Current Gastroenterology Reports最新文献

Purpose of review: The purpose of this review is to explore the role of specialized pro-resolving mediators (SPMs) in the resolution of inflammation in inflammatory bowel disease (IBD) focusing on their potential therapeutic benefits in these conditions.

Recent findings: IBD is characterized by chronic inflammation and mucosal barrier dysfunction, driven by a dysregulated immune response. SPMs, which are derived from polyunsaturated fatty acids, have been identified as active agents in resolving inflammation without impairing immune function. Preclinical studies indicate that SPMs can reduce intestinal inflammation, but clinical data are still limited. Moreover, SPMs may influence colorectal cancer (CRC) by modulating tumor-promoting inflammation and enhancing chemotherapy response. SPMs offer a promising approach to inflammation resolution and mucosal healing in IBD and CRC. However, further research is necessary to better understand their therapeutic potential and to establish their clinical applicability in these diseases.

Purpose of review: While societal guidelines help direct management of diverticulitis and diverticular bleeding broadly, our review focuses on the latest data for nuanced care of older patients affected by these conditions.

Recent findings: Diverticulitis in older patients can present with non-specific symptoms so a broad work up is recommended. Once diagnosed, those with uncomplicated disease (Hinchey Class 0 or 1a) can be safely managed without antibiotics or admission depending on frailty and comorbidities. Most older patients with complicated diverticulitis (abscess, perforation or obstruction) should be hospitalized. Elective or emergent surgery for complicated disease (Hinchey Class 1b-4) is associated with higher morbidity and mortality, particularly in older patients. The risk of diverticular bleeding and re-bleeding significantly increases with age, potentially due to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants. Diverticular disease and its associated complications disproportionately affect older adults. Management should focus on resuscitation, having low threshold for comprehensive work up and re-evaluating medication use for comorbid conditions to prevent recurrence.

Purpose of review: The treatment of inflammatory bowel disease (IBD) has evolved significantly over time based on "treat-to-target", an approach which uses sequential objective makers to monitor response to therapy with the ultimate goal of achieving endoscopic healing. Biomarkers, including C-reactive protein and fecal calprotectin, are an important noninvasive intermediate step in this treatment approach as well as in routine monitoring of disease activity. While widely utilized, there is significant variability and some uncertainty in biomarker implementation; this review summarizes evidence for the use of biomarkers in IBD.

Recent findings: The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) update in combination with the 2023 American Gastroenterological Association (AGA) guidelines on the role of biomarkers in the management of both Crohn's disease and ulcerative colitis have offered significant new guidance for those who manage IBD. Biomarkers offer important insight into disease activity and can be used to track progress toward deeper levels of remission in IBD.

Purpose of review: Pouchitis is a common complication in patients with ulcerative colitis who undergo total colectomy with ileal pouch anal anastomosis that presents a challenge to clinicians. In the article, we review the management of patients with pouchitis based on best available evidence.

Recent findings: Pouchitis can be practically classified into acute intermittent pouchitis (AIP), chronic antibiotic dependent pouchitis (CADP) and chronic antibiotic refractory pouchitis (CARP) based on the frequency of pouchitis episodes and response to antibiotics. Antibiotics are effective for treatment of AIP and CADP. However, prolonged antibiotic use, which is often necessary in CADP, may be associated with the risk of side effects and antibiotic resistance. Advanced immunosuppressive therapy can be a reasonable alternative to antibiotics in CADP. Advanced immunosuppressive therapies are effective in CARP and Crohn's like disease of the pouch (CLDP) and are the recommended treatments for these conditions. Evaluation to confirm pouchitis and rule out other etiologies that can present with pouchitis-like symptoms should be considered in antibiotic refractory patients. Antibiotics are the mainstay of medical treatment of pouchitis. Advanced immunosuppressive therapies can be effective in situations where antibiotics are not preferred or are ineffective. The treatment targets in pouchitis need to be better defined.

Purpose of review: Because dysphagia occurs when the esophageal luminal diameter is < 13 mm, the traditional goal of dilation is set at 14-16 mm (42-48 Fr) to relieve symptoms. This study was designed to determine whether increasing the size of dilators further would improve durability of response to bougienage.

Recent findings: Patients with severe or non-severe esophageal stricture and dysphagia were randomized to two different sizes of dilators. Diet and Dysphagia scores were calculated before and after index dilation, then every 4-8 weeks by phone for 12 months. Of 35 patients (mean age 63.1 yrs, 37.1% male) in the study, 11 had severe post-radiation strictures randomized to 42 Fr (n = 5) vs. 51 Fr (n = 6) Savary, 24 had non-severe strictures randomized to 46 Fr (n = 11) vs. 60 Fr (n = 13) Maloney. For severe strictures, number of dilations was nonsignificantly less with the larger 51 Fr versus 42 Fr (4.0 ± 1.73 vs. 5.2 ± 2.17, p = 1.00), and duration between dilations was longer (167 ± 154 vs. 64 ± 25 days, p = 0.41). For non-severe strictures, the smaller size 46 Fr dilator versus 60 Fr was associated with nonsignificantly fewer dilations (1.74 ± 0.81 vs. 1.77 ± 0.83, p = 0.70) and longer duration between sessions (265 ± 123 vs. 239 ± 103 days, p = 0.63). Bougienage with dilators larger than 14-16 mm (42-48 Fr) does not improve durability of symptomatic relief, either by decreasing the total number of dilations required or by increasing the symptom-free duration of response between sessions.

Purpose of review: This review examines the current evidence and practical considerations for endoscopic surveillance of Barrett's esophagus (BE) in elderly patients, focusing on balancing the potential benefits and risks associated with endoscopic surveillance and eradication therapies in this population.

Recent findings: Elderly patients with BE have a higher baseline prevalence of dysplasia and esophageal adenocarcinoma (EAC). Additionally, the risk of progression from BE to EAC increases with advancing age, making surveillance particularly relevant in this population. However, recent studies suggest the benefits of surveillance decline with increasing age, greater comorbidities, and reduced life expectancy. Despite increasing awareness that ongoing surveillance endoscopy may be of minimal benefit for certain patient groups, there remains a paucity of data to guide decisions regarding discontinuation of surveillance. The management of BE in elderly patients requires a careful balance between the potential benefits of endoscopic surveillance and eradication therapies and the risks and costs associated with repeated invasive procedures. Decisions to continue endoscopic surveillance in this population should be individualized, taking into account life-expectancy and comorbidities rather than focusing solely on chronological age.

Purpose of review: The purpose of this review is to provide a comprehensive review and recent updates in the understanding of the pathogenesis, diagnosis, and management of small bowel vascular lesions.

Recent findings: Recent terminology has shifted from "obscure GI bleeding" to "small bowel bleeding", with the former reserved for cases when the source of bleeding is not detected despite a thorough evaluation of the entire GI tract, including the small bowel. Recent diagnostic advances including imaging, video capsule endoscopy (VCE), and deep enteroscopy have allowed for the identification of most small bowel bleeding sources. The incidence of small bowel bleeding remains a relatively uncommon event. Vascular lesions remain the most common etiology of small bowel bleeding, with angiodysplasia representing the majority of vascular small bowel lesions. Standard therapeutic approach includes adequate resuscitation and endoscopic evaluation, with consideration of medical therapy (including somatostatin analogues and antiangiogenic agents), endoscopic interventions, radiologic procedures, or surgical therapy in select patients.

Purpose of review: Metabolic dysfunction-associated steatotic liver disease (MASLD) has become the leading cause of chronic liver disease. This risk paralleled the rise in obesity rates, making MASLD a consequence of the Metabolic Syndrome (MetS). Until recently, clinicians have had limited pharmaceutical options in management this disorder. Glucagon-like Peptide 1 Receptor Agonist (GLP-1 RA) treatments have emerged as potential agents for noted benefits in many aspects related to the pathology and progression of MASLD.

Recent findings: Numerous trials including a recent Phase 3 trial utilizing GLP-1 RA based therapies have shown benefits for improvement in MASLD including MASH and fibrosis. Molecules that also act upon the glucose-dependent insulinotropic polypeptide (GIP) and/or glucagon have shown potential synergistic benefits in reversing inflammation and fibrosis. In summary, GLP-1 RA based therapies are being rigorously studied in management of MASLD in particular more advanced stages and likely will become foundational therapies in the future.

Purpose of review: This review summarizes the literature on IL-23 inhibitors for inflammatory bowel disease and the role of these agents in clinical practice.

Recent findings: The last decade has seen several pivotal trials investigating IL-23 inhibitors. These agents are effective in inducing and maintaining remission of moderate-to-severe inflammatory bowel disease, including among those with prior biologic failure, and have low adverse events. IL-23 inhibitors are safe and effective for treatment of moderate-to-severe inflammatory bowel disease and appear more effective than ustekinumab for Crohn's disease. The currently available IL-23 inhibitors likely have similar efficacy, but practical considerations may influence preferences.