Current Opinion in Gastroenterology最新文献

Purpose of review: Interest in the esophageal microbiome has expanded rapidly, yet its functional and clinical relevance remains incompletely defined. This review synthesizes emerging evidence on host-microbe interactions in esophageal diseases, with a focus on mechanistic pathways and translational potential.

Recent findings: Recent studies demonstrate that esophageal microbes influence epithelial differentiation, barrier integrity, and inflammatory signaling in conditions such as eosinophilic esophagitis and Barrett's esophagus. Microbial metabolism, particularly bile acid transformation, links microbial composition to epithelial stress responses and neoplastic progression. In esophageal cancer, tumor-associated microbes modulate epigenetic regulation and suppress antitumor immunity. Integrative multiomics approaches have further identified microbial signatures associated with disease progression and treatment response.

Summary: The esophageal microbiome influences disease pathogenesis and has potential for risk stratification and therapeutic targeting. Future progress will depend on longitudinal studies, improved functional resolution, and integration of microbial data with epithelial and immune biology to enable clinical translation.

Purpose of review: This review summarizes recent evidence on the use of glucagon-like peptide-1 (GLP-1) and glucagon-like peptide-2 (GLP-2) agonists in the management of short bowel syndrome (SBS), with a focus on emerging therapies and real-world experience. It evaluates their impact on intestinal adaptation, safety, and future clinical potential.

Recent findings: GLP-2 agonists such as teduglutide continue to demonstrate improvements in intestinal absorption resulting in reductions in parenteral support (PS) requirements and improved quality of life. Clinical trials report that newer long-acting agents, such as apraglutide and glepaglutide, allow less frequent dosing with a reduction in PS and structural intestinal changes on imaging. Safety profiles remain favourable, with gastrointestinal symptoms, fluid balance issues, gallbladder events and injection-site reactions reported most frequently. GLP-1 agonists show promise in slowing transit time and offer an area for further research.

Summary: While GLP-2 agonists shape the current landscape of SBS management, GLP-1 based therapies may complement future treatment strategies offering the potential to reduce or even eliminate dependence on PS. Continued long-term studies and registry data are essential to optimize patient selection, safety monitoring, and personalized use of GLP agonists.

Purpose of review: Despite significant progress in evidence-based therapies and models of care, hepatology continues to face challenges in translating proven interventions into routine clinical practice. Variability in adoption has contributed to ongoing gaps in quality, outcomes, and equity of care across diverse settings. Implementation science offers a systematic approach to understanding and improving how evidence-based interventions are delivered, adapted, and sustained in real-world environments. This review provides an overview of implementation science and discusses its increasing importance for advancing hepatology research and practice.

Recent findings: Recent studies in hepatology have applied implementation science frameworks to better understand why effective interventions fail to reach patients and how those barriers can be addressed. Work in areas such as viral hepatitis elimination, cirrhosis management, palliative care integration, hepatocellular cancer surveillance, and alcohol use disorder treatment illustrates the value of focusing on context, stakeholder engagement, and strategy selection. These studies commonly use established frameworks, pragmatic trial designs, and mixed methods to assess outcomes such as adoption, fidelity, and sustainability alongside clinical impact.

Summary: Implementation science offers a practical bridge between discovery and routine care in hepatology. Integrating implementation principles into research, quality improvement initiatives, and trainee education can accelerate the translation of evidence into practice, reduce unwarranted variation in care, and promote more equitable delivery of liver-related services.

Purpose of review: Immune-related enteropathies (IREs) represent a heterogeneous group of disorders characterised by immune-mediated small bowel injury. While coeliac disease is the most common cause, widespread use of small bowel endoscopy has expanded the recognition of rarer causes. This review aims to summarise recent advances in diagnosis, classification and management of IRE.

Recent findings: Significant overlap exists between coeliac disease, autoimmune enteropathy, collagenous sprue, drug-induced enteropathies, common variable immunodeficiency (CVID) associated enteropathy and other IRE. A recent meta-analysis supports a no-biopsy approach in selected adults with significantly elevated IgA tissue transglutaminase levels and suspected coeliac disease. Refractory coeliac disease type II is now recognised as a low-grade intraepithelial T-cell lymphoma with a high risk of progression to enteropathy-associated T-cell lymphoma (EATL). Drug-induced enteropathies, particularly olmesartan-associated enteropathy, are increasingly detected and may mimic autoimmune enteropathy histologically. Novel therapeutic approaches, including cladribine, JAK inhibitors and biologics, have shown promise in refractory disease, although evidence is limited to small studies.

Summary: IREs present substantial diagnostic and therapeutic challenges due to overlapping characteristics and variable disease course. A structured approach integrating clinical, serological and histopathological data is essential for accurate diagnosis. Early recognition and tailored management are crucial to prevent long-term complications.

Purpose of review: Acute liver failure is a life-threatening condition that requires intensive medical management or liver transplant for survival. Plasma exchange has been investigated as a supportive intervention to provide a bridge to hepatic recovery or to liver transplant. This review aims to explain the physiologic rationale, provide historical context, and review recent evidence on the use of plasma exchange in acute liver failure.

Recent findings: Recent studies paint a mixed picture of plasma exchange's role in the current armamentarium for the management of acute liver failure. Although multiple meta-analyses have shown a survival benefit from plasma exchange, the results from original studies published in the interim are less consistent, with some showing a survival benefit and others not. Further, the literature on this topic is quite heterogeneous with respect to baseline patient characteristics, etiologies of acute liver failure, the dose of plasma exchange administered, and the outcomes assessed. The takeaways and limitations of recent evidence will be discussed.

Summary: Plasma exchange has a clear physiologic basis for use in acute liver failure, and multiple prospective studies have shown its ability to improve survival. The effectiveness of plasma exchange, however, depends on appropriate patient selection and timely initiation.

Purpose of review: Pancreatic exocrine insufficiency (PEI) has long been associated with intrinsic pancreatic disease, yet emerging evidence shows it is under-recognized in patients with nonspecific gastrointestinal symptoms. This review summarizes prevalence data, evaluates the performance and utility of faecal elastase-1 (FE-1), highlights the co-existence of PEI with other luminal conditions, and explores the presence of early pancreatic dysfunction among a subset of patients with irritable bowel syndrome (IBS)-type symptoms. Updates from the 2025 European guidelines are discussed.

Recent findings: Population studies estimate PEI prevalence at 11-21% in unselected gastroenterology cohorts. PEI is reported across coeliac disease, inflammatory bowel disease and functional gastrointestinal disorders, where overlapping symptoms can delay diagnosis. A 2025 meta-analysis of FE-1 performance demonstrated high sensitivity for moderate-severe PEI. Cohort data indicates repeat sampling can clarify borderline results. PEI may be an early marker of pancreatic dysfunction in a subset of patients with IBS-type symptoms. Identifying this group may offer opportunities for lifestyle modification with potential long-term benefit.

Summary: Collectively, these findings expand the relevance of PEI beyond classical pancreatic disease. Broader, proactive FE-1 testing may allow earlier recognition, which might allow intervention at a potentially modifiable stage of pancreatic dysfunction, accepting the limitations of the test.

Purpose of review: This review summarizes the recent developments of one of the most controversial entities in hepatology, variant syndromes of primary biliary cholangitis (PBC) with characteristics of autoimmune hepatitis (AIH).

Recent findings: Recently a consensus process was initiated to find agreement on the terminology, diagnostic criteria and treatment recommendations for patients with PBC-AIH variant syndromes. The concept and terminology of a variant syndrome, with one component of either AIH or PBC dominating over the other, is currently preferred. No single test can establish the diagnosis of a variant syndrome, only a combination of biochemical, serological and/or histological tests can support the diagnosis. If classical PBC is dominating, histology is mandatory for the diagnosis of a PBC-AIH variant syndrome. Treatment of PBC-AIH variants is based on a combination of ursodeoxycholic acid and immunosuppression. Since the prognosis of a PBC-AIH variant syndrome seems to be worse than the prognosis of classical PBC, the diagnosis of PBC-AIH must not be missed.

Summary: The recent consensus process on PBC-AIH variant syndromes does not provide answers to all questions regarding this entity. Rather, it serves as a starting point for future studies to confirm or even challenge the current consensus.

Purpose of review: Autoimmune hepatitis (AIH) presenting with decompensated cirrhosis poses a major therapeutic dilemma for clinicians. Although the prompt initiation of immunosuppression (IS) can reverse disease activity and lead to the clinical resolution of decompensation, avoiding the need for liver transplantation (LT), it may also be futile or even harmful. International guidelines and cohort studies have begun to address this challenge, making it timely to synthesize available evidence and provide practical guidance for clinicians.

Recent findings: Emerging data highlight that the benefit of IS in AIH-related decompensated cirrhosis is closely related to disease activity, as well as to the type and severity of decompensation. In this context, patients with "burn-out" cirrhosis, advanced hepatic encephalopathy and severely elevated prognostic scores have a low probability to benefit from IS and face a greater risk of developing treatment-related complications. Therefore, international guidelines emphasize individualized decision-making, integrating clinical scores and predictors of treatment benefit, as well as timely evaluation for LT.

Summary: This review summarizes the current evidence and evolving recommendations for managing AIH-related decompensated cirrhosis, providing a structured approach to help clinicians identify candidates for IS and balance treatment decisions to optimize outcomes.