Current Gastroenterology Reports最新文献

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.

Purpose of review: Abdominal pain in constipation-predominant irritable bowel syndrome (IBS-C) and functional constipation (FC) remains a difficult clinical challenge due to unclear pathophysiological mechanisms and limited pain-targeted treatments. This review critically evaluates the evidence on the underlying pain mechanisms in IBS-C and/or FC and explores management strategies, their limitations, and future directions.

Recent findings: Most research on constipation-related pain is based on IBS-C patients or animal models, with limited studies focusing on FC. Visceral hypersensitivity, serotonin dysregulation, gut-brain axis dysfunction, and central/peripheral nervous system alterations are implicated in IBS-C pain, while FC pain is less studied and may be primarily linked to colonic distension and motility dysfunction. Management strategies include 5-HT4 agonists, GC-C agonists, chloride channel activators, psychological therapies, probiotics and complementary medicine. Despite available treatment options, managing abdominal pain in IBS-C and FC remains challenging due to heterogeneous pathophysiology and limited targeted therapies. While some interventions provide symptomatic relief, there is no universally effective treatment for abdominal pain across all patients. Future research should focus on identifying pain-specific biomarkers, refining diagnostic criteria, and integrating multi-omics data and neuroimaging techniques to better distinguish pain mechanisms in IBS-C versus FC and develop more precise, patient-centered interventions.

Purpose of review: Supragastric belching (SGB), rumination syndrome (RS), and abdominophrenic dyssynergia are often misunderstood and underdiagnosed syndromes. Better understanding of these conditions is needed to increase recognition and guide treatment.

Recent findings: Diagnosis is typically made by history and physical examination though supplementary evaluations can be considered in difficult to diagnose cases. These diseases are unique in that their optimal therapies are behavioral and focused entirely on the basic physiology of breathing techniques. Once one of these syndromes is recognized, the change in life for these patients can be formidable. As a result, recognition and proper treatment of these syndromes is essential for the gastroenterologist.

Purpose of review: Cystic fibrosis is a chronic condition that has significant effects on the nutritional status of pediatric patients. Malnutrition is frequently encountered in this population and has been shown to contribute to poor pulmonary and overall disease outcomes. This article will provide an overview of the physiologic and psychosocial challenges toward attaining optimal nutrition in pediatric cystic fibrosis patients.

Recent findings: Newer therapies such as CFTR modulators have played significant roles in improving the nutritional status of patients with cystic fibrosis. There is also a greater focus on becoming more aware of psychosocial and cultural barriers in the care of cystic fibrosis patients. Many challenges exist in optimizing nutritional support including but not limited to the patient's clinical manifestations and disease severity, caregiver ability, and access to care. Both gastrointestinal and non-gastrointestinal disorders lead to insufficient caloric intake, increased loss and metabolic needs, and micronutrient and macronutrient deficiency. Social factors including stressful patient and caregiver relationships and altered body image also contribute to poor nutritional status.

Purpose of review: The current review aims to summarize the benefits and limitations of the novel multicancer detection tests (MCD) for diagnosing gastrointestinal (GI) malignancies.

Recent findings: Traditional cancer screening methods can reduce deaths in malignancies involving the GI tract. For GI cancers, screening options vary by type and often involve invasive techniques with limited sensitivity. MCDs offer a promising, non-invasive (simple blood draw) alternative by analyzing biomarkers such as cell-free DNA and RNA using advanced techniques and machine learning to detect cancers across multiple organ sites. Large studies like the PATHFINDER trial and THUNDER study have demonstrated the feasibility and accuracy of MCD assays in identifying cancer signals, with high sensitivity and specificity in some GI organs that lack routine screening tests (e.g., liver, pancreas, and stomach). Despite these advancements, MCD testing faces challenges, including high costs, lack of FDA approval, false positives, and limited data on clinical utility in reducing cancer-specific mortality. MCD should not be a substitute for age-appropriate cancer screenings but may complement existing methods, particularly for cancers with no current screening tools, such as cholangiocarcinoma and pancreatic cancer. Clinicians need to discuss the limitations of MCDs, including the potential for overdiagnosis, patient anxiety, and financial burden due to insurance coverage gaps. MCD is a promising, non-invasive test that can augment traditional cancer screening. As the role of MCD in cancer detection evolves, further research is essential to establish how it will be integrated into clinical practice, ensuring informed, shared decision-making with patients.

Purposeof review: Hepatitis C virus (HCV) infections continue to steadily increase in the United States and remain a major public health challenge. This review aims to provide a comprehensive overview of HCV infection in children, focusing on recent advancements in screening, diagnosis, and treatment.

Recent findings: Effective screening strategies, including universal screening of pregnant women and nucleic acid testing for all perinatally exposed infants at 2 to 6 months of age, have been implemented to identify infected individuals early. Direct-acting antiviral agents have revolutionized treatment, offering high cure rates for children of all ages. Despite significant progress, challenges remain in achieving HCV elimination. These include the need for improved access to testing and treatment, as well as ongoing efforts to develop a preventive vaccine. Continued research and implementation of effective strategies are essential to reduce the burden of HCV infection.

Purpose of review: Many patients with chronic health conditions experience anxiety, which can have significant implications on physical health outcomes and quality of life. This systematic review and meta-analysis aimed to examine the prevalence of anxiety in gastroenterology and hepatology outpatients, across factors such as physical health condition, type of anxiety, and patient demographics, with the intention to support clinicians in providing effective patient care.

Recent findings: Several recent systematic reviews have been published investigating rates of anxiety in different outpatient settings, and have found consistently high rates across the dermatology, endocrinology, cardiology and respiratory/sleep medicine fields, ranging between 25.1% and 30.3%. Whilst there are established links between gastroenterology and hepatology conditions with anxiety, there has yet to be a study estimating the overall global prevalence of anxiety in this outpatient setting. PubMed, Embase, Cochrane and PsycINFO databases were searched from database inception to January 2023 for studies reporting anxiety in gastroenterology and hepatology outpatients ≥ 16 years of age. Prevalence was extracted from self-report questionnaires, diagnostic interviews, and records. The final meta-analysis included 81 studies, with 28,334 participants. Pooled prevalence of anxiety was 31.2% (95% CI 28.2%-34.4%). Subgroup analyses identified significant differences in prevalence across anxiety type, with health anxiety showing the highest prevalence at 23.7%, followed by generalised anxiety 14.5%, specific phobia 12.5%, panic disorder/agoraphobia 12.2%, social anxiety 11.3%, post-traumatic stress disorder 4.9%, and obsessive-compulsive disorder 4.2%. No other significant differences were found. Anxiety is thus common amongst gastroenterology and hepatology outpatients, and so it is important that careful consideration be given to the identification and management of anxiety in these settings.

Purpose of review: Esophageal atresia/tracheoesophageal fistula (EA/TEF) causes gastrointestinal (GI) complications that can begin in infancy and extend into adulthood. The etiology of these is frequently multifactorial, and they can adversely affect feeding, growth, respiratory health, and overall quality of life. This review highlights the importance of early diagnosis, multidisciplinary surveillance, and individualized treatment strategies to effectively manage these complications and improve long-term outcomes for affected children.

Recent findings: Recent studies have focused on the development of evidence-based surveillance protocols to optimally manage the numerous observed EA/TEF-associated digestive complications. Many of these complications stem from the combination of gastroesophageal dysmotility and mechanical obstruction inherent to EA/TEF and its surgical management, and include gastroesophageal reflux disease, feeding difficulties, dysphagia, eosinophilic esophagitis, and pulmonary consequences of aspiration. Management of GI complications in children with EA/TEF requires careful, multidisciplinary evaluation and treatment, incorporating dietary modifications, feeding therapy, pharmacotherapy, and surgical and endoscopic interventions.