Expert Review of Gastroenterology & Hepatology最新文献

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.

Introduction: Functional gastrointestinal disorders (FGIDs) and inflammatory bowel diseases (IBD) present significant challenges for both pediatric and adult populations. The low FODMAP diet (LFD) has gained prominence as an evidence-based dietary intervention, offering symptom relief for abdominal pain, bloating, and altered bowel habits. However, concerns about adherence, nutritional adequacy, and long-term safety remain critical, particularly in pediatric populations.

Areas cered: This narrative review examines the nature and physiological impact of FODMAPs, focusing on the practical application of the low-FODMAP diet (LFD) in adults and pediatric gastroenterology. Particular attention is given to emerging insights into its impact on gut microbiota and long-term safety.

Expert opinion: While LFD effectively alleviates symptoms in FGIDs and functional symptoms in IBD, its restrictive nature demands professional supervision to mitigate nutritional risks. For pediatric patients, adherence and reintroduction protocols require optimization. Further research into personalized dietary approaches and microbiome-targeted strategies could enhance the clinical utility of the LFD, ensuring its long-term safety and efficacy for diverse patient groups.

Plain language summary: Many people, both children and adults, experience stomach and bowel problems like pain, bloating, and changes in bowel habits. These symptoms are common in conditions such as functional gastrointestinal disorders (FGIDs). One dietary approach, called the low FODMAP diet (LFD), has been shown to help reduce these symptoms. The diet limits certain types of carbohydrates, called FODMAPs, which are found in foods like some fruits, vegetables, dairy products, and grains. These carbohydrates can ferment in the gut, causing discomfort in some people.This review looks at how the LFD works, its effectiveness, and its safety. Research shows that the diet can reduce symptoms for many people, particularly those with FGIDs, and it can also help people with IBD who experience additional gut symptoms even when their disease is not active. However, the LFD is a restrictive diet, which means it may be hard to follow and could lead to nutritional issues, especially in children, without professional support.The review also explores how the LFD affects gut bacteria, as the diet can reduce some beneficial bacteria. To make the diet more practical, researchers recommend working with dietitians to ensure it is followed safely and effectively. More studies are needed to understand the long-term impact of the LFD and how it can be adapted to different people's needs.This summary aims to explain the benefits and challenges of the LFD, highlighting the importance of professional guidance and further research to improve its use.

Background: A laparoscopic ileocolic resection could lead to a better outcome to infliximab for ileocolic Crohn's disease. The aim of this study was to explore real world clinical outcomes in biologic-naïve patients with ileocolic Crohn's disease.

Research design and methods: All patients with ileocolic Crohn's disease treated at our institution between January 2011 and December 2018 with biologics or surgical resection were included.

Results: Overall, 222 patients were included, of which 149 (67%) underwent surgery before biologic therapy. Among these, 54 patients (36%) required post-operative biologic therapy. Seventy-three patients were treated with biologics first, of which 29 (40%) subsequently required a surgical resection (p = 0.60). There were 95 patients (43%) who were successfully treated with a surgery-first approach alone. Median follow-up was 73 months (0-406). Characteristics associated on multivariable analysis with change from surgery to biologics were: gender (female) (p = 0.010), presence of obstructive symptoms (p = 0.028), and smoking (p = 0.030). Characteristics associated with changing from biologics to surgery were: isolated terminal ileum disease (p = 0.001) and the presence of obstructive symptoms (p = 0.003).

Conclusions: In our cohort, the risk of recurrent ileocolic Crohn's disease was similar whether patients were treated with a 'surgery first' or 'biologic first' approach.

Introduction: Subepithelial lesions (SELs) of the upper gastrointestinal tract are commonly encountered during endoscopic evaluations and pose a diagnostic challenge due to their origin from deeper layers of the gastrointestinal wall. Accurate diagnosis is essential, as some SELs have malignant potential.

Areas covered: This review presents a comprehensive, structured approach to the evaluation and management of upper gastrointestinal SELs. Key features of common SELs - including gastrointestinal stromal tumors (GISTs), neuroendocrine tumors (NETs), and benign lesions like lipomas and leiomyomas - are discussed. Emphasis is placed on the utility of endoscopic ultrasound (EUS) for lesion characterization and tissue acquisition. Literature was identified through a MEDLINE search up to December 2024, with inclusion of major society guidelines and studies relevant to diagnostic methods and clinical features.

Expert opinion: EUS, particularly with tissue sampling, has revolutionized SEL evaluation, allowing earlier diagnosis and risk stratification. Future advancements, including artificial intelligence, molecular diagnostics, and improved resection and biopsy techniques, are poised to enhance precision, accessibility, and outcomes in SEL management.

Introduction: Surgical bypass, the traditional approach for managing gastric outlet obstruction (GOO), is effective but associated with increased morbidity and short-term complications. Enteral self-expanding metal stents (SEMS) provide a safe, effective, and minimally invasive alternative to surgical bypass, though they carry an increased risk of re-interventions due to stent blockage. Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a recently developed, novel minimally invasive procedure that serves as an alternative to enteral SEMS placement.

Areas covered: We performed an electronic search in PubMed and included all the types of articles on EUS-GJ written in English language till February 2025. This review discusses both the technical details and outcomes of EUS-GJ.

Expert opinion: EUS-GJ involves creating an anastomosis between the stomach and the small intestine using a lumen-apposing metal stent (LAMS). There are three basic techniques for performing EUS-GJ: the direct technique, the balloon-assisted technique, and the EPASS (EUS-guided double-balloon-occluded gastrojejunostomy bypass) technique. Among these, the free-hand direct approach is the most widely used due to its shorter procedure time and comparable technical outcomes to the other two techniques. Stent misdeployment is the most dreaded complication of EUS-GJ; however, fortunately, the majority of misdeployments can be successfully managed through rescue endoscopic methods.

Introduction: Postoperative recurrence of Crohn's disease after surgery remains common. The aim of this article is to present a comprehensive review of recent advancements in postoperative prognostication, surveillance, and the therapeutic prophylaxis.

Areas covered: Reduction in postoperative recurrence risk is a multifactorial process requiring risk stratification, prophylactic therapeutics, and postoperative monitoring. Recent studies have explored the clinical utility of risk stratification paradigms. There are many ongoing trials including SOPRANO-CD which aims to evaluate and compare postoperative medical prophylaxis to endoscopy-driven management and POMEROL to determine optimal management strategy for moderate endoscopic disease activity. Postoperative disease activity monitoring including intestinal ultrasound, fecal calprotectin, and cross-sectional enterography offer a cost-effective and noninvasive alternative to ileocolonoscopy with new guideline recommendations for fecal calprotectin in the postoperative period. Data is emerging on outcomes between postoperative prophylactic versus endoscopy driven management algorithms. Tissue transcriptomics and serum proteomics provide a noninvasive surrogate measure of disease activity by detecting biomarkers of inflammation.

Expert opinion: Through the advancements in risk stratification, monitoring modalities and algorithms, and postoperative therapeutics, there is reduction in the rate of postoperative Crohn's recurrence.

Introduction: Functional dyspepsia (FD) and irritable bowel syndrome (IBS) are the most prevalent disorders of gut-brain interaction (DGBI), frequently overlapping and associated with complex pathophysiological mechanisms. Increasing evidence implicates gut microbiota alterations in driving symptoms via immune activation, altered motility, gut vascular barrier and gut-brain axis disruption.

Areas covered: This review explores the role of gut microbiota in FD and IBS pathogenesis and symptomatology. A comprehensive literature search was conducted using PubMed, EMBASE, and Google Scholar databases, including studies published between January 2013 and March 2025. Particular focus is given to microbiota-targeted therapies such as prebiotics, probiotics, synbiotics, postbiotics, and fecal microbiota transplantation (FMT). The review also discusses multidimensional treatment strategies combining dietary and lifestyle modification, cognitive-behavioral therapy, and pharmacological neuromodulation. Recent advances in diagnostic methods, including capsule-based microbiota sampling and digital tools for remote psychogastroenterology care, are highlighted.

Expert opinion: Despite scientific progress, current DGBI management remains insufficiently personalized. Future approaches should integrate individualized microbiota profiling with targeted interventions and utilize innovative diagnostic and digital health technologies to enhance clinical outcomes in FD and IBS.