Current Gastroenterology Reports最新文献

Purpose of review: Enteral nutrition plays a pivotal role in maintaining nutritional status and supporting recovery in hospitalized patients who are unable to meet their caloric requirements. The benefits of enteral nutrition include preserving gut integrity, reducing infection risks, and supporting immune function, which are vital in critically ill and post-operative patients. Nasoenteric feeding tubes often serve as important tools to deliver enteral nutrition efficiently, yet their optimal placement remains a subject of significant clinical consideration.

Recent findings: Nasoenteric feeding tubes can be compromised by placement-related complications such as displacement, malpositioning, and tube-related discomfort. Our review of the relevant literature is complemented by review of our recent data. Our own clinical experience suggests that endoscopic placement of naso-enteric feeding tubes fails during the wire exchange process.

Summary: This report reviews the importance of enteral nutrition for enhancing patient outcomes, documents findings from our retrospective study on endoscopically placed nasoenteric feeding tubes and focuses on the challenges and future advancements in nasoenteric feeding tube placement techniques.

Purpose of review: Dysphagia with an identifiable stricture occurs frequently following chemoradiation therapy for head/neck cancer patients, some developing complete obliteration of the esophageal lumen. Combined Antegrade Retrograde Dilation (CARD) is designed to restore luminal patency. This paper reports how experience at one institution shaped a more effective strategy for the long-term management of this difficult patient population.

Recent findings: Twenty patients, mean age 62.6 years, initially undergoing CARD procedure, subsequently required a total of 278 dilation sessions (average 13.9 sessions/patient) performed on average every 8.2 weeks (range 2.7-12.6). All patients achieved luminal patency. Complications occurred in 7 patients (35.0% of patients, 2.5% of all procedures) and included traumatic bleeding, pneumothorax, overt esophageal perforation, microscopic perforation with cervical osteomyelitis, and perforation at the gastrostomy site. Diet and dysphagia scores were ineffective at directing the schedule for maintenance dilation. The CARD procedure is effective at restoring initial esophageal patency, but must be followed closely with long-term maintenance dilation. Over a large number of dilations, complications are infrequent and difficult to predict. Their incidence may be reduced by use of prophylactic antibiotics, prior removal of a tracheoesophageal prosthesis, avoiding dilation of the gastrostomy tract, modest dilation goal, and scheduled "stricture surveillance" with dilations performed under fluoroscopic guidance.

Purpose of review: Breath testing to diagnose intestinal microbial overgrowth (MO) is being increasingly utilized, in part due to direct-to-consumer testing modalities. However, the concept of breath testing in the diagnosis of MO is controversial due to numerous limitations regarding optimal substrate, diagnostic thresholds, and confounding variables. We provide seven real-world cases which comprehensively illustrate the principles and nuances of the interpretation of breath testing.

Recent findings: We highlight recent studies which examine the optimal substrate for breath testing (glucose versus lactulose), the subtypes and clinical significance of breath test patterns including hydrogen, methane, and hydrogen-sulfide, elevated baseline gas levels, and confounders to breath test interpretation including transit time and diet. Reviewing the latest evidence, we provide recommendations for a personalized interpretation of breath tests utilizing unique patient factors. We conclude with an algorithm to assist clinicians in providing more accurate diagnoses.

Purpose of review: The pandemic of obesity preceded global spread of Inflammatory Bowel diseases by almost 2 decades. A pathogenic relationship has been described between obesity and inflammatory bowel diseases, but Crohn`s disease may be selectively impacted. The role of diet in pathogenesis has also gained significant support in the last few decades. This review explores dietary relationships to account for epidemiological observations. Quantifiable indices for diets have been described including a glycemic index, inflammatory indices and levels of food processing. Meta-analyses have been published which examine each for effects on obesity and co-morbidities as well as Crohn's disease and ulcerative colitis. This review suggests that ultra-processed foods provide the best link between obesity and Crohn's disease explaining epidemiological observations. However, the other 2 types of dietary indices likely contribute to ulcerative colitis as well as to co-morbidities related to both obesity and inflammatory bowel diseases. The term ultra-processed foods cover a large number of additives and extensive work is needed to define individual or combined harmful effects. Furthermore, the interactions among the 3 main indices need clarification in order to precisely apply therapeutic diets to both diseases (obesity and inflammatory bowel disease).

Purpose of review: We present an introduction to the neuroimmune axis with a focus on the gastrointestinal system, its role in numerous chronic multisystem disorders, and emerging tools and therapies to diagnose and treat these conditions.

Recent findings: There have recently been tremendous breakthroughs in our understanding of how the nervous, immune, and endocrine systems, as well as the extracellular matrix and microbiota, interact within the gastrointestinal system to modulate health and disease.

Purpose of review: Non-celiac enteropathies (NCE) can be due to a variety of causes. The workup for NCE includes history, physical, laboratory and histology review and can be difficult. Enteropathies can result in serious illness due to consequences of malabsorption including severe weight loss, nutritional deficiencies, and debilitating diarrhea. Recognition and support of these consequences while investigating underlying etiology is essential.

Recent findings: Recent studies in NCEs have focused on improving diagnostic accuracy and predicting long-term outcomes in patients with NCEs. Further, literature has emphasized the importance of histological analysis, with a focus on differentiating between various enteropathies that cause villous atrophy, highlighting the complexity and need for personalized approaches in managing these conditions. Identification of etiologies of NCEs requires review of patients' detailed history, medications, and lab results. Common etiologies include immunodeficiencies, infectious, iatrogenic, and malignant causes. Using a systematic approach can lead to proper diagnosis and tailor treatment choices, benefiting patient outcomes. Supportive nutrition care should be initiated early when applicable to minimize morbidity.

Purpose of review: tTo assess the evolving role of endoscopy assessment for esophageal varices in cirrhosis.

Recent findings: The approach to screening endoscopy for varices has significantly changed in the last 10 years with the refinement of non-diagnostic tests. Non-invasive diagnostic methods have reduced the need of upper endoscopies for variceal screening in patients with compensated cirrhosis, focusing primarily on those with ambiguous risk assessments or contraindications to non-selective beta-blockers (NSBBs). In contrast, decompensated cirrhosis patients require more frequent endoscopic evaluations due to their heightened risk of complications and the potential benefit of combination therapy (NSBBs + variceal ligation). In patients with hepatocellular carcinoma (HCC) the performance of non-invasive tests is suboptimal and most patients require endoscopy. Emerging applications of artificial intelligence (AI) can assist in patient triage and the interpretation of endoscopic findings, potentially improving care. Further research is essential to validate these technologies within clinical practice and optimize their integration into patient management strategies.

Purpose of review: Telehealth has become an integral component of healthcare delivery in the US. While telehealth has been utilized within Hepatology for decades for HCV through Project ECHO and adapted by the VA, the COVID-19 pandemic catalyzed an unprecedented expansion of telehealth. This review examines the evolution, benefits, challenges, and future implications of telehealth in Hepatology.

Recent findings: Telehealth can improve access to care for underserved patient populations and provide continuity of care for chronic liver disease and liver transplant patients. Studies suggest that telehealth can deliver equivalent quality of care to in-person visits with high satisfaction rates among patients and providers. However, there are barriers to telehealth including disparities in technology access, limitations in quality of virtual encounters, and limited insurance policies. However, many questions remain. As Hepatology enters the digital era, telehealth holds promise for enhancing care delivery, but its integration must be guided by evidence-based practices.

Purpose of review: To present and discuss recent and previous literature on the nutritional implications and management of gastroparesis. We also briefly review its epidemiology, pathophysiology, and clinical manifestations.

Recent findings: - Low viscosity soluble fibers are well-tolerated in patients with mild to moderate gastroparesis symptoms and can thus be used to supplement the diets of these patients. - High-fat liquid meals are reasonably well-tolerated in patients with gastroparesis and can be used to supplement diet as tolerated. - The risk of tardive dyskinesia (TD) with long-term use of metoclopramide is much lower than previously thought. The nutritional status of patients with gastroparesis ranges across a wide spectrum, depending on the severity of their disease. Some patients improve simply with dietary modifications, others respond well to medical therapy, and those with severe, drug-refractory disease often require enteral nutrition or TPN (total parenteral nutrition). Generally, the recommended diet is composed of small particles, low fat, and low fiber; however recent studies showed that low viscosity soluble fibers and high-fat liquid fats can be tolerated. Metoclopramide is the first prokinetic agent of choice, and while the risk of TD is lower than previously thought, long-term use should be avoided in certain patient populations. For those on enteral nutrition, the choice of formula should be based on osmolarity, fat content, and fiber content, in accordance with the patient's tolerance.

Purpose of review: Fiber restriction has been a long-standing strategy for patients with inflammatory bowel disease (IBD), ostensibly to improve symptoms and reduce complications. Fiber though has a well-documented trophic effect on gut barrier defenses and the intestinal microbiome. This report discusses how texture modification may allow the safe and effective provision of much needed fiber to this patient population.

Recent findings: The effect of dietary fiber is characterized by maintenance of gut integrity, support of the microbiome, and immune modulation. Low-fiber diets in patients with IBD result in greater dysbiosis, intestinal permeability, and mucosal inflammation. New recommendations from international IBD guidelines now promote texture modification to allow for inclusion of fiber in certain conditions of IBD. For patients flaring with acute inflammation, or those with ileostomy, intestinal stricture, or ileal pouch anastomosis, continued fiber intake with softer textures and mechanical modification should be prioritized when feasible. For patients recovering from surgery, diet advancement should include reintroduction of soluble and insoluble fibers, while those in remission should have little or no dietary restrictions. Texture modification of high fiber foods may be accomplished by a variety of strategies involved in the selection, preparation, and cooking of fruits and vegetables. Greater effort to include dietary soluble and insoluble fiber should result in clinical benefit to the IBD patient, avoiding the adverse consequences of a low-fiber diet.