risk of developing CD compared with adult exposure (adjusted HR (aHR) 4.00; p=5.3×10−4), which was validated in the South Korean dataset (aHR 2.54; p=6.0×10−6).”
  • “Childhood exposure was associated with reduced abundances of Lachnospira,
    Roseburia     and Colidextribacter, reductions that mediation analysis identified as partially mediating CD risk.”
  • “In vivo, transplantation of childhood exposure-associated microbiota into germ-free recipient mice exacerbated colitis and elevated mucosal interleukin-22 expression, supporting a potential mechanistic role.”
  • This “model identified siblings with elevated FCP and Blautia-enriched or
    Prevotella-enriched enterotypes as highest risk, with a 10-year cumulative incidence of 22.5%.”
Figure 1b. Childhood exposure to CD was demonstrated to associate with increased disease susceptibility in the GEM cohort, and confirmed in an independent nationwide dataset.
Figure 1d. Among siblings with childhood exposure to CD, the authors developed and validated a risk stratification based on gut inflammation and enterotypes to identify individuals at high risk of CD onset
Figure 3a. Bar chart presenting the proportion of individuals with gut barrier dysfunction and gut inflammation among those exposed to CD during childhood (blue) or adulthood (orange).
Figure 5d. Kaplan-Meier curves showing the cumulative CD-free probability for individuals classified as having non-inflammation (blue), gut inflammation with Bact2 (green) and gut inflammation with Blau/Prev (orange) in the GEM cohort.

Discussion

  • This “study demonstrates that the timing of exposure to a sibling with CD, specifically childhood versus adult exposure, plays a critical role in disease susceptibility. Childhood exposure was associated with a fourfold higher risk of CD, potentially mediated by alterations in the gut microbiome.”
  • “Genetic predisposition has traditionally been considered the primary explanation for the elevated disease risk among siblings of persons with CD. However, genetic factors account for only about 10% of the variance in CD risk…childhood exposure to a sibling
    with CD, compared with adulthood exposure, was associated with a fourfold increased risk of disease onset, independent of the CD-PRS [CD – polygenic risk score].”
  • This study adds to “a growing body of evidence [that] implicates early-life exposures in CD pathogenesis. A recent meta-analysis reported that prenatal exposure to antibiotics and cigarette smoking increased the risk of CD, while breastfeeding was protective. Similarly, a large population-based study found that rural residence during childhood, but not adulthood, was associated with a lower risk of CD.”

Limitations:

  • Participants were from high-income countries.
  • Study did not include dietary intake.
  • These findings do not prove causation. There may be additional unrecognized genetic factors between the groups with exposure before and after 18 years of age.

My take: The increasing prevalence of Crohn’s disease, particularly over the last few decades, must be related to environmental factors; population genetics and genetic predisposition are unlikely to rapidly change. This is a very important study supporting the notion that exposure to siblings with Crohn’s disease and alteration of the gut microbiome increases the risk of Crohn’s disease. By identifying a microbiome group with a higher risk, this study may facilitate research to determine whether manipulation of the gut microbiome could reduce the likelihood of developing Crohn’s disease. If we can reduce Crohn’s disease in a high risk population, it may allow broader use of the same treatment principles to lower risk groups as well.

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Audio-Recorded Gut-Directed Hypnotherapy for Disorders of Gut-Brain Interaction Plus Measles Update

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L Barash et al. J Pediatr Gastroenterol Nutr. 2026; doi.org/10.1002/jpn3.70545. The role of audio‐recorded gut‐directed hypnotherapy onsleep and abdominal pain: A pilot and feasibility study.

Background: Gut-directed hypnotherapy (GDH) is an evidence-based treatment that improves abdominal pain and quality of life in pediatric DGBI both in the short- and long term.3, 4 Home-based audio-guided GDH has shown comparable efficacy to in-person treatment, while enhancing access to care for families with logistical or socioeconomic barriers.5, 6 

Methods: This was a non-blinded randomized controlled trial with partial crossover. Treatment includes three 25-min audio sessions every 2 weeks and daily 10–20-min sessions, with a goal of ≥5 sessions per week. Out of 25 participants who initiated GDH 16 (64%), completed treatment. Reasons for dropout included side effects (nausea, n = 2), lack of improvement (n = 1), resolution of symptom (n = 1), and unknown (n = 5).

Key findings:

  • Combined abdominal pain scores significantly improved post-treatment with GDH, with a 40.2% reduction from baseline (p < 0.001; d = 0.9), compared to a 16.6% reduction in the standard medical therapy (SMT) group
  • The SMT group had no improvements in sleep-related impairment (SRI) (p = 0.90) … whereas those who completed GDH demonstrated significant improvements in SRI at both 4 weeks (p = 0.01) and at the completion of treatment (p = 0.01)
  • Two participants in our study discontinued due to worsening nausea. Many of the audio recordings included motion-related imagery, which may have contributed to symptoms in susceptible participants.

In a separate study (n=230) (JTW Snijkers et al. Gut Published Online First: 25 July 2026. doi: 10.1136/gutjnl-2026-338385. Open Access! In-person therapist-delivered hypnotherapy versus smartphone-based self-guided hypnotherapy in IBS: a multicentre three-armed randomised controlled trial), a self-guided smartphone hypnotherapy program did not meet the prespecified threshold for noninferiority to in-person hypnotherapy for abdominal pain response in patients with irritable bowel syndrome (IBS). At weeks 13-16, Food and Drug Administration-defined abdominal pain response rates were 48.1% with in-person therapist-delivered hypnotherapy, 33.3% with smartphone-based self-guided hypnotherapy, and 21.8% with online psychoeducation. 

My take (borrowed in part from the JPGN authors): “Providers may consider GDH as a low-risk, home-based therapeutic option for children with DGBI, particularly when sleep is also a concern.”

Rigorous pharmacologic studies show that medications, to date, recommended for patients with DGBIs have difficulty outperforming placebo. With hypnotherapy, having an adequate control group is problematic. It would not be surprising, though, for GDH to have difficulty outperforming pharmacologic agents/placebo despite its good response in patients with DGBIs. In this setting, the use of GDH or medications with a low incidence of adverse effects and plausible beneficial effects continue to have a role in improving symptom control.

From AGA Today: US Measles Outbreak Tops 3,000 Cases Reaching 35-Year High

NBC News (9/4, Edwards) reports, “A 6-week-old baby girl is one of two people with measles who died in Pennsylvania, the Lancaster County coroner said Friday, as the nation’s measles tally hit a new 35-year record of 3,134 cases. … At least 115 more people in Pennsylvania, mostly in Lancaster County, have been diagnosed with measles in the last week, the health department said Friday, bringing the state’s outbreak to about 577 cases within the last few months.” Experts say there are likely many more across the country who have contracted measles but have not gotten tested. NBC adds, “The new milestone, the highest number of confirmed cases since 1991, is yet another indication that the highly contagious virus is taking over, particularly in areas of the country with plummeting vaccination rates.”

Related blog posts (for DGBIs):

Related blog posts (for Measles)