Crohn's disease (CD) remains a significant therapeutic challenge, with limited treatment options and heterogeneous clinical responses. The selective JAK1 inhibitor filgotinib has shown great potential in treating ulcerative colitis but failed to demonstrate consistent efficacy in CD, for reasons that remain unclear. Here, we address this gap using an immunocompetent ex vivo model of precision-cut intestinal slices (PCIS) from CD patients, allowing region-specific analysis of ileal and colonic responses. We reveal that colonic PCIS display strong T cell activation and are highly sensitive to filgotinib, with suppression of Th1/Th17 cytokines, oxidative stress, and STAT signaling ex vivo. In contrast, ileal PCIS exhibited predominantly innate and Th17-driven inflammation, and were less sensitive to JAK1 inhibition. These data provide a potential mechanistic explanation for the limited efficacy of filgotinib in CD clinical trials and established PCIS as a human-relevant ex vivo model for region-specific drug responses, underscoring the importance of developing therapies tailored to different segments of the gut in inflammatory bowel disease.

Enteric duplication cysts are rare congenital malformations of the gastrointestinal tract that may present with a broad spectrum of clinical manifestations, ranging from incidental findings to life-threatening complications such as intestinal obstruction, volvulus, perforation, and gastrointestinal bleeding. Due to their nonspecific clinical presentation, preoperative diagnosis remains challenging. We report the case of a four-year-old boy who presented with a three-day history of fever, diarrhea, progressive lethargy, and colicky abdominal pain. Initial clinical assessment suggested acute infectious gastroenteritis with dehydration. Laboratory investigations demonstrated elevated inflammatory markers, while abdominal ultrasonography revealed bowel wall thickening, mesenteric lymphadenopathy, and a cystic lesion associated with dilated bowel loops. Despite conservative treatment with intravenous fluids and symptomatic management, the patient's condition progressively deteriorated. He developed worsening abdominal pain, increasing abdominal distension, impaired passage of stool and flatus, and persistent fever. Repeat imaging demonstrated persistent bowel dilatation and multiple air-fluid levels consistent with mechanical intestinal obstruction. Emergency exploratory laparotomy revealed a large enteric duplication cyst arising from the mesenteric border of the small intestine. Partial small bowel resection and drain placement were performed. This case illustrates the diagnostic challenges posed by enteric duplication cysts presenting with symptoms mimicking acute gastroenteritis. Progressive abdominal distension and failure to improve with conservative treatment should prompt repeated surgical assessment and further imaging to exclude underlying mechanical obstruction.

Sigmoid volvulus (SV) is an uncommon cause of intestinal obstruction resulting from axial twisting of the sigmoid colon around its mesenteric base. In the absence of complications, endoscopic detorsion is considered the first-line treatment, whereas urgent surgery is required in cases of perforation, peritonitis, or failed detorsion (1). The "coffee bean sign" (massively dilated sigmoid loop directed to the right upper quadrant) and the "whirl sign" (twisting of mesentery and vessels) are well-established radiological findings of SV (2). By contrast, endoscopic features are less well characterized, and evaluating mucosal ischemia or necrosis endoscopically remains challenging. Completely black mucosa is indicative of full-thickness necrosis, while borderline ischemia may present with variably discolored mucosa, including yellowish and reddish spots. In 2021, Uysal et al. described this finding as the "fallen leaves in autumn" sign, reflecting superficial necrosis with preserved viability of deeper layers. We report the case of an 83-year-old male admitted to the emergency department with abdominal pain and rectal bleeding. Imaging revealed classic signs of SV (Figure 1). During endoscopic detorsion, findings consistent with borderline ischemia were noted: loss of submucosal vascularity and scattered reddish-yellowish dots, some confluent. Areas suspected of complete necrosis displayed black mucosa with a sandpaper-like appearance (Figure 2). The patient underwent surgery for irreversible ischemia (Figure 3) but unfortunately died a few days later due to postoperative complications. This case highlights that the "fallen leaves in autumn" sign may serve as a useful endoscopic descriptor of borderline ischemia in SV, complementing established radiological features.

Small intestinal bacterial overgrowth (SIBO) refers to an abnormal increase in the number of bacteria in the small intestine and is observed in various diseases. SIBO can also develop after long-term use of proton pump inhibitors (drug-induced SIBO), bariatric surgery, gastrectomy, and other surgeries (postoperative SIBO). The aim of this narrative review is to summarize all of the published information on the treatment of SIBO in as much detail as possible and present it separately for each specific disease and intervention associated with SIBO. The most extensively studied drug for the treatment of SIBO is rifaximin. It eliminates SIBO in 63% of cases; however, most studies lack a control group. Small RCTs assessing the effects of this antibiotic on SIBO have reported conflicting results, and a meta-analysis showed no effect. A large RCT is required to verify the results of uncontrolled studies. Neomycin and norfloxacin showed efficacy in the treatment of SIBO in single RCTs, with elimination rates of 20 and 100%, respectively. Ciprofloxacin, rifamycin, metronidazole, and other antibiotics, as well as ursodeoxycholic acid, showed positive effects for the treatment of SIBO, but only in uncontrolled studies or in comparison with rifaximin or other drugs. The reported elimination rates were 54%, 67%, 79%, and 75%, respectively. Eradication therapy for Helicobacter pylori infection eliminated SIBO at a rate of approximately 70%. Probiotics have been tested for treatment of SIBO in various diseases. VSL#3 and Saccharomyces boulardii CNCM I-745 were effective in RCTs, with elimination rates of 58% and 80%, respectively. In conclusion, when selecting SIBO treatment regimens, those that have demonstrated the greatest efficacy for a specific concomitant disease should be preferred, despite the generally low level of evidence supporting these approaches in most cases.

Trichobezoars are rare intragastric masses composed of ingested hair, most commonly affecting young females with underlying psychiatric conditions. Rapunzel syndrome is a rare variant characterized by extension beyond the stomach into the small intestine. We report the case of a 27-year-old female with a 6-month history of abdominal pain, vomiting, weight loss, and intolerance to oral intake. Endoscopy revealed a large gastric trichobezoar occupying ~90% of the gastric lumen, causing functional pyloric obstruction. Contrast-enhanced computed tomography demonstrated marked gastric and proximal duodenal dilation with imaging features suggestive of secondary superior mesenteric artery (SMA) syndrome (Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149-56. https://doi.org/10.1159/000102097; Ganss A, Rampado S, Savarino E et al. Superior mesenteric artery syndrome: a prospective study in a single institution. J Gastrointest Surg 2019;23:997-1005. https://doi.org/10.1007/s11605-018-3984-6). Surgical exploration confirmed a giant trichobezoar extending from the pylorus to near the cardia with duodenal extension. Complete removal was achieved via laparotomy and anterior gastrotomy. The postoperative course was uneventful, and psychiatric evaluation confirmed trichotillomania and trichophagia. This case highlights the importance of multimodal diagnosis and suggests a possible pathophysiological relationship between severe gastric obstruction and secondary SMA syndrome.

Anastomotic leakage and anastomotic stenosis are among the most severe complications of rectal resection, among patients receiving neoadjuvant radiotherapy, the incidence of anastomotic stricture ranges from 3% to 6%. Anastomotic stricture can lead to abdominal pain and bowel obstruction, significantly affecting the quality of life and sometimes necessitating the creation of permanent stomas. This article reviews the definition of rectal anastomotic stricture. The development of anastomotic stricture is closely related to multiple factors, such as the healing characteristics of the bowel wall, local ischemia, anastomotic leakage, and the effects of preoperative radiotherapy. Furthermore, the choice of surgical anastomosis techniques significantly impacts the incidence of strictures. To enhance treatment outcomes for anastomotic strictures, this review summarizes different therapeutic strategies for membranous and tubular strictures. Transanal endoscopic resection and reconstruction surgery has significant advantages in the treatment of severe rectal anastomotic stenosis, providing standardized suggestions and guidance for the treatment of this clinical difficulty.

Colorectal serrated polyps are now recognized as an important pathway in colorectal carcinogenesis. An association between serrated polyposis syndrome (SPS) and duodenal serrated lesions sharing a similar immunophenotype in both the colon and duodenum has been reported in the literature. We present a case of a 38-year-old male who presented in June 2023 with abdominal pain and fever. Initial investigations, including multiple computed tomography scans of the abdomen and pelvis, revealed an appendiceal abscess and small bowel intussusception involving two segments of the jejunum without evidence of obstruction, along with multiple polyps throughout the small and large bowel suggestive of an intestinal polyposis syndrome. Further evaluation with colonoscopy, esophagogastroduodenoscopy, and magnetic resonance enterography confirmed the presence of numerous polyps of varying sizes involving the duodenum, jejunum, ileum, and all segments of the colon. The initial differential diagnosis included familial adenomatous polyposis, Peutz-Jeghers syndrome, and PTEN hamartoma tumor syndrome. The patient subsequently developed complicated small bowel obstruction due to intussusception and underwent open small bowel resection. Multiple intestinal polyps were identified, and histopathological examination confirmed the diagnosis of SPS. At a later stage, the patient was planned for subtotal colectomy, preceded by elective endoscopic polypectomy, which achieved clearance of the left colon up to 20 cm from the anal verge. Gross examination of the colectomy specimen revealed more than 20 large polyps measuring up to 4 cm. Histopathological analysis demonstrated colonic serrated polyposis without evidence of invasive malignancy, wall infiltration, or lymph node involvement, with clear surgical margins.