Current Opinion in Gastroenterology最新文献

Purpose of review: To critically evaluate the literature over the past year on microbial therapeutics in the management of disorders of the large intestine. The primary focus is on disorders where the microbiome has been implicated in pathophysiology, and its modulation has been a therapeutic target.

Recent findings: Though widely consumed, data on the impact of probiotics and prebiotics in gastrointestinal disorders continue to pose challenges in interpretation due to shortcomings in study design; postbiotics, meanwhile, because of some logistical and regulatory advantages, are attracting attention. Though time-honored for its role in infections due to Clostridioides difficile (CDI), FMT has encountered challenges in relation to regulation leading to the appearance of highly standardized, extensively screened and rigorously prepared microbial products [defined as live biotherapeutic products (LBP)], which show great promise; two have been approved by the FDA for prevention of recurrent CDI. Outside of CDI, efforts to define a role for FMT in the management of various diseases have met with mixed results.

Summary: The translation of findings in studies of microbiome composition to successful therapies has proven disappointing to date, though attempts to develop selective and targeted microbial consortia show promise and may lead the way to personalized bacteriotherapy.

Purpose of review: Colorectal cancer (CRC) is common and rising among persons under age 50, but screening uptake is sub-optimal, particularly in 45-49 year-olds. Death from CRC can be prevented through detection and removal of advanced precancerous colorectal lesions (APLS) or detection of CRC at an early stage. In this review, we cover average-risk CRC screening options and present a framework for test selection in different clinical settings.

Recent findings: The optimal CRC screening test should be highly sensitive for APLs and early stage CRC, easy to access, affordable to patient and payers, and appropriate for screening settings. Organized screening is administered systematically on the population-level, while opportunistic screening relies on individual provider-patient shared decision making. In addition to established options such as fecal immunochemical testing, multitarget stool DNA testing, and colonoscopy, novel options include stool-based RNA testing, next-generation stool-based DNA testing, and blood-based DNA testing. Although blood-based tests may be convenient, their low sensitivity for APLs can unintentionally lead to negative consequences for CRC prevention.

Summary: Uptake, cost, and efficacy of established and novel CRC screening tests influence the modality of choice for specific screening settings. Colonoscopy and stool-based tests should generally be first-line for CRC screening.

Purpose of review: Malignant colorectal obstruction (MCO) is a common and life-threatening presentation of colorectal cancer, traditionally managed with emergency surgery associated with high morbidity and high stoma rates. Self-expanding metal stents (SEMS) have emerged as an important alternative for both palliation and as a bridge to curative resection. This review summarizes recent advances in indications, technical aspects, and emerging applications of colonic stenting, highlighting its role in modern multidisciplinary care.

Recent findings: Current evidence supports the use of SEMS as one of the first-line palliative approaches in selected patients, providing rapid symptom relief and reducing the need for permanent stomas. In carefully selected patients, colonic SEMS can convert urgent high-risk operations into planned resections, facilitating minimally invasive approaches, though concerns remain regarding perforation risk and long-term oncologic outcomes. Increasing operator expertise, device innovation, and technical advances continue to improve safety and success rates. Beyond malignancy, expanding applications include refractory benign strictures, diverticular obstruction, and the use of lumen-apposing metal stents (LAMS) in inflammatory bowel disease and anastomotic complications.

Summary: Colonic stenting has emerged as a valuable alternative to surgery for the management of MCO and is being investigated in select benign conditions, though broader adoption requires further evidence. Future research should refine patient selection, compare stenting with surgical alternatives, and clarify long-term outcomes.

Purpose of review: Irritable bowel syndrome (IBS) has a considerable impact on patients and healthcare systems. IBS is a disorder of brain-gut interaction with numerous biopsychosocial factors involved, including early life experiences, previous gastrointestinal infections, and coexisting mood disorders. An understanding of the role of the gut-brain axis in symptom generation is vital to enable delivery of holistic care.

Recent findings: We explore psychological mechanisms, such as coexisting anxiety and depression, adverse life experiences, and somatisation and how these impact symptom severity. There is evidence for psychological therapies, such as cognitive behavioural therapy or gut-directed hypnotherapy, in IBS. We go on to summarise gut-based mechanisms, such as abnormal motility, visceral hypersensitivity, inflammation, and dysbiosis. Efficacious treatments targeting these include antidiarrhoeals, laxatives, antispasmodics, drugs acting on ion channels or serotonin, gut-brain neuromodulators, and treatments targeting the microbiota or inflammation. Finally, we consider emerging evidence from models describing distinct IBS phenotypes and their potential to facilitate a more integrated approach to identify best treatment options.

Summary: For many patients with IBS, both brain and gut mechanisms must be considered within the context of the biopsychosocial model to enable effective delivery of holistic and personalised care.

Purpose of review: Chronic constipation remains challenging to manage, particularly when lifestyle measures prove insufficient. With an expanding range of pharmacologic options available, clinicians face the task of choosing the right agent for the right patient. This review explores recent developments in prescription laxatives and their evolving role in practice.

Recent findings: Randomized controlled trials have confirmed the safety and efficacy of newer prescription laxative agents including secretagogues (linaclotide, lubiprostone, plecanatide), sodium/hydrogen exchanger isoform 3 (NHE3) inhibitors (tenapanor), serotonin 5-hydroxytryptamine receptor agonists (prucalopride), and bile acid reabsorption inhibitors (elobixibat). Each drug offers its own unique advantages, with new evidence suggesting these therapies may provide symptom relief beyond managing stool consistency alone.

Summary: Patients with constipation now have access to a wide range of medications, from over-the-counter osmotic and stimulant agents to prescription laxative combination strategies. This breadth allows clinicians to tailor therapy to diverse pathophysiology and symptom profiles. Yet despite this choice, real-world adherence remains poor and many patients are dissatisfied, reflecting the complexity of treating constipation and frequent mismatches between therapy and patients' most bothersome symptoms. Management should emphasize careful symptom assessment, shared decision-making, and clear expectation setting, while leveraging the available armamentarium.

Purpose of review: The field of inflammatory bowel disease (IBD) continues to evolve at an unprecedented rate as the past decades have borne witness to the complete transformation of our approach to IBD and its care. Despite that, we continue to face major challenges, including rising incidence, shifting demographics, financial toxicity, as well as a frequently encountered therapeutic ceiling. This review aims to highlight the main factors driving the shifting landscape of IBD therapy.

Recent findings: Many steps are being taken to improve efficacy and raise the therapeutic ceiling. Mounting evidence from clinical trials suggests that the use of various dual advanced therapies is well tolerated and may increase overall efficacy. Novel therapeutic mechanisms are being explored, including various novel oral agents as well as antihuman tumor necrosis factor-like cytokine A (anti-TL1A) antibodies with their novel antifibrotic potential. Delivery of care is also being optimized and refined with greater emphasis on early diagnosis, early effective therapy, treating to target and monitoring objective outcomes, therapeutic drug monitoring, and more effective use of current therapies. Greater recognition of the impact of IBD on patients beyond the disease itself is driving the spread of a patient-centric, multidisciplinary team-based approach to IBD care.

Summary: As we continue to refine and deepen our understanding of IBD, the landscape of IBD therapy continues to shift and evolve as it aims to meet the needs of IBD patients with hope for brighter days ahead.

Purpose of review: Endoscopic resection is now the standard of care for the management of colorectal polyps. With increased training and expertise in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), it is important to recognize their complementary roles, as well as their individual strengths and limitations.

Recent findings: Here, we draw upon the experience of a real patient scenario to provide a case-based review on EMR and ESD. We will review evidence-based technical refinements to EMR which have improved procedural safety and decreased recurrence rates, as well as how expanded access to ESD and enhanced training has resulted in improvements in outcomes and adverse events. Finally, we will discuss how lesion, patient, and endoscopist factors influence the overall endoscopic resection strategy.

Summary: EMR and ESD are complementary tools in the modern endoscopic resection toolkit, and the correct resection strategy draws upon a deep understanding of the tools available and is individualized based upon patient, endoscopist, and lesion characteristics.

Purpose of review: Kupffer cells (KCs), the resident liver macrophages, are absolutely critical in immune surveillance and intravascular pathogen eradication. This mini-review highlights KCs' contributions to host protection of intravascular infections.

Recent findings: KCs, uniquely originated and self-renewing, demonstrate remarkable functional plasticity and trained immunity. KCs are frontline responders in infections: they phagocytose microorganisms but can succumb to certain infections. We highlight some of the recent findings in this regard.

Summary: Understanding KCs' complex interactions with diverse pathogens is key to improving treatment modalities in infection. Future research, needs to focus on how certain pathogens evade KCs and how we can aid these macrophages in eradicating microbes. A move towards humanized KC models in vivo and in vitro incorporating key environmental factors such as shear flow and unique sinusoidal components will be essential to unravel their comprehensive roles.

Purpose of review: We review and summarize current evidence-based management strategies in the field of endobariatrics (EBT) for the management of obesity during a time of rapidly expanding pharmacologic options, particularly with rising popularity of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs).

Recent findings: National trends show increased use of GLP-1 RAs in obesity management. EBT are minimally invasive endoscopic therapies that offer durable weight loss with low complications rates. Patient comorbidities, socioeconomic factors, and adherence are critical considerations in treatment selection. Emerging data suggest that combining GLP-1 RAs with EBTs may yield synergistic effects.

Summary: A growing array of treatment options are available in the management of obesity. Personalized, combination therapy that integrates mechanism-based interventions with pharmacotherapy may optimize long-term outcomes for sustained weight loss. Multidisciplinary approach remains essential for delivering comprehensive multidisciplinary care.