Extending Benjamin Franklin’s Observations: Chart Your Fart Study

Posted on July 16, 2026 by gutsandgrowth

E Brindal et al. JAMA Netw Open. 2026;9;5):e2615637. doi:10.1001/jamanetworkopen.2026. 15637. Open Access! Regular Flatulence Patterns Among Community-Dwelling Individuals in Australia. Thanks to Stan Cohen for sharing this study.

Methods: Cross-sectional study with 6416 participants Data were recorded into a purpose-designed mobile phone application (Chart Your Fart) by participants who logged their flatus passages in real time, consistent with experience sampling methods.³

Key findings:

See Table below – Mean flatus per day was 5.0

Discussion:

“In terms of range, observed data suggest good consistency with other methods, including retrospective frequency reports in a large US sample of individuals experiencing gas or bloating (n = 16 537),⁶ a small laboratory study that collected a median of 8 emissions throughout 24 hours,⁷ and even Benjamin Franklin’s personal account of “discharging wind from bowels” 7 times a day.⁸“
“Limitations of this study include failing to quantify emissions made while asleep due to reliance on self-report.”

My take: Looks like another good study to discuss at the GI dinner table. Also, lots of jokes that would be apropos. Here’s one:

An elderly patient goes to her doctor and at the end of her exam she tells him there is one other matter that she would like to discuss. “It seems that I have frequent gas but fortunately it is silent and does not smell. I have even passed some gas while I’ve been here.” The physician says, “Hmmm… take these pills for one week and then come back.”

When she returns, she complains, “I don’t know what was in those pills. The gas now smells terrible but thank goodness it is silent.” The doctor replies, “Well, it looks like the antibiotics have improved your ability to smell. Now we need to get your hearing evaluated.”

Related blog post: Somewhat Funny Flatulent Research

Safety Data Up to Seven Years with Vedolizumab

Posted on July 15, 2026 by gutsandgrowth

E Louis et al. Clin Gastroenterol Hepatol 2026; 24: 1654-1665. Open Access! Long-Term Safety of Vedolizumab in Patients With Ulcerative Colitis/Crohn’s Disease: A Prospective Observational Study

Methods: This was a prospective, observational, multicenter cohort study in adult patients (n=5208) with UC or CD starting treatment with vedolizumab or other biologics. The primary safety outcome was serious infections compared between cohorts using a Cox proportional hazards model adjusted by propensity score. Clinical effectiveness was a secondary outcome. Mean follow-up duration was 37.4 months. The vedolizumab group had greater age, duration of disease, and concomitant medication use at baseline, indicating more advanced disease.

Key findings:

In patients with UC, the incidence rate per 100 person-years of serious infections was 5.5 (vedolizumab) and 7.0 (other biologic), with an adjusted hazard ratio of 0.89 (P = .38).
In patients with CD, corresponding findings were 7.9 (vedolizumab) and 6.5 (other biologic) with adjusted hazard ratio of 1.15 (P = .16).
Rates of clinical response and clinical remission were similar in patients treated with vedolizumab compared with other biologics for both UC and CD.

Time to treatment failure in (A) biologic-naïve. Treatment failure included discontinuation of biologic treatment, IBD nonsurgical hospitalization, primary IBD surgery, and corticosteroid initiation.

Time to treatment failure in (B) biologic-experienced CD patients.

My take: This large prospective study showed no new safety signals with mean followup of more than 3 years. There were no new trends or changes of clinical importance for infections (serious and opportunistic infections, gastrointestinal infections, respiratory tract infections, other infections), malignancies, infusion-related reactions, hepatotoxicity, and pregnancies. No cases of PML were reported. Efficacy was similar between vedolizumab and other biologics.

Related blog posts:

How Does Remission in Crohn’s Disease Affect the Abnormal Microbiome/Gut Signature?

Posted on July 14, 2026 by gutsandgrowth

T Braun et al. Gastroenterol 2026; 170: 971-984. Open Access! Perturbations of Diet and Gut Signatures Persist During Remission in Crohn’s Disease Despite Effective Immune Suppression

Methods: The authors analyzed diet, ileal transcriptomics, microbiomics, and metabolomics across patients with CD in remission, patients with active CD, and non–inflammatory bowel disease (IBD) controls as the reference for healthy signals.

Key findings:

Immune signals: Ileal transcriptomics revealed a significant decrease in genes and pathways associated with adaptive T cells and innate granulocytes during remission, which was even deeper than observed in non-IBD controls.
Antimicrobial gene expression: Patients in remission showed an increase in the expression of epithelial antimicrobial pathways and related genes, including DUOX2, along with an increase in genes associated with goblet cells and mucin glycosylation.
Microbiome and diet: In patients in remission, there was persistent pathogenic gut microbial composition, metabolic alterations, and less healthy dietary habits, which were characterized by a higher intake of ultraprocessed foods and lower consumption of fiber, folate, vitamin C, and vegetables

**Purple** = control (n=64), **Yellow** = CD remission (n=56), **Red** = CD active disease (n=24). Fecal signals persist during remission and substantially correlate with dietary exposures. (A) Boxplots of Faith’s phylogenetic alpha diversity, our previously defined health index,²³ the previously defined Gevers IBD dysbiosis index²¹, and our IBD-specific index²³ between controls, CD patients in remission, and CD with active disease.

Fecal signals persist during remission and substantially correlate with dietary exposures. (A) Boxplots of Faith’s phylogenetic alpha diversity, our previously defined health index,²³ the previously defined Gevers IBD dysbiosis index²¹, and our IBD-specific index²³ between controls, CD patients in remission, and CD with active disease.

My take (borrowed from the authors): This study shows that, during remission with advanced therapies, “disturbances in antibacterial epithelial signals, along with unhealthy dietary patterns, altered microbiome, and perturbed metabolome, continue and are partly linked to the risk of flare 6 months later.”

Related blog posts:

NSAIDs and IBD Flares (2026)

Posted on July 13, 2026 by gutsandgrowth

AS Mayer,et al. Arthritis Care Res. https://doi.org/10.1002/acr.80067. Open Access! Safety of Prescription Nonsteroidal Anti-inflammatory Drugs in Adults With Inflammatory Bowel Disease: Data From a Large Administrative Claims Cohort.

Methods:

“This retrospective cohort study included patients with IBD aged at least 18 years from Optum’s deidentified Clinformatics Data Mart Database (2000–2022). Patients with a new NSAID prescription fill were matched to those without an NSAID fill during the study period…Propensity score-based inverse probability of treatment-weighted Cox proportional hazards models evaluated the association between NSAID exposure and time to IBD-related hospitalization across IBD subtypes.”

Key findings:

Unweighted Kaplan-Meier curve for IBD-related hospitalization in patients
with Crohn disease (B).

Unweighted Kaplan-Meier curve for IBD-related hospitalization in patients
with ulcerative colitis (C).

Discussion:

“The use of IPTW [inverse probability of treatment weighting] to balance an extensive number of confounders associated with NSAID use optimizes the assessment of the association of NSAID exposure with IBD-related hospitalization and helps address recent concern of residual confounding in observational studies of NSAID risk in IBD.”
Besides the potential risk of an IBD flare, “NSAID use is associated with risk of hospitalization from several non-IBD–related entities such as acute kidney injury and adverse cardiac events…a large prospective multicenter observational study of more than 18,000 admitted patients in England found that NSAIDs were responsible for 29.6% of admissions related to adverse drug reactions, including gastrointestinal bleeding, stroke, and renal impairment.³⁴“

My take: This study shows an association of increased hospitalization in patients with CD but not UC based on NSAID exposure. The absolute risk of this appears low and could be in fact related to residual confounders (despite use of IPTW) as this was not a prospective study. The risk of NSAIDs outside the GI tract are likely more significant for most patients. Nevertheless, there are limited options for pain management and NSAID benefits have to be weighed against other approaches.

Related blog post: Rethinking the Link between NSAIDs and IBD Flares

Health Risks from Too Much Dietary Protein

Posted on July 12, 2026 by gutsandgrowth

Sophie Egan, NY Times 5/28/26: 5 Health Risks From Consuming Too Much Protein

An excerpt:

“Most Americans eat more protein than they need. We asked experts what can happen if people have too much of a good thing…

If you’ve browsed the packaged-food aisle of a grocery store lately, or scanned the updated Dietary Guidelines for Americans, you might think that when it comes to protein, more is better…the new inverted food pyramid, released by the Trump administration in January, features protein prominently, with steak, chicken and cheese at the top…

Potential problems can arise when people eat much more than around 1.2 grams of protein per kilogram of body weight per day…

Heart Disease and Type 2 Diabetes

Research suggests that those who eat larger amounts of red and processed meat tend to have higher risks of heart disease and Type 2 diabetes…In one large analysis published in 2023, for instance, researchers found that eating an extra 100 grams of red meat (equivalent to about one thin, boneless pork chop) per day increased the risk of heart disease by 11 percent — and every additional 50 grams of processed red meat (equivalent to about one standard hot dog) per day increased it by 26 percent. Another study, also published in 2023, found that among the nearly 217,000 (mostly female) participants, those who ate the most red meat had a 40 percent higher risk of developing Type 2 diabetes than those who ate the least, and that those who ate the most processed red meat had a 51 percent higher risk…

Cancer

In one study published in 2024, researchers found that diets high in red meat were linked with a 30 percent increased risk of developing colorectal cancer, and that those high in processed meat were linked with a 40 percent increase in risk…People who prioritize vegetables, fruits and whole grains, along with lean or plant-based proteins, are less likely to develop certain types of cancer (as well as cardiovascular disease and Type 2 diabetes).

Constipation and Other Digestive Concerns

People who are focused on increasing their protein consumption (especially those on low-carb diets) sometimes inadvertently leave out high-fiber foods, like vegetables and whole grains [which may increase the likelihood of constipation and irritable bowel syndrome]…

Weight Gain

Excess calories, including those from protein, will be turned into fat…A half-cup of cooked vegetables, for instance, has an average of about 25 calories, whereas a half-cup of cooked chicken has about 140 calories…

Kidney Issues

If your kidneys are healthy, you probably don’t need to worry much about excess protein consumption…for the more than 1 in 7 Americans with chronic kidney disease — especially those who may be close to needing dialysis — metabolizing large amounts of protein can stress the kidneys…Kidney stones are also a potential side effect of consuming too much animal protein.”

My take: The famous line by Mae West “Too much of a good thing can be wonderful!” is not true for dietary protein.

Related blog posts:

Geese on the Chattahoochee near Island Ford

Invisible Workload of Caring for Pediatric Patients with Inflammatory Bowel Disease

Posted on July 10, 2026 by gutsandgrowth

JS Huang et al. Inflam Bowel Dis, 2026; izag097, https://doi.org/10.1093/ibd/izag097 Open Access! Between-visit care represents a substantial and underrecognized component of health care utilization in pediatric inflammatory bowel disease
R Kellermayer. Inflam Bowel Dis, 2026; izag100, https://doi.org/10.1093/ibd/izag100. (Editorial) Before the engine stalls: confronting the invisible workload in pediatric IBD

Background: “Historically, telephone calls were the primary means of communication between families and clinicians. With the widespread adoption of electronic health records (EHRs) and patient portals, asynchronous digital messaging has become increasingly common. Although these platforms may enhance access and patient engagement, evidence suggests they do not simply replace telephone encounters; instead, they may increase overall communication volume.⁷ Lower thresholds for initiating messages, the need for iterative clarification, and miscommunication may all contribute to this rise, raising concerns about added workload and potential clinician burnout…Understanding the timing, magnitude, and predictors of between-visit communication is essential to improving care delivery and accurately estimating workforce needs to effectively manage pediatric IBD patients.”

Methods: From the shared electronic health record, the data from 226 patients (0 to22 years) was quantified. This included outpatient visits, emergency care, and procedures, as well as between-visit care (portal messages from patients, telephone encounters, and clinician-patient review of results) from prediagnosis through long-term follow-up.

Key findings:

Between-visit care rose from a median of 1 event per 6 months at time >1 year prediagnosis to 64 events in the year following diagnosis
After the first year following diagnosis, between-visit care was a median of 41 events per year
There was a strong, graded relationship between disease severity and health care utilization, with the greatest increases seen in subspecialty visits, emergency care, and between-visit care among patients with moderate to severe symptoms

The number of results review and portal message encounters relative to the time of diagnosis

This chart shows the number of telephone encounters relative to the time of diagnosis

Disease severity affects frequency of messages/phone calls.
But, these interactions are frequent even in asymptomatic patients.

Discussion Points:

“Even during periods of relative disease quiescence, patients generated substantial volumes of portal messages, telephone encounters, and result review requirements. These findings underscore that the longitudinal management of pediatric IBD extends far beyond scheduled clinic visits and episodic care.”
“This persistent care burden likely reflects the complexity of pediatric IBD management including medication titration, symptom monitoring, laboratory surveillance, comorbidity screening, insurance navigation, school-related concerns, anticipatory guidance, administrative needs, transitional readiness planning, and caregiver and patient education.¹¹ Unlike acute care utilization, which may diminish as disease control improves, the need for ongoing communication and care appears intrinsic to chronic disease management in the pediatric IBD population.”
“Despite its clinical importance, between-visit care remains largely invisible in traditional utilization metrics and is frequently unreimbursed. Our findings indicate that this hidden workload is substantial, persistent, and closely tied to disease complexity rather than patient demographic factors.”

The editorial from Kellermeyer notes that this invisible care did not include “the substantial administrative workload associated with prior authorization (PA) for advanced IBD therapeutics, insurance denial management, appeals, and peer-to-peer reviews …[which] are notoriously difficult to capture in electronic health record (her) metadata.”

My take: There is a lot of behind the scenes physician work that is needed to help manage patients with inflammatory bowel disease. I suspect most families do not realize the extent of this work.

Related blog posts:

Colic and Later Food Allergies

Posted on July 9, 2026 by gutsandgrowth

K Switkowski et al. The Journal of Pediatrics, 2026; 294. Open Access! Associations of Colic and Excessive Crying in Infancy with Food Allergy Outcomes in Childhood and Adolescence

Background: The authors have previously observed “increased risks of eczema, allergic rhinitis, and asthma throughout childhood and adolescence among children with a history of infant colic compared with unaffected infants.¹⁴“

Methods: Prospective study of 1263 generally-healthy participants with parent-reported food allergy from early childhood through mid-adolescence using multivariable logistic regression. In a subset (n = 242) with available biomarkers, the associations of colic with food-specific IgE sensitization in early childhood were examined.

Key findings:

“In early childhood, 10% of children in Project Viva had a food allergy reported by their mothers. Peanut or tree nut allergies were most prevalent (6%), followed by cow’s milk (4%) and egg (2.5%) allergies”
“Participants who had colic (25%, n=320) had a greater risk of any food allergy in early childhood than those unaffected by crying or colic (13% vs 8%; OR 1.7)”
“The risk of current milk and egg allergies in early childhood also was greater for those who had colic as infants vs those unaffected (OR for milk allergy: 1.8)”
“In early adolescence, the colic group had 2.1 times the risk of peanut allergy (8% vs 4%) vs the unaffected group”
“In the subset with IgE, the colic group had 2.5 times the risk of early childhood IgE sensitization to peanuts compared with the unaffected (22% vs 11%).” However, none of the other foods had significant IgE sensitization: Cow’s milk OR 0.7, Egg white OR 0.5, Wheat OR 1.1, Soy OR 1.9, Sesame OR 1.4, Any IgE sensitization OR 0.8

Discussion Points:

The authors “do not believe that colic itself is a cause of later food allergy but rather could be an early marker of greater risk for developing food allergy…these findings argue against characterizing colic as a benign, transient, and self-resolving condition as some have suggested.”
Preventive measures should be implemented. “Early and consistent exposure to potential allergens at specific critical windows of life, particularly among high-risk children, is now known to be effective in promoting allergen tolerance and preventing the development of food allergy.³“
Study limitations:
- “Parent-reported food allergies [were used] to define this outcome and acknowledge that this may involve some misclassification of outcome status if parents report allergies that have not been clinically validated.” Though, in a previous study, the “overall agreement between parent-reported and clinician-documented allergy status” was 98%.
- There was no data indicating whether food introduction in infants with colic was different than other infants.

My take: It is unclear to me whether colic (now labeled Infant Distress Syndrome) is a true risk factor for later atopic diseases. It is possible that the presence of colic could increase the use of more elemental formulas and postpone food introduction which could increase the risk of food allergies.

AGA Clinical Practice Update: Clostridioides difficile Infection in Inflammatory Bowel Disease

Posted on July 8, 2026 by gutsandgrowth

S Khanna et al. Gastroenterology, 2026 (In press). Open Access! AGA Clinical Practice Update on Management of Clostridioides difficile Infection in Inflammatory Bowel Disease: Expert Review

Best Practice Advice Statements

In patients with IBD who have new or worsening diarrhea, CDI should be excluded, especially among those with colonic involvement, as they are at increased risk of CDI. Clinicians should consider and treat CDI in patients with end ileostomy or ileo-anal pouch anastomosis with worsening diarrhea.
In patients with IBD and suspected CDI, a multistep toxin-based assay should be used for diagnostic evaluation.
In patients with IBD and recent CDI who have been treated successfully with antibiotics, recurrent diarrhea should prompt retesting for CDI.
In patients with IBD who develop an initial episode of CDI, clinicians should preferentially use fidaxomicin or use vancomycin if fidaxomicin is unavailable or cost-prohibitive. Metronidazole should not be used.
Clinicians should strongly consider hospitalization for patients with IBD and CDI who demonstrate features of severe colitis or systemic toxicity (eg, more than 6 bowel movements per day, severe abdominal pain, marked leukocytosis, hemodynamic instability, or other evidence of sepsis).
When selecting an immunosuppressive therapy to treat IBD, no class or mechanism of action has a differential risk of CDI and, therefore, clinicians should choose the therapy that is best to treat the IBD.
In patients with IBD and acute CDI, concurrent treatment of IBD is critical and clinicians should continue therapy with the required immunosuppressive therapies (ie, immunomodulators, biologics, or small molecules). Steroids can also be used if deemed necessary while CDI is treated with antibiotics.
Clinicians should consider endoscopic evaluation for IBD activity and exclusion of concomitant cytomegalovirus infection if symptoms persist 48–72 hours after initiation of treatment for CDI.
Clinicians may consider loperamide in patients with improving inflammation and infection but ongoing diarrhea.
Clinicians should offer microbiome-based therapies (eg, fecal microbiota, live-jslm, fecal microbiota spores, live-brpk, or unapproved fecal microbiota transplantation) to patients with IBD with at least 1 recurrence of CDI to prevent future infection.
In patients with IBD, clinicians should not advise probiotics for primary or secondary prevention of CDI.
In patients with IBD and a history of CDI who are receiving systemic antibiotics, clinicians may consider oral vancomycin prophylaxis as secondary prevention.

Testing Caveats:

“Because NAAT (nucleic acid amplification test) alone can detect colonization, positive EIA (enzyme immunoassay) with NAAT confirms diagnosis. Positive NAAT and negative EIA should be interpreted with caution due to low sensitivity of EIA.”

Related blog posts:

Interleukin-10 Autoantibodies and Development of IBD Plus One

Posted on July 7, 2026 by gutsandgrowth

N Gharahdaghi et al. N Engl J Med 2026;394: 2212-2222. Interleukin-10 Autoantibodies and HLA-DRB1*01:03 in Inflammatory Bowel Disease

Background: “The allele HLA-DRB1*01:03 is the strongest genetic risk factor not only for susceptibility to ulcerative colitis but also for complicated phenotypes, including acute severe ulcerative colitis and an increased likelihood of surgical resection.^2-5 However, the underlying pathogenic mechanism linking this HLA allele to disease remains unclear.”

“Neutralizing autoantibodies against interleukin-10 can result in a phenocopy of monogenic defects of interleukin-10 signaling in children and may be associated with inflammatory bowel disease (IBD)…In one child, anti–interleukin-10 titers and disease activity responded to B-cell–depleting anti-CD20 therapy.¹²“

Methods:

Key findings:

Interleukin-10–neutralizing autoantibodies were detected in 173 of 4909 patients with IBD (3.5%) and in none of 1006 controls (P<0.001)
High anti–interleukin-10 activity in serum was associated with a reduction in detectable interleukin-10 and with an exaggerated proinflammatory cytokine response
Anti–interleukin-10 seropositivity was strongly associated with HLA-DRB1*01:03 on the basis of imputed data from the Oxford cohort (odds ratio, 50.0), the U.K. IBD BioResource cohort (odds ratio, 24.7), and in a high-resolution sequencing analysis of data from the Oxford cohort (odds ratio, 29.5)

Discussion Points:

“The genetic association between HLA-DRB1*01:03 and anti–interleukin-10 autoreactivity provides mechanistic insight into one of the strongest known genetic susceptibility factors for IBD, with possible diagnostic, prognostic, and therapeutic implications.”
“Monogenic interleukin-10–signaling defects tend to manifest during infancy with colonic and penetrating disease, poor response to IBD therapies, high inflammatory activity with notably elevated C-reactive protein levels, and a high incidence of postoperative complications.²⁷ It will be informative to establish the extent to which anti–interleukin-10 seropositivity associates with a similar disease pattern.”
“Our data highlight the need for research into therapeutic maneuvers to reduce anti–interleukin-10 titers — for example, by means of B-cell and plasma-cell depletion (e.g., anti-CD19, anti-CD20, anti-CD38, or CD19 chimeric antigen receptor [CAR] T-cell therapy),^29-31 plasma exchange, or blockade of the neonatal Fc receptor.³²“

My take: Historically, in younger patients (6 or younger) and those with more severe inflammatory bowel disease, it has been common to evaluate for monogenetic diseases which may require different treatment approaches. For similar reasons, assessing for neutralizing autoantibodies against interleukin-10 is likely to become part of routine care.

Related study: Q Zhang Q, Shakweh E, Sharip M et al. The Lancet Gastroenterology & Hepatology, 2026; 0. Open Access! HLA-DRB1*01:03 in patients with inflammatory bowel disease: a genotype–phenotype association study Key findings:

Among 43,762 patients with IBD (21 839 with Crohn’s disease and 21 923 with ulcerative colitis or IBD unclassified), HLA-DRB1*01:03 carriage was observed in 2009 (4·6%) patients with IBD and associated with multiple severe outcomes …including colonic resection in patients with Crohn’s disease (odds ratio 1·35), colectomy in patients with ulcerative colitis or IBD unclassified (1·99), and perianal disease in both patients with Crohn’s disease (1·65) and patients with ulcerative colitis or IBD unclassified (1·70)

Related blog posts:

Dr. Valeria Cohran: Short Bowel Syndrome/Intestinal Failure in Pediatrics 2026

Posted on July 6, 2026 by gutsandgrowth

Recently, Dr. Valeria Cohran gave our group a terrific update on Short Bowel Syndrome (SBS)/Intestinal Failure (IF). My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides. Dr. Cohran has been a leader in intestinal rehabilitation. Among many accomplishments, she was the 2025 recipient of the 2025 Margaret Stallings NASPGHAN Distinguished Service Award.

Key points:

Most children with SBS/IF are able to taper off parenteral nutrition (PN). Even ~30% of those with extreme SBS (<10% of expected bowel length) are able to achieve enteral autonomy.
SBS/IF due to NEC has a generally more favorable outcome than other etiologies
Stoma takedown is associated with better outcomes (eg. more likely to taper off PN). (Raghu et al. JPEN. 2023;47:1047-55). Taking down stoma may be beneficial if unable to taper PN and in those developing liver disease
SBS/IF caretakers spend a median of 29 hrs/week managing PN, enteral nutrition, medications, and other tasks
In the nursery, one study reported that NICU patients with IF spent a median of 150 days and cost more than $500K
Overall, advances in SBS/IF management have been associated with lower death rates and lower intestinal transplant rates (~30 ITx last year), yet similar rates of achieving enteral autonomy

Overall, Group 1 SBS is least likely to achieve enteral autonomy

Intestinal length with maximal increase in first year of life

•N=362 children in over 26 centers world-wide, started 2018 (enrolled if PN >2 months)

Fish oil based lipid emulsions do not always work; cirrhosis can still develop even with minimal biochemical marker alterations

IFALD mortality is associated with degree of conjugated hyperbilirubinemia, though we are not seeing this complication much with current management

GLP-2 can reduce PN requirements by more than 20% in the majority of those with SBS/IF and may help achieve enteral autonomy in about 20%. However, their use requires close monitoring for fluid overload and electrolyte disturbances