Expert Review of Gastroenterology & Hepatology最新文献

Introduction: Gut microbiota plays a crucial role in the treatment outcomes of inflammatory bowel disease (IBD). Evidence suggested a bidirectional interaction between gut microbiota and medical treatments, in which drugs modulate microbial composition, while microbiota, in turn, impact drug metabolism. This influences the effectiveness of therapy and leads to individual variations in treatment responses, opening the door to personalized medicine in IBD management.

Area covered: This review summarizes how various therapeutic agents - including aminosalicylates, corticosteroids, immunomodulators, and newer drug classes such as biologics and small molecules - modulate gut microbiota and how gut microbiota conversely impact their pharmacological effects. The clinical outcome of microbiota to medical treatment is also discussed. PubMed/Medline databases were used in the search for the pre- and post-therapeutic results of microbiota-IBD drug interactions, covering publications from January 2000 to March 2025.

Expert opinion: Drug-microbiota interactions are crucial in personalized medicine. Nevertheless, therapeutic strategies for modulating the interaction of microbiota and the drugs remain largely unexplored. In addition, clinical applications of microbiota profiling are restricted by technical challenges and inter-individual variability. Future integration of microbiome sequencing in clinical practice combined with advanced analytics is fundamental for a more thorough identification of diagnostic markers and optimizing therapeutic strategies for IBD patients.

Introduction: Fluoroscopy-guided procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), gastrointestinal stenting, balloon-assisted enteroscopy (BAE), and tube placement, are essential in gastroenterology. However, radiation exposure poses risks to patients and clinicians. Many gastroenterologists receive limited training in radiation safety, underscoring the need for increased awareness of radiation and dose management strategies.

Areas covered: This review discusses safety and dose optimization strategies for fluoroscopy-guided procedures. Radiation exposure in different procedures, imaging techniques, and methods for minimizing radiation doses are reviewed. International guidelines, including those from the American Society for Gastrointestinal Endoscopy (ASGE), the European Society of Gastrointestinal Endoscopy (ESGE), and Japan's Diagnostic Reference Levels (DRLs), are reviewed. Recommendations, including reducing fluoroscopy durations, performing pulsed fluoroscopy, optimizing collimation, and implementing appropriate shielding measures, are provided. The importance of structured radiation safety education for gastroenterologists is emphasized. Relevant literature was identified through a manual PubMed search.

Expert opinion: Increasing radiation safety in gastrointestinal fluoroscopy requires education, technology, and adherence to guidelines. Establishing procedure- and facility-specific DRLs can help standardize dose management. Further research and global collaboration are needed to refine safety protocols. Integrating these strategies into routine practice will significantly reduce radiation exposure, improving safety for patients and clinicians.

Introduction: Inflammatory bowel disease (IBD) is a life-long illness that is increasing in prevalence and incidence, disproportionately among young adults. The diagnosis often coincides with emerging adulthood, a critical developmental stage when young adults face formative life changes such as independent living, finalization of education and career path, redefining relationships with parents, the pursuit of romantic relationships, marriage, and parenthood. A diagnosis of IBD during emerging adulthood can have significant impacts on these domains.

Areas covered: Current research supports incorporating comprehensive psychosocial care for emerging adults dealing with IBD. These dimensions include the mental health needs of patients, the social needs and barriers of living with IBD, the impact chronic illness has on intimate relationships and family planning, and the impact on career and finances. Literature search was conducted using online databases including PubMed, Google Scholar, and OpenEvidence.

Expert review: By addressing the psychosocial needs of IBD patients, healthcare providers can empower emerging adults to navigate the challenges of chronic illness and achieve personal and professional fulfillment. Review of published literature demonstrates that comprehensive, compassionate care during this vulnerable period can improve patient outcomes, resilience, and quality of life, enabling young adults with IBD to lead successful and meaningful lives.

Introduction: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly gaining relevance both as a public health issue and a clinical challenge. The development of portal hypertension in MASLD challenges traditional paradigm that it arises only in the context of cirrhosis.

Areas covered: This review explores the understanding of portal hypertension in MASLD, addressing recent advances in pathophysiology, diagnosis, and potential therapeutic approaches. Particular attention is given to studies that highlight non-cirrhotic contributors to increased portal pressure. Pathogenic mechanisms, as well as advances in noninvasive diagnostic tools are discussed, focusing on their utility in identifying early hemodynamic changes and stratifying the risk of clinical complications. A comprehensive literature search was conducted using PubMed and major databases, including studies published up to April 2025.

Expert opinion: The future of MASLD management lies in early detection, improved noninvasive risk stratification, and personalized treatment strategies. Advances in technology and artificial intelligence will likely enhance diagnostic precision while ongoing research into molecular mechanisms and portal hypertension may enable earlier and effective therapeutic interventions.

Introduction: In the metabolic dysfunction-associated steatotic liver disease (MASLD) scenario, more and more evidence has emerged indicating that MASLD patients can develop portal hypertension (PH), which has a direct impact on the prognosis of the disease and represents a significant challenge during the clinical approach.

Areas covered: There are different explanations for early PH pathophysiology in patients with MASLD, among which are dysbiosis, microthrombosis, impairments in inflammatory mediators, sinusoid-level alterations in the liver architecture, genetic factors, and so on. Currently, we have evidence in animal models and humans demonstrating that all these factors could be modulated or modified; unfortunately, we are far from translating these results into clinical scenarios. The early PH phenomenon only occurs in 20% patients with MASLD. This review aims to describe the current evidence from the pathophysiological and treatment point of view, as well as the implications in the clinical care of patients with MASLD presenting early PH.

Expert opinion: Although the presence of PH in these patients has a significant clinical impact, the traditional diagnostic approach may not be the best option; other diagnostic tools have been studied, and perhaps, at some point, they can be added to the treatment algorithms of these patients.

Introduction: Belching, bloating, and flatulence are common complaints that significantly affect quality of life. Although these often arise from benign functional disorders, their underlying mechanisms are multifactorial, involving disordered motility, visceral hypersensitivity, and psychological influences.

Areas covered: A selective literature search was conducted across electronic databases (PubMed, MEDLINE, Embase, and Cochrane Library) to identify relevant publications on intestinal gas related symptoms. Randomized controlled trials, meta-analyses, systematic reviews, evidence-based clinical practice guidelines and selected expert consensus statements and narrative reviews were included.This narrative review highlights common diagnostic and therapeutic pitfalls in managing gas-related symptoms, including failure to recognize alarm features, misclassifying symptoms, excessive investigations, and inappropriate treatment choices. It discusses intestinal gas's physiological basis, challenges distinguishing pathological from normal symptoms, and provides a framework for evidence-based evaluation and treatment.

Expert opinion: Effective management requires a structured, individualized approach incorporating thorough clinical assessment, dietary evaluation, psychological screening, and judicious use of noninvasive tests. Neglect of psychosocial contributors often lead to suboptimal care. Personalised strategies such as breath testing, low FODMAP diet, microbiota-targeted therapies, and cognitive-behavioral interventions can improve outcomes. Enhancing clinician education and fostering interdisciplinary collaboration is essential to bridging the gap between current evidence and clinical practice.

Introduction: Tumor Necrosis Factor α (TNF) is a significant systemic inflammatory cytokine in several immune-mediated inflammatory diseases (IMIDs) including inflammatory bowel disease (IBD, Crohn's disease (CD), and ulcerative colitis) and was the first target approved for biologic therapy in IBD.

Areas covered: This article reviews the efficacy and safety of antiTNF agents for the treatment of CD including specific conditions (e.g. perianal fistula, prevention of post-operative recurrence), and practical approaches to managing antiTNF therapy (e.g. combination with immunosuppressants, early introduction of antiTNF treatment, and therapeutic drug monitoring (TDM)). This review is based on data from randomized controlled trials, real-world evidences and comparative studies gathered over the past 25 years.

Expert opinion: Anti-TNF agents have revolutionized treatment of IBD and other IMIDs. Early introduction of treatment, concurrent use of immunomodulators, and TDM are associated with improved clinical outcomes. Anti-TNF agents are preferred for subpopulations of CD including patients with perianal CD, extraintestinal manifestations, and postoperative prevention of CD. Biosimilars have increased access to anti-TNF agents and lowered overall costs. Future studies are needed to determine which agents are most likely to be efficacious and safe for subpopulations with CD.

Introduction: Diverticulitis is the most common complication related to the diverticulosis of the colon. Since there are some concerns about the management of complicated diverticulitis, the aim of this review was to analyze current medical and surgical approaches to complicated diverticulitis and evolving advances in its management.

Area covered: An analysis of the current PubMed literature about the medical and surgical management of complicated diverticulitis was performed.

Expert opinion: Attentive evaluation of the characteristics of complicated diverticulitis may make the difference when approaching its management: detection of large abscesses, or perforation with significant free air in the abdomen remain typical predictors of failed medical management, therefore often requiring surgery. However, recent data support the medical approach as first choice in managing small abscesses or small perforation with small bubble of free air in the abdomen. Further studies have to point out better the evolution of the medical approach also in patients with complicated diverticulitis.