Rule of Two’s No Longer Valid For Diagnosis of Meckel’s Diverticulum

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Polachek A, Mehta MS, Shalaby A, Vadsariya A, Zong W, Troendle DM.J Pediatr Gastroenterol Nutr. 2026; 83: 658-664. Reevaluating the rule of two’s: age and epidemiological variations in Meckel’s diverticulum.

Background: “Meckel’s diverticulum (MD) is traditionally considered a disease of early childhood and is commonly summarized by the “Rule of Twos”; presenting before the age of 2 years, found 2 ft. from the ileocecal valve, approximately 2 in. in length, and present in roughly 2% of the population.” (I was taught an additional rule that it takes 2 physcians to diagnose)

Methods: A total of 1004 patients with a primary diagnosis of MD were identified from the Kids’ Inpatient Database (KID) for 2016 and 2019 in this retrospective review. In addition, 147 patients identified in the single-center cohort.

Key findings:

  • More than half were diagnosed after 5 years of age (n = 648, 64.8%) in the KID group and 63% in the single-center cohort
  • In the single-center cohort, patients ≤5 years more commonly presented with painless rectal bleeding (38.9%, p = 0.017) and underwent Meckel’s scintigraphy more frequently (48.1%, p < 0.005). In contrast, patients >5 years more often presented with abdominal pain (61.3%) or vomiting (54.8%) and were more likely to undergo abdominal computed tomography (68.9%, p < 0.0001).

My take: This study shows the “Rule of Two’s” for the diagnosis of Meckel’s is not helpful; nearly two-thirds of patients present after 5 years of age. The authors note that “overreliance on age-based assumptions and presenting symptoms associated with this paradigm may lead to missed or delayed diagnoses, especially in patients who present with atypical features.”

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Glymur Waterfall. This is the second tallest waterfall in Iceland
with a 198-meter (650-foot) drop into a narrow basalt canyon.

Diet Based on Confocal Laser Endomicroscopy Did Not Improve Irritable Bowel Syndrome Symptoms: A Randomized Controlled Crossover Trial

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L Balsiger et al. Gastroenterology, 2026. Individualized Targeted Exclusion Diet Based on Confocal Laser Endomicroscopy Does Not Improve Irritable Bowel Syndrome Symptoms: A Randomized Controlled Crossover Trial

While foods often trigger IBS symptoms, there has not been a simple way to identify these foods with objective testing. Previous small studies have indicated that confocal laser endomicroscopy has the potential to identify these triggers (See prior post: Is There a Way to Prove Which Dietary Factors Trigger Irritable Bowel Syndrome?).

“The advent of confocal laser endomicroscopy (CLE) has enabled in vivo real-time visualization of the gastrointestinal mucosa.9 Using this approach, researchers have demonstrated acute food-induced mucosal alterations in the duodenum of patients with IBS.10,11 …The reliable identification of foods responsible for symptoms in individual patients with IBS is of great interest. Not only would it streamline the current trial-and-error approach, but it could also potentially avoid overly restrictive dietary patterns, which potentially can lead to avoidant restrictive food intake disorder.”

Methods: “This was a double-blind, controlled, crossover study in patients with IBS. After CLE, patients excluded up to 2 foods that did (= real diet) and up to 2 foods that did not (= sham diet) cause alterations in a randomized order. Diets were followed for 4 weeks each. Clinical response was defined as improving ≥50 points on the IBS Symptom Severity Score. Healthy controls underwent the same CLE protocol as patients with IBS.” 31 patients (median age 33 years) completed both phases of dietary interventions.

Key findings:

  • Clinical response rates were not different between real and sham diet (42% vs 36%; odds ratio, 1.33; P = .6). Symptoms improved both on the real and the sham diet (−30 vs −20; P = .7). 
  • In 15 healthy volunteers, altered mucosa was visualized in 100% of the examinations either at baseline (13%) or after food administration.

My take: CLE-based tailored diet was not beneficial compared to a sham diet. In addition, CLE changes were present in all of the healthy volunteers indicating that altered mucosa is a nonspecific reaction rather than pathognomonic IBS reaction. Thus, there remains no proven way to identify trigger foods in IBS. Exclusion diets can improve symptoms but require careful monitoring.

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Phase 3 Trial: Fecal Microbiota Transplantation Fails in IBS

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PH Johnsen et al. The Lancet, 2026 (published online September 24, 2026) https://doi.org/10.1016/S0140-6736(26)01424-8 Faecal microbiota transplantation in irritable bowel syndrome (REFIT2): a randomised, double-blind, placebo-controlled, phase 3 trial

Methods: This was a randomised, double-blind, multicentre study at five hospitals in Norway. Participants (median age 36 years, 65% women) were randomly assigned 2:1 to faecal microbiota transplantation (FMT) with faeces samples from either healthy donors (intervention, n=298) or the participants themselves (placebo group, n=150). All participants had baseline screening including prior colonoscopy. At baseline, the intervention group had 38% receiving a low FODMAP diet compared to 39% in the placebo group. There was also a similar degree of IBS severity: 93% and 96% had moderate-to-severe IBS, respectively. Each participant received one retention enema (60 g faeces); in the intervention group, the enema consisted of faeces from one of three donors.

Key findings:

  • 119 (40%) participants in the donor FMT group and 57 (38%) in the placebo group showed an improvement of at least 75 points on the IBS-SSS at 90 days after treatment.
  • The proportion of participants with adverse events was similar in the two study groups; however, the six serious adverse events all occurred in the donor FMT group; these included diverticulitis, cholecystitis, escalation of psychiatric condition, and appendicitis.
  • At 90 days after treatment, recipients of donor faecal microbiota transplantation showed a significant change in relative microbial abundance compared with baseline, and both relative microbial abundance and alpha diversity were significantly different in the intervention and placebo groups.
Treatment success at 90 days and 365 days follow-up. Treatment success defined as a 75-point drop in IBS-SSS score compared with baseline. IBS-SSS=Irritable Bowel Syndrome-Severity Scoring System.

Discussion points:

  • “Some earlier trials have reported clinical benefits of faecal microbiota transplantation in IBS; however, many studies have been limited by small sample sizes, single-donor designs, and less stringent endpoint definitions or did not allow for a robust assessment of donor-dependent effects… Although the gut microbiota might still contribute to IBS pathophysiology,
    these findings indicate that non-specific microbiota replacement strategies are unlikely to provide consistent therapeutic benefit.”
  • “The strengths of the current trial were the large sample size, rigorous design with double-blinding, random assignment of participants by donor, and multicentre recruitment.”
  • Limitations: “The reliance on patient-reported outcome measures is an inherent limitation in IBS trials, as few objective measures are available to assess clinical effects.”

My take (borrowed from the authors): “This phase 3 trial did not show any clinical benefit of
faecal microbiota transplantation for treating patients with moderate or severe IBS.”

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Evaluating Anti-TNF Withdrawal Success in UC Remission (BIOSTOP Study)

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IP Berset et al. Journal of Crohn’s and Colitis, 2026; 20: jjag110. Anti-TNF withdrawal or long-term treatment in ulcerative colitis (BIOSTOP): a multicentre open label, randomized controlled trial 

Methods: “In this prospective, multicentre, randomized, controlled, open-label non-inferiority study, patients in deep clinical, biochemical and endoscopic remission were randomized 1:1 to anti-TNF withdrawal or maintenance treatment. Primary endpoint was endoscopically confirmed remission (Mayo Endoscopic Score 0 or 1) after two years, including UC flares treated with anti-TNF, or non-biologic agents.” This study analyzed 163 adult UC patients (2017-2021, median age 45 years). 29% of patients in the withdrawal group were receiving azathioprine.

Inclusioin criteria:

  • Clinical remission defined as six-point Mayo score≤1
  • Endoscopic remission defined as Mayo endoscopic score (MES) 0 or 1
  • Biochemical remission defined as two consecutive fecal (f-) calprotectin tests<200µg/g
  • Minimum one year of first-line anti-TNF treatment (94% of withdrawal group had rec’d anti-TNF therapy for at least two years)

Key findings:

  • Eighty percent (66/82) of anti-TNF withdrawal group and 96% (78/81) of maintenance patients were in endoscopic remission after 2 years
  • UC flares occurred in 52% (45/86) of withdrawal and 12% (10/86) of maintenance patients
  • Anti-TNF retreatment was successful in 74% (20/27) in the intervention group
  • 48% of anti-TNF withdrawal patients remained in steroid-free remission
  • There were no significant predictors for successful anti-TNF withdrawal
  • Serious adverse events:
    • In the withdrawal group: colectomy (n=1), and hospitalizaiton for flare-up (n=2)
    • In the control group: hospitalization for infection (n=2), and cancer (n=1) which was successfully treated and included anti-TNF discontinuation

The authors conclude that “withdrawal of anti-TNF treatment should be restricted to selected, well-informed and highly motivated patients.”

My take: This two-year randomized study showed that among patients in deep remission, almost half who stopped anti-TNF treatment continued with a steroid-free clinical remission after two years; however, there were no factors which identified those who were able to successfully withdraw from anti-TNF therapy. The results may overestimate the success rate of anti-TNF withdrawal as ~30% of patients were receiving azathioprine. In pediatrics, expert advice has favored continuation of advance therapies when patients are in remission.

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Declining Child Health in the U.S.

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CB Forrest, N Halfon. N Engl J Med 2026;395:1147-1149. Declining Child Health in the United States — Addressing the Developmental Ecosystem

This commentary paints a broad picture of declining health for U.S. children and what is needed to change the trajectory. Here are some excerpts:

Child health has been deteriorating in important and alarming ways in the United States…over the past two decades.1 Infants, children, and adolescents in the United States are 80% more likely to die than their peers in other high-income countries…77% of Americans 17 to 24 years of age would be ineligible to enlist in the U.S. military without a waiver, for reasons including obesity, mental health problems, and other medical conditions.2…

Researchers, policymakers, and the media have tended to attribute these trends to independent challenges — an obesity crisis, a mental health crisis, loneliness, gun violence — with distinct programmatic responses and potential remedies supported by separate advocacy groups and funding streams. But many of them have common origins and drivers…Interventions that target a single risk factor may relieve immediate suffering but will generally be insufficient to change developmental ecosystems in ways that can reverse generational declines in health…

At the base of the iceberg are a developmental ecosystem’s foundational values, which are often expressed in shared narratives about childhood: that raising children is chiefly a private responsibility, that markets are the fairest arbiters of who can be healthy…and that public support should be provided for children’s health programs only in exceptional circumstances…

The influence of these beliefs can be observed in the choices that society has made, including spending less than peer countries on early-childhood programs, opting not to regulate digital platforms that profit from the commodification of children’s attention, and organizing health care systems around the treatment of illness, rather than the promotion of healthy development.

The Elephant Rock is a natural rock formation located on the island of Heimaey in the Westman Islands

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More on Measles (October 2026)

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Trisha Pasricha, Washington Post 10/5/26: Measles can erase up to 73 percent of your immune system’s memory

An excerpt:

“My sister says there’s no real difference between a child getting the measles vaccine and just catching measles, since either way the child ends up immune. Is she right?

I wouldn’t describe it as “just catching measles.” In the United States, about 1 in 5 unvaccinated people who get measles is hospitalized, and 1 to 3 of every 1,000 children infected will die, according to the Centers for Disease Control and Prevention…

Children with measles become more susceptible to other infections like ear infections or diarrhea. Today, the most common cause of death among young children with measles is pneumonia…

In a study published in Science in 2015, researchers analyzed decades of childhood mortality data from the United States, England and Wales, and Denmark. They noticed that in the pre-vaccine era, when measles cases spiked, deaths from other infections rose, too — and not just immediately but for the subsequent two to three years…When the measles vaccine arrived, and measles cases fell, deaths from other infectious diseases fell along with them. The scientists estimated that where measles was common, measles infections could have been implicated in as many as half of all childhood deaths from infectious disease.

Center for Infectious Disease Research and Policy, University of Minnesota: “Pennsylvania confirms more than 1,000 measles cases. Nationwide, the Centers for Disease Control and Prevention (CDC) reported 3,887 measles cases as of October 2… Health department officials in South Carolina also have said that the state likely had more measles cases this year than the official count of 997. Doctors in South Carolina aren’t required to report measles-related hospitalizations, according to a report from ProPublica.”

Measles: 99% of the cases (n=1004) are in the unvaccinated which represent 7% of Pennsylvania’s population. Graph courtesy of Neil Stone, MD (via X). All of the deaths have occurred in the unvaccinated.

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PrEggNut Trial: Pregnancy Egg and Peanut Intake Didn’t Prevent Allergy

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DJ Palmer et al. N Engl J Med 2026;395:1090-1099. Trial of a Maternal Diet Rich in Eggs and Peanuts to Reduce Infant Allergy

Methods: For “The PrEggNut Trial,” a multi-site, randomized trial, “pregnant women whose unborn child had at least two biologic family members with medically diagnosed allergic disease were eligible to participate. Participants were assigned in a 1:1 ratio to follow either a diet high in eggs and peanuts that included at least 6 eggs and 60 peanuts per week (high egg–peanut group [n=1070]) or a standard (control) egg and peanut diet that included no more than 3 eggs and 30 peanuts per week (standard-diet group [n=1067]), from before 23 weeks’ gestation until 4 months postnatally during lactation. The primary outcome was IgE-mediated egg or peanut allergy in the infant at 1 year of age.

Key findings:

  • There was no significant difference in the percentage of infants with IgE-mediated egg or peanut allergy between the maternal high egg–peanut group (83 of 1066, 7.8%) and the standard-diet group (89 of 1064, 8.4%) (relative risk, 0.93; P=0.65)
  • A potential limitation of the trial was the lower-than-anticipated prevalence of egg or peanut allergy (8% actual vs. 16% anticipated)

My take: Increased exposure to eggs and peanuts during pregnancy did not reduce allergies in infants. Exposure during infancy, however, can reduce the rates of allergies.

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Proposed Treatment Algorithm for Water Bead Ingestions

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KH Denton et al. J Pediatr: Clin Pract 2026;22:200239. Pediatric Water Bead Ingestion: Experience from a Quaternary Care Children’s Hospital and a Proposed Management Algorithm

Methods: This retrospective chart review identified 36 pediatric patients (median age 2 yrs) who presented to a quaternary care children’s emergency department for water bead ingestion from 2015 to 2024.

Key findings:

  • The majority (n = 28, 78%) were asymptomatic.
  • Only 4 of 52 (8%) imaging studies were abnormal.
  • Endoscopy was performed in 6 (17%) patient encounters, none of which
    successfully retrieved water beads.
  • There were no patients with bowel obstructions or complications.

Discussion:

  • The results are “similar to a prior case series from 2011 to 2016, which examined 110 patients aged 19 years or younger who had called the Texas Poison Control Center for water bead ingestion. The study found that many were managed at home, without any known complications.”
  • “However, there are reports of morbidity and mortality associated with water bead ingestions. A literature review published in 2022 described 43 cases of bowel obstruction
    and 2 deaths following the ingestion of water beads.”
  • “Current NASPGHAN guidelines recommend early endoscopy in cases involving high-risk or potentially obstructive foreign bodies, with emphasis on emergent endoscopy in the case of superabsorbent objects such as water beads…Upon reviewing our data and the current
    literature, we propose a new algorithm for managing pediatric patients presenting with water bead ingestion.“
This “suggested algorithm remains provisional and informed by both experience and available literature to guide clinical decision-making but will require further validation before widespread adoption.”

My take: This article offers a practical approach to manage water bead ingestion and includes appropriate caution and caveats.

The recent ESPGHAN 2026 Position Paper (O Ledder et al. J Pediatr Gastroenterol Nutr. 2026;83:539–554) has not incorporated this suggested algorithm and is similar to previous NASPGHAN recommendations. See blog post on 9/28/26: “In cases of witnessed or suspected ingestion of SAP [superabsorbent polymers], emergency endoscopy should be performed to attempt retrieval of the material. If this is unsuccessful, or not completely retrieved, the child should be admitted for close observation with surgical support.”

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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.

“Battle of Hospital A.I. vs. Insurer A.I.”

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Reed Abelson , Teddy Rosenbluth. NY Times 4/24/26: Battle of Hospital A.I. vs. Insurer A.I. Is Pushing Medical Costs Higher. Thanks to Seth Marcus for sharing this article.

An excerpt:

In the latest sign that artificial intelligence is fueling higher health care costs, a group of insurers released a report Thursday claiming that hospitals’ use of A.I. was responsible for nearly $1 billion in additional expenses over two years…

Using codes for various medical conditions, hospitals submitted claims for tens of thousands of patients that described their illnesses as more complex in 2024 and 2025 than in 2023. Despite the added conditions, there was no evidence that the patients had received different treatment from the hospitals, according to the analysis by the Blue Cross Blue Shield Association, which represents state Blue Cross plans.

Using A.I. tools, hospitals are collecting more information about their patients, and submitting bigger claims, the association said…

Just as providers are using sophisticated A.I. tools to say their patients are sicker, insurance companies have been accused of using the tools to delay or deny care. The companies have come under intense criticism for their use of A.I. when requiring prior approval of treatments and medicines…

But as more hospitals and doctors use A.I., costs will continue to rise. Benefit consultants and insurers cite it as one of the factors that could lead to double-digit increases next year. A recent survey of employers suggested that costs could go up as much as 11 percent next year for employers unless they cut back on benefits.

My take: By leveraging AI, doctors and hospitals are able to claim that patients have increased complexity to justify higher reimbursement codes. This shift has caught insurance companies flat-footed and increased hospital profitability. When the insurance companies negotiated the rates for each reimbursement code, historical data allowed them to predict the costs based on projected use of each code; these projections are way off now. Using AI to document complexity, these hospital coding changes can no longer be denied as “upcoding” by insurance companies.

Over the long term, I expect insurance companies to work on lower reimbursement for higher-complexity coding. Over the short term, the increase in hospital profits will result in higher insurance costs for patients and businesses.

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Svartifoss (which translates to “Black Falls”), one of the most distinctive and photographed waterfalls in Iceland. The hexagonal basalt columns which frame an 80-foot cascade were formed geologically by lava flowing down a cliff face and cooling incredibly slowly, a process called columnar jointing.

Expert Practice Recommendations for C difficile Infection in Adults

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M Fischer et al. Clin Gastroenterol Hepatol 2026; 24: 2359-2369. AGA Clinical Practice Update on Management of Clostridioides difficile Infection in Adults: Expert Review

This article provides 14 “Best Practice Advice” statements. Since this is geared to adults, some are not applicable for the pediatric age group. I have highlighted five of them:

  • #4: Fidaxomicin (200 mg twice daily oral for 10 days) is a narrower spectrum agent, and given lower recurrence rates, is favored as first-line therapy for nonfulminant C difficile infection. However, given practical considerations, vancomycin (125 mg 4 times daily oral for 10 days) is also acceptable therapy. Metronidazole should not be used outside of fulminant disease.
  • #6: Following treatment of C difficile infection, clinicians should not perform routine test of cure. Stool testing should only be performed for persistent worsening of diarrheal symptoms.
  • #9: Prolonged, low dose, suppressive vancomycin regimen (125 mg daily) for secondary prophylaxis may be considered in patients with multiple recurrent episodes who are not candidates for fecal microbiota-based therapies due to ongoing comorbidities, limited life expectancy, or ongoing/frequent systemic antibiotics or who have failed multiple courses of fecal microbiota-based therapy.
  • #10: Fulminant C difficile infection should be managed by a multidisciplinary team (gastroenterology/infectious disease, surgery, medicine/critical care) and treated with high-dose vancomycin 500 mg every 6 hours (oral or enteral), with metronidazole 500 mg intravenously every 8 hours, and if ileus is present, rectal vancomycin 500 mg every 6 hours should be added.
  • #12: Use of vancomycin is not advised during systemic antibiotic administration to prevent C difficile infection. Probiotics are not advised to prevent an initial or recurrent C difficile infection. To promote restoration of healthy gut microbiota, patients should be instructed to consume a healthy diet including a variety of fruits and vegetables, rich in both soluble and insoluble fiber. ” Although some guidelines suggest OVP in high-risk patients, these recommendations were conditional and based on low-quality evidence.20“
Some of the advice from Table 1 on household prevention of CDI

For recurrent CDI, “experts recommend treating a first recurrence with an agent different from that used initially.” One option discussed by authors and in the treatment algorithms (Figure 2) includes use of a vancomycin taper. After a course of vancomycin 125 mg QID x 14 days, a typical taper would be BID x 14 days, then daily x 14 days, then every 3rd day x 14 days. An alternative is a fidaxomicin EXTEND (200 mg BID days 1-5, then every other day, days 7-25 days.

My take: This is a useful reminder of current best practices for C diff infection (in adults). Updated guidelines in pediatrics would be helpful.

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.