Current Gastroenterology Reports最新文献

Purpose of review: Acute Colonic Pseudo-obstruction (ACPO) is a cause of large intestinal dilation and obstruction without any physical transition point. It remains difficult to diagnose and treat. We review the recent updates on diagnosis and management of ACPO.

Recent findings: Recent guidelines have posited that conservative management can be tried in most cases of ACPO, but that early decompression and surgery should be considered. Use of neostigmine is still a viable option but there is also promising data on pyridostigmine as well as prucalopride. Resolution of ACPO should be followed by daily use of polyethylene glycol (PEG) to help prevent recurrence. ACPO warrants early and accurate diagnosis with exclusion of alternate causes of large bowel dilation. Conservative management can be attempted for 48-72 h in those with cecal diameters < 12 cm and without signs of peritonitis and perforation. Early escalation of management should be attempted with neostigmine followed by endoscopy and/or surgery as needed, given that longer periods of dilation are associated with worse outcomes. There is promising new evidence for use of pyridostigmine and prucalopride, but further trials are needed prior to incorporating them into regular use. Finally, studies are lacking regarding prevention of ACPO after initial resolution.

Purpose of review: Enteral feeding is commonly used to provide patients with nutrition. Access via feeding tubes can be attained by multiple medical specialties through a variety of methods.

Recent findings: There are limited data available on direct comparisons amongst gastroenterologist, interventional radiologists and surgeons, although there appears to be similar rates of complications. Fluroscopically and surgically placed feeding tubes may have a higher technical success rate than endoscopically placed tubes. The preferred specialty for feeding tube placement varies per institution, often due to logistical matters over technique or concern for complications. Ideally, a multidisciplinary team should exist to determine which approach is best in a patient-specific manner.

Purpose of review: As abdominal imaging becomes more sensitive and regularly used, pancreatic cystic lesions (PCLs) are being diagnosed more frequently. A small but clinically significant minority of these lesions have a predisposition to either harbor malignancy or undergo malignant transformation. This review highlights the current state and performance of cystic fluid biomarkers and how they may be incorporated into management.

Recent findings: Among the major domains of molecular testing for PCLs, DNA based analyses have demonstrated the highest accuracy in identifying cyst type and have the most data to support their clinical use. However, epigenetic and protein biomarker based molecular assessments have emerged with the potential to complement DNA based approaches. In addition, recent studies have increasingly demonstrated the value associated with combinations of mutations and other biomarkers in identifying higher grade mucinous cystic lesions. We present the performance of individual biomarkers in cyst fluid analysis with an emphasis on an algorithmic approach to improve the accurate identification of both cyst type and risk of malignant transformation.

Purpose of review: Anastomotic ulceration following intestinal resection is an under- recognized problem in pediatrics. We discuss the relevant literature regarding this condition.

Recent findings: Anastomotic Ulceration following intestinal resection is a potentially life threatening cause of refractory anemia. Evaluation should include correction of micronutrient deficiencies and endoscopic evaluation by upper and lower endoscopy and small intestinal endoscopy if necessary. Initial treatment by medical therapy may consist of anti-inflammatory agents as well as antibiotics to treat small intestinal bacterial overgrowth. Surgical resection should be considered if refractory to treatment. Anastomotic ulcers in pediatric patients with small bowel resection should be considered as a cause of refractory iron deficiency anemia. Endoscopic evaluation should be undertaken to look for evidence of anastomotic ulcers. Surgical resection should be considered if medical therapy fails.

Purpose of review: Treatment of inflammatory bowel disease (IBD) in the elderly requires special attention to treatment efficacy while considering drug safety, other medical comorbidities, and the patients' risk for treatment related adverse events. In this article, we reviewed the indications and safety of the newer IBD therapies in the older IBD patient beyond anti-TNF agents, thiopurines, and corticosteroids.

Recent findings: Vedolizumab, ustekinumab, and risankizumab have favorable side effect profiles with regards to infections and malignancy. Ozanimod has a favorable side effect profile with regards to infection and malignancy, however cardiac events and macular edema are potential risks. Tofacitinib and upadacitinib are associated with an increased risk of serious infections, herpes zoster, malignancy, and have potential for an increased risk of cardiac events and thrombosis. From a safety profile perspective, vedolizumab, ustekinumab, and risankizumab should be considered first line treatment options for moderate-to-severe IBD in the elderly. Risk-benefit discussions are indicated for ozanimod, tofacitinib, and upadacitinib.

Purpose of review: While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

Recent findings: In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

Purpose of the review: Our national guidelines regarding screening and surveillance for colorectal cancer recommend individualized discussions with patients 75-85 years of age. This review explores the complex decision-making that surrounds these discussions.

Recent findings: Despite updated guidelines for colorectal cancer screening and surveillance, the guidance for patients 75 years of age or older remains unchanged. Studies exploring the risks to colonoscopy in this population, patient preferences, life expectancy calculators and additional studies in the subpopulation of inflammatory bowel disease patients provide points of consideration to aid in individualized discussions. The benefit-risk discussion for colorectal cancer screening in patients over 75 years old warrants further guidance to develop best practice. To craft more comprehensive recommendations, additional research with inclusion of such patients is needed.

Purpose of review: The aim of this paper is to review and assess the appropriateness of eradication of nondysplastic Barrett's esophagus. Dysplasia in Barrett's esophagus is a known predictor for the development of esophageal cancer, and is currently the best marker in aiding the decision making regarding treatment options. Current data supports endoscopic eradication therapy for most patients with dysplastic Barrett's. The controversy, however, lies in the management of nondysplastic Barrett's and when to recommend ablation versus ongoing surveillance.

Recent findings: There have been increasing efforts to identify factors that can help predict which patients with nondysplastic Barrett's esophagus are at increased risk for cancer progression, and to quantify that risk. While there is currently varying data and literature supporting this, a more objective risk score is likely to soon become available and accepted, in an effort to differentiate between low and high risk nondysplastic Barrett's, and better aid in decision making regarding surveillance versus endoscopic eradication. This article reviews the current data on Barrett's esophagus and its risk for cancer progression, and it outlines several factors which impact progression that should be considered in the management approach to nondysplastic Barrett's esophagus.

Purpose of review: A distinctive, possibly "novel" form of a segmental inflammatory colonic disease process associated with diverticular disease (so-called SCAD or segmental-colitis-associated-diverticulosis) is reviewed.

Recent findings: Although this phenotype of inflammatory colonic disease was initially recognized decades ago, mainly in the elderly, recent evidence from long term natural history studies along with meta-analyses confirms that its clinical course is usually benign and drug-responsive. Interestingly, its appearance in some treated with monoclonal agents (eg., ipilimumab associated colitis) or infected with coronavirus-19 may have critical implications for its pathogenesis. This review further explores the implications of recognition of this pattern of colonic inflammatory disease, with relevance for physicians involved in both clinical practice and clinical trials of newer therapeutic agents.

Purpose of review: Artificial intelligence (AI) is a rapidly growing field in gastrointestinal endoscopy, and its potential applications are virtually endless, with studies demonstrating use of AI for early gastric cancer, inflammatory bowel disease, Barrett's esophagus, capsule endoscopy, as well as other areas in gastroenterology. Much of the early studies and applications of AI in gastroenterology have revolved around colonoscopy, particularly with regards to real-time polyp detection and characterization. This review will cover much of the existing data on computer-aided detection (CADe), computer-aided diagnosis (CADx), and briefly discuss some other interesting applications of AI for colonoscopy, while also considering some of the challenges and limitations that exist around the use of AI for colonoscopy.

Recent findings: Multiple randomized controlled trials have now been published which show a statistically significant improvement when using AI to improve adenoma detection and reduce adenoma miss rates during colonoscopy. There is also a growing pool of literature showing that AI can be helpful for characterizing/diagnosing colorectal polyps in real time. AI has also shown promise in other areas of colonoscopy, including polyp sizing and automated measurement and monitoring of quality metrics during colonoscopy. AI is a promising tool that has the ability to shape the future of gastrointestinal endoscopy, with much of the early data showing significant benefits to use of AI during colonoscopy. However, there remain several challenges that may delay or hamper the widespread use of AI in the field.