Current Gastroenterology Reports最新文献

Purpose of review: The purpose of this narrative review is to describe the mechanisms for gut dysfunction during critical illness, outline hypotheses of gut-derived inflammation, and identify nutrition and non-nutritional therapies that have direct and indirect effects on preserving both epithelial barrier function and gut microbiota during critical illness.

Recent findings: Clinical and animal model studies have demonstrated that critical illness pathophysiology and interventions breach epithelial barrier function and convert a normally commensal gut microbiome into a pathobiome. As a result, the gut has been postulated to be the "motor" of critical illness and numerous hypotheses have been put forward to explain how it contributes to systemic inflammation and drives multiple organ failure. Strategies to ameliorate gut dysfunction have focused on maintaining gut barrier function and promoting gut microbiota commensalism. The trajectory of critical illness may be closely related to gut epithelial barrier function, the gut microbiome and interventions that may contribute towards a deleterious pathobiome with immune dysregulation.

Purpose of review: This review aims to explain the causes, diagnosis, and treatment of malnutrition in hospitalized patients with inflammatory bowel disease (IBD), focusing on both adults and children.

Recent findings: Malnutrition is common among IBD patients, affecting up to 85% of individuals, and is linked to higher rates of illness, death, and longer hospital stays. Recent studies highlight the importance of early detection using tools like the Subjective Global Assessment (SGA) and handgrip strength tests. Nutritional interventions-such as exclusive enteral nutrition (EEN) and parenteral nutrition (PN)-have proven effective in inducing remission and improving patient outcomes, especially in pediatric Crohn's disease. New evidence suggests that optimizing nutrition before and after surgery, as well as using immunonutrition, may reduce postoperative complications. Early identification and management of malnutrition in hospitalized IBD patients may be important for improving clinical outcomes. Using appropriate nutritional screening tools and creating personalized nutrition plans can help with recovery, decrease hospital stays, and improve quality of life. Further research is needed to develop standard protocols for nutritional assessment and treatment in this patient population.

Purpose of review: The number of hospitalizations for gastroparesis has risen over 300% in recent decades with increased physical, psychological, and healthcare burdens. Gastric per-oral endoscopic myotomy (G-POEM) is a promising therapy for patients with refractory gastroparesis. This article reviews important considerations for G-POEM.

Recent findings: Predictive factors for clinical success after G-POEM include diabetic and idiopathic gastroparesis, shorter gastroparesis duration, symptoms predominant of nausea and emesis, and gastric emptying study showing gastric retention of > 20% at 4 h. Mucosal closure is a critical step for G-POEM; both sutures and clips have high success rates, with clips having a trend to lower success rates but with significantly shorter procedure time and cheaper cost. G-POEMs have an overall 61% pooled success rate at one year with a yearly 13% symptom recurrence rate. A careful patient selection can yield higher clinical success rates. Further studies are needed on variant G-POEM techniques for more durable outcomes.

PURPOSE OF REVIEW: Esophageal cancer is one of the most common cancers in the world and carries a poor prognosis. While esophagectomy poses considerable mortality and morbidity risks, endoscopic resection can provide a safer and less invasive alternative. RECENT FINDINGS: Endoscopic resection therapy has allowed a less invasive approach with comparable outcomes to esophagectomy. EMR is considered safe and requires less intensive training, yet it does not offer complete histopathological assessment due to the nature of piecemeal resection for larger lesions. Alternatively, ESD offers an R0 resection, therefore allowing precise histopathological evaluation. Training in ESD is essential; however, a uniform training model has not been agreed upon. The Japanese apprenticeship training model has proven effective, with promising training outcomes from the Eastern experience. In the West, a comprehensive training model through a combination of apprenticeship with progressive exposure, including ex-vivo and live animal hands-on training, could be the optimal approach. Different methods of ESD training are currently available, all of which aim to provide the experience needed to perform safe ESD. Despite the differences in training styles between the East and the West, a modified apprenticeship model could potentially result in more effective and better training outcomes. The currently available technologies provide the environment to enhance ESD training.

Purpose of review: Endoscopic submucosal dissection (ESD) has been found to increase en bloc and R0 resection as well as decrease risk of recurrence. However, despite literature supporting the benefits of endoscopic submucosal dissection, adoption of ESD in the United States has been challenging, driven by factors including requirement for specialized training as well as limitations in training availability.

Recent findings: Many devices have been developed to improve ease and therefore adoption for the procedure, with advancements in stability, resection as well as closure of the mucosal defect following resection. While the Japanese model of training in ESD centers around the Master-Apprentice model, this is scarce in the United States. Most US endoscopists therefore must follow other paths to learn and become proficient at ESD. There has been a rapid expansion in literature on ESD, fellowship programs, opportunities for case observation, and significant evolution in ex vivo training models that can assist an endoscopist in receiving training in ESD. Currently, there are three main ways of learning to perform ESD in the United States: 1. Third space endoscopy fellowship; 2. Master-apprentice model; 3. Utilization of live courses and proctored procedures. ESD is the optimal method to ensure en bloc resection of large mucosal neoplasms of the gastrointestinal tract. While several barriers hinder adoption of ESD in the United States, there has been significant development both in procedural and training aspects. Further research and discussions are needed to determine criteria for credentialing and proficiency in ESD.

Purpose of review: This review details the pathophysiologic mechanisms from medical, surgical to psychosocial factors that illustrate how and why sexual health and intimacy are impacted in IBD.

Recent findings: Recent clinical surveys of practicing gastroenterologists document that clinicians should routinely address sexual health when addressing patient reported outcomes but very few actually make direct inquiry or suggest management into this important aspect of human life. Example 'patter' are suggested to clinicians to demonstrate how to introduce the subject of sexual intimacy and well-being and engender patient trust on this sensitive topic. Once specific symptomatology are elicited, then a review follows on how referral to a cadre of available multidisciplinary specialists can help directly manage the patient's concerns. Specific emphasis on addressing the sexual health in ostomate and sexual and gender minority populations is focused upon as well. Overall, this in depth review highlights a practical clinical approach to understanding how to address sexual wellbeing and human intimacy in IBD patients.

Purpose of review: Inflammatory bowel disease (IBD) patients commonly inquire about the role of diet in the onset and management of their disease process. This review sought to assess the impact of the inflammatory bowel diseases on the nutritional state of patients and evaluate the evidence supporting nutritional interventions as therapy.

Recent findings: The role of nutrition has evolved from one of deficient nutrient and calorie replacement alone into a proactive therapeutic for treating active inflammatory disease symptoms. The realization that initiating total parenteral nutrition (TPN) in place of oral take could improve disease symptoms provided the first indication that food intake played a causative role in the IBD. The evolution of TPN to enteral nutrition improved tolerance and reduced side effects but clouded the role of oral intake in the pathophysiology of IBD. Advanced understanding of the role of the microbiota in IBD combined with recognition of the influence of nutrients on microbial composition have ushered in a new era of food as therapy. The role of nutrition in IBD has evolved significantly over the past 30-40 years. From complete elimination of oral intake to the carefully curated menu intended to mold the intestinal microbiota to a non-inflammatory milieu has revolutionized the approach to dietary intervention. Additional studies are warranted to optimize dietary intervention strategies.

Purpose of review: In this review, we discuss the role of endoscopic gallbladder drainage for acute cholecystitis in non-surgical candidates, describe technical aspects, clinical outcomes, and elaborate on considerations when determining which approach to adopt for a given patient.

Recent findings: Cholecystectomy remains the criterion standard for management of acute cholecystitis in patients who can safely undergo surgery. For non-surgical candidates, percutaneous cholecystostomy (PTC-GBD) has been the traditional strategy to drain and decompress the gallbladder. Advances in endoscopy have further expanded the nonsurgical interventions and approaches to cholecystitis. Both endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound guided gallbladder drainage (EUS-GBD) have become acceptable alternatives to PTC-GBD, with growing literature supporting their efficacy, safety and improved patient quality of life when compared to a percutaneous approach. Choosing the appropriate endoscopic technique for gallbladder drainage should be tailored to each patient, keeping in view the specific clinical scenarios, endoscopist preference and following a multi-disciplinary approach.

Purpose of review: Alcohol use disorder (AUD) drives alcohol-associated liver disease (ALD), and relapsing after abstinence remains a significant challenge before and after transplantation. This review summarizes evidence for pharmacotherapies in relapse prevention and their integration into ALD care.

Recent findings: Naltrexone and acamprosate reduce the relapse in the general AUD population, though data in ALD are limited. Baclofen is the only drug tested in randomized trials in cirrhosis, with early benefit but mixed results in later studies. Gabapentin and topiramate are promising off-label options. Emerging agents include glucagon-like peptide-1 (GLP-1) receptor agonists, psilocybin, and fibroblast growth factor-21 (FGF21) analogs, all showing early signals in reducing alcohol use. Despite guideline support, pharmacotherapy is underutilized in ALD due to lack of insight, stigma, provider inexperience, and fragmented care. Integrated programs across the disease spectrum demonstrate feasibility and may improve pharmacotherapy uptake. Pharmacotherapy is effective yet underused for relapse prevention in ALD. Integration with behavioral interventions and multidisciplinary care is essential to expand access, evaluate novel therapies, and improve patient outcomes.

Purpose of review: To review the clinical utility of botulinum toxin (BTX) injections in children with gastrointestinal (GI) disorders.

Recent findings: BTX is a presynaptic acetylcholine inhibitor with medical indications ranging from the treatment of muscle spasticity to gastrointestinal disorders involving sphincter dysfunction. BTX injections to the upper esophageal sphincter are used to target cricopharyngeal achalasia and retrograde cricopharyngeal dysfunction as temporary measures to decrease sphincter tone and improve swallowing, potentially eliminating the need for surgery. Lower esophageal and pyloric BTX injections have shown benefit in achalasia and gastroparesis, particularly in children unable to undergo or refractory to definitive treatments. Anorectal indications represent the largest experience, especially in children with persistent obstructive defecation symptoms after surgery for Hirschsprung's disease. BTX injection is a minimally invasive, reversible, and generally well-tolerated intervention with mild, self-limited side effects. However, its limitations include transient effects, procedural variability, and primarily off-label use, with most pediatric experience derived from small series. Prospective studies are needed to further evaluate patient selection, standardization, dosage, and long-term efficacy in pediatric gastrointestinal disorders.