Abstract Background Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), may present with complex, treatment-refractory forms.In response to this clinical challenge, the IOIBD 2023 consensus proposed a standardized definition of difficult-to-treat IBD (IBD-DTT), based on therapeutic, surgical, and psychosocial criteria. This classification enables identification of patients with poor prognosis who require a multidimensional approach. However, data describing this population in middle-income countries remain limited. In this context, assessing the frequency and phenotypic features of IBD-DTT in real-world tertiary care cohorts is essential to optimize diagnostic and therapeutic strategies in resource-constrained settings. Methods An observational, retrospective, cross-sectional study was conducted at the IBD Clinic of the Hospital General de México between March 2023 and June 2025. Patients with confirmed UC or CD who met at least one IOIBD 2023 diagnostic criterion for IBD-DTT were included. Clinical, demographic, therapeutic, and surgical variables were extracted from institutional records. Data analysis was performed using SPSS v29.0. Quantitative variables were summarized with means and standard deviations; qualitative variables with absolute and relative frequencies. Chi-square or Fisher’s exact test was used to compare proportions, and Student’s t test for means. A p value 0.05 was considered significant. Results Of 298 patients with IBD, 40 (13.4%) met at least one IOIBD 2023 criterion for IBD-DTT. Of these, 15 had UC and 25 CD. Demographic, clinical, therapeutic, and diagnostic characteristics are shown in Table 1. No significant differences in age or sex were found between groups. Conventional therapy use was more frequent in UC (53.3% vs. 20.0%, p = 0.0223), whereas advanced therapy, particularly ustekinumab, predominated in CD (80.0% vs. 46.7%, p 0.0001). Refractory pouchitis and psychosocial issues were more common in UC (p 0.001 and p = 0.04, respectively). In contrast,the need for surgery was significantly higher in CD (88.0% vs. 40.0%, p = 0.0336).The most frequent diagnostic criterion for IBD-DTT was complex perianal disease in Crohn’s disease, present in 35% of cases. In addition, 7.5% of patients (3/40), all with CD, met two or more IOIBD criteria Conclusion In this cohort, 13.4% of IBD patients met at least one IOIBD 2023 consensus criterion for IBD-DTT, more frequently in CD than UC. Distinct patterns in therapy use, surgical indication, and associated manifestations were observed between phenotypes. Complex perianal disease was the most prevalent criterion among CD patients. These findings highlight the need for individualized therapeutic strategies, tailored to clinical phenotype, to optimize the management of difficult-to-treat IBD Conflict of interest: Sebastian Ocampo, Valeria Natalie: No conflict of interest Contreras Aviles, Estefania: No conflict of interest Philippe Ponce, Mildred: No conflict of interest Rosales Tellez, Paola: No conflict of interest Gonzalez Lopez, Roberto Emmanuel: No conflict of interest Hernandez Antolin, Victor: No conflict of interest Rodriguez Cruz, Hector: No conflict of interest Lopez Perez, Raquel Yazmin: No conflict of interest Jimenez Bobadilla, Billy: No conflict of interest De Leon Rendon, Jorge Luis: Dr. Jorge Luis De León Rendón is a member of Advisory Boards, key opinion leader, and speaker for Abbvie Mexico, Takeda Mexico, and Janssen Mexico. He has served as a key opinion leader and lecturer for Schwabe Pharma Mexico, Servier, Pfizer, Alfasigma, and Siegfried Rhein Mexico. He has received support for research manuscript publication and editing from Takeda and Schwabe Pharma Mexico. Additionally, he has coordinated research studies and medical education programs with Shire, Bristol Myers Squibb, Takeda, Schwabe Pharma, Abbvie, Janssen, MSD, and Roche.
Ocampo et al. (Thu,) studied this question.