Expert Review of Gastroenterology & Hepatology最新文献

Introduction: Celiac disease (CD) is an autoimmune enteropathy characterized by atrophy of the intestinal mucosa triggered by the ingestion of gluten in individuals with a genetic predisposition. CD manifests with heterogeneous array of symptoms, including a wide range of intestinal and extraintestinal symptoms and manifestations (EIMs). The mechanisms involved in the pathogenesis of EIMs in CD are not only related to intestinal mucosal damage and associated malabsorption but also to systemic inflammation. To date, the only effective treatment for CD is a lifelong gluten-free diet (GFD). Proper adherence to the GFD leads in most cases to a gradual resolution of intestinal atrophy and results in an improvement of the clinical manifestations associated with intestinal damage.

Areas covered: This review, based on a Pubmed literature search, describes the extraintestinal complications associated with CD, emphasizing strategies for therapeutic management and responsiveness to the GFD.

Expert opinion: CD is associated with different EIMs which can affect different organs. The main clinical interest is if these complications respond to the GFD, which occur at variable rate and not for all disorders associated with CD. Therefore, often complementary additional therapies are needed to achieve optimal symptoms resolution.

Introduction: The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

Areas covered: This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

Expert opinion: A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.

Introduction: The management of pediatric inflammatory bowel disease (PIBD) has drastically changed in the last decade. The limited availability of new biologics or small molecule therapies, and concerns about durability in children has necessitated the development of other advances in management to optimize care.

Areas covered: This review covers guidance for management targets and advances in optimizing biologic therapies, new medical therapies, adjuvant therapies, precision medicine and mental health concerns in PIBD. This review focused on recent advances and was not intended as a complete overview of the investigations and management of pediatric IBD.

Expert opinion: Advancements include standardization of treatment goals via a treat-to-target strategy, optimizing anti-TNF biologics through combination therapy or proactive drug monitoring, earlier initiation of treatment for Crohn's disease, the emergence of new biologic/advanced therapies and a growing focus on adjuvant therapies targeting the microbiome. Future progress relies on the inclusion of children/adolescents in clinical trials to facilitate faster regulatory approval for pediatric therapies and the integration of precision medicine and mental health screening to improve patient care and outcomes.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with an extremely poor prognosis. The most common complications after a pancreaticoduodenectomy (PD) include surgical site infection (SSI), postoperative pancreatic fistula (POPF), and delayed gastric emptying (DGE). The potential role and mechanisms of microbial colonization of key surgical sites resulting in perioperative complications after PD remain to be fully elucidated. In this key paper evaluation, the role of different microbiota in perioperative morbidity and mortality following PD are discussed, and key microbial signatures are identified that may shape the future management of post-operative surgical care.

Introduction: Diverticular disease, including diverticulosis and diverticulitis, presents a significant health concern globally, with increasing prevalence in Western societies and emerging trends in Asia. The incidence of diverticulitis, is on the rise, leading to significant morbidity and healthcare costs.

Areas covered: A literature search was conducted using the PubMed database, and studies published between 1995 and 2024 were selected based on their relevance to the overall understanding of disease. This review investigates the clinical spectrum, classification, and management strategies of diverticular disease, focusing particularly on evolving trends in diagnosis and treatment. Discussions regarding the prevalence of diverticulosis, the identification of risk factors associated with disease progression, recent advancements in research, and the utilization of biomarkers in disease monitoring and treatment decision-making are considered in detail.

Expert opinion: The discourse on diverticular disease underscores the pressing need for tailored management strategies and innovative treatments. Understanding the intricacies of the disease's pathophysiology is paramount for effective intervention. Recent advances in diagnostic imaging and biomarker identification are promising, yet more research is imperative to further refine patient care. Advances in these areas hold the potential for significantly improving outcomes in disease management.

Introduction: Resistance to the antibiotics used to treat Helicobacter pylori (H. pylori) has risen to alarming levels worldwide emphasizing the need to reconsider the approach to therapy generally and to reconsider whether to continue use of many previously highly effective treatment regimens.

Areas covered: This review covers current aspects management of the response to the effects of antimicrobial resistance on H. pylori therapy.

Expert opinion: The prevalence of antimicrobial resistance to H. pylori is increasing and must now be integrated into management of the infection. Bacterial factors responsible for resistance include mutations, efflux pumps, and biofilm formation. Societal factors include overuse and misuse of antibiotics, including in the therapy of H. pylori infections. H. pylori infections should be managed as an infectious disease based on the principles of antimicrobial stewardship which should be incorporated into ongoing community-based and hospital programs of antibiotic stewardship to provide up-to-date advice regarding susceptibility and locally optimized best treatment practices (i.e. advice on which drugs, doses, formulation, frequency of administration, etc. The infection would best be managed in concert with infectious disease especially in asymptomatic patients. Gastroenterology's input remains critical for management of complications of the infection such as peptic ulcer disease.

Introduction: Gastroesophageal reflux disease (GERD) is a frequent digestive disorder that presents with a broad spectrum of symptoms. Global consensus on which patients should be selected for anti-reflux surgery is lacking.

Areas covered: This evidence-based review will analyze current indications for anti-reflux surgery, outcomes of the operation, and potential side effects.

Expert commentary: Treatment of GERD has three main purposes: control symptoms, improve quality of life, and prevent potential serious complications such as bleeding, esophageal stenosis, Barrett's esophagus, and esophageal adenocarcinoma. Although medical therapy is effective in the majority of patients, some might require anti-reflux surgery in order to achieve these goals. Adequate patient selection for anti-reflux surgery is critical to obtain optimal outcomes. Most patients undergoing a fundoplication have adequate long-term symptomatic relief. However, potential side effects of anti-reflux surgery should also be discussed with patients to help manage expectations from the operation.

Introduction: Senescent cells are characterized by replicative arrest and phenotypes that produce diverse pro-inflammatory and pro-oxidant mediators. The senescence of diverse hepatic cell types could constitute an unrecognized pathogenic mechanism and prognostic determinant in autoimmune hepatitis. The impact of cellular senescence in autoimmune hepatitis is unknown, and it may suggest adjunctive management strategies.

Areas covered: This review describes the molecular mechanisms of cellular senescence, indicates its diagnostic features, suggests its consequences, presents possible therapeutic interventions, and encourages investigations of its pathogenic role and management in autoimmune hepatitis. Treatment prospects include elimination or reversal of senescent cells, generation of ectopic telomerase, reactivation of dormant telomerase, neutralization of specific pro-inflammatory secretory products, and mitigation of the effects of mitochondrial dysfunction.

Expert opinion: The occurrence, nature, and consequences of cellular senescence in autoimmune hepatitis must be determined. The senescence of diverse hepatic cell types could affect the outcome of autoimmune hepatitis by impairing hepatic regeneration, intensifying liver inflammation, and worsening hepatic fibrosis. Cellular senescence could contribute to suboptimal responses during conventional glucocorticoid-based therapy. Interventions that target specific pro-inflammatory products of the senescent phenotype or selectively promote apoptosis of senescent cells may be preferred adjunctive treatments for autoimmune hepatitis depending on the cancer risk.

Introduction: Advancements in scintigraphic gastrointestinal motility testing that were developed, validated, and replicated in clinical practice at Mayo Clinic have significantly enhanced our understanding and management of gastrointestinal motility disorders. Importantly, normative values in at least 100 healthy controls and estimated inter- and intra-individual coefficient of variation for all parameters have been published for these tests.

Areas covered: This article reviews methodology, accuracy, reproducibility, and diagnostic cutoffs of scintigraphic techniques for measuring gastric emptying, gastric accommodation, and colonic transit, comparing methods from Mayo Clinic with those used elsewhere when appropriate. The review used PubMed and Google Scholar from inception to August 2024, utilizing relevant keywords.

Expert opinion: In our view, scintigraphic testing with high standards of validation, reproducibility, and robust normal control data is required, including the choice of the composition of the meal for gastric emptying of solids. The utility of the distribution of isotope in the proximal and distal stomach as a measurement of accommodation, a vegan meal for gastric emptying measurement, and the use of orally administered radiolabeled liquid to measure colonic transit are promising methods requiring further validation. It is necessary for organizations to develop guidelines on optimizing scintigraphic gut motility measurement.