Current Opinion in Gastroenterology最新文献

Purpose of review: Crohn's disease is a chronic, relapsing and remitting inflammatory process that can involve the entire length of the gastrointestinal tract. Upper gastrointestinal involvement (UGI) in Crohn's disease is present in up to 15% of patients and can present as a diagnostic challenge given nonspecific symptoms and overlapping disease entities. This review provides an update on diagnosing and risk stratifying UGI-CD.

Recent findings: Literature suggests the use of imaging modalities (such as video capsule endoscopy, cross-sectional imaging and intestinal ultrasound) to help identify proximal inflammation when clinical suspicion for UGI involvement exists based on symptoms and patient factors. Additionally, proximal disease involvement has been associated with increased disease severity, a higher prevalence of strictures and an increased risk for surgery. First-line therapies are corticosteroids and antitumor necrosis factor therapies if systemic treatment is needed based on disease severity. For stricturing disease, endoscopic balloon dilation, strictureplasty, surgical resection or bypass can be considered for medically refractory or recurrent disease.

Summary: As the prevalence and progression of UGI-CD is still understudied due to its variable definition, presentation and incidence, the development of a standardized approach to diagnosis could aid in determining the overall prevalence and most effective treatments.

Purpose of review: The aim of this review is to summarize the most pertinent data on management of malignant gastric outlet obstruction (MGOO), with an emphasis on recent updates.

Recent findings: Traditionally, options to restore luminal patency in patients with MGOO were surgical gastrojejunostomy (SGJ) and endoscopic insertion of an enteral stent. The latter was reserved for patients with poor performance status or anticipated survival less than 2 months. Endoscopic gastroenterostomy (EUS-GE) is a newer technique that aims to mimic a SGJ and involves placement of a lumen apposing metal stent (LAMS) from the stomach directly into the jejunum. In a recent randomized trial of EUS-GE vs. enteral stent, the former was associated with reduced re-interventions, improved stent patency, and improved patient reported eating habits. Recent publications suggest that EUS-GE may offer substantial advantages over S-GJ; a randomized trial is currently underway. Venting gastrostomy may be the most suitable option for patients with markedly impaired gastric motility or with multiple luminal obstructions.

Summary: MGOO is a debilitating late complication of advanced upper gastrointestinal malignancies, resulting from blockage or mechanical compression of the distal stomach, pyloric antrum or duodenum. Various modalities are currently available, and should be tailored to patient's expectations, underlying cause, life expectancy, and functional status.

Purpose of review: Small intestinal bacterial overgrowth (SIBO) has been a recognized condition for more than half a century. Early descriptions of SIBO were based on the concept of colonic bacteria "backing up" into the small intestine. This was based on techniques using unprotected aspiration catheters and earlier culture techniques. Recent advances in breath testing, small bowel sampling, culture techniques, and next generation sequencing have helped expand our understanding of SIBO.

Recent findings: "SIBO" is now understood to encompass at least three different types of overgrowth including SIBO, intestinal methanogen overgrowth (IMO) and intestinal sulfide overproduction (ISO). Each has their own unique microbial profile. In addition, next generation sequencing has revealed that SIBO is not a migration of colonic flora into the small intestine, but rather overgrowth of two predominant species/strains from phylum Proteobacteria ( Escherichia coli and Klebsiella ). Lastly, results from next generation sequencing of the stool and small intestinal microbiomes have validated breath testing as a diagnostic tool.

Summary: Together, these advances have allowed the identification of key microbes in overgrowth syndromes, uncovering their relationships to conditions such as irritable bowel syndrome, and paving the way for the development of novel customized treatment options in the future.

Purpose of review: Acid suppression is the mainstay of management of common foregut disorders, including gastroesophageal reflux disease (GERD), peptic ulcer disease and Helicobacter pylori infection. Drawbacks of standard management with proton pump inhibitors (PPIs) include acid lability requiring enteric coating, slow onset of effect, lack of suppression of nocturnal acid breakthrough, and need for administration before meals.

Recent findings: Potassium-competitive acid blockers (PCABs) are a novel class of acid suppressants that are effective in the management of symptomatic and erosive GERD, peptic ulcer disease and H. pylori infection. Administration before meals is not needed, and these agents achieve profound acid suppression right from the first dose, with control of daytime as well as nocturnal acid. In randomized controlled trials, PCABs are noninferior and often superior to PPIs, especially in healing of advanced grade esophagitis and eradication of treatment-naive as well as refractory H. pylori. The safety profile of PCABs over 10 years of use is reassuring, although profound acid suppression may contribute to hypergastrinemia and increased risk of gastrointestinal infections.

Summary: As PCABs become available in many countries around the globe, real-world use will allow further research to determine the clinical niche of these acid-suppressive agents.

Purpose of review: To provide an updated overview of the management of nonvariceal upper gastrointestinal bleeding, focusing on recent advancements in endoscopic hemostasis techniques and evidence-based clinical practices.

Recent findings: Recent studies and societal guidance emphasize the importance of early triage, restrictive transfusion strategies, and the integration of risk stratification tools for management of nonvariceal upper gastrointestinal bleeding. Notable advancements in endoscopic modalities for hemostasis include cap-assisted clips, noncontact thermal therapies, and the expansion of available topical hemostatic agents.

Summary: Effective nonvariceal upper gastrointestinal bleeding management requires a multidisciplinary approach that prioritizes early resuscitation, risk assessment, and the use of evolving endoscopic technologies to achieve optimal hemostasis.

Purpose of review: This review explores the evolving landscape of third-space endoscopy (TSE) techniques for the management of gastrointestinal (GI) tumors. With rapid technological advances and accumulating evidence, there is a pressing need to synthesize current knowledge and clarify the comparative utility of approaches like submucosal tunneling endoscopic resection (STER) and tunneling endoscopic submucosal dissection (ESD).

Recent findings: STER is safe and effective for resection of subepithelial lesions, offering mucosal preservation, high en bloc resection rates, and reduced recovery time compared to ESE, ESD, and endoscopic full-thickness resection. Piecemeal STER is a potential alternative to surgery in managing large esophageal sub-epithelial lesions without compromising outcomes. For early epithelial neoplasms, pocket-creation and tunneling variants of ESD improve dissection speed and reduce adverse events, especially in large lesions. Comparative studies across esophagus, stomach, and colon confirm these benefits. Additionally, risk scoring systems and resection algorithms may guide personalized technique selection.

Summary: STER and tunneling ESD represent significant advances in minimally invasive management of GI tumors. Incorporating these techniques into practice can enhance safety and efficacy, especially when guided by risk stratification tools. Ongoing innovation, including artificial intelligence and robotics, is likely to further refine third-space interventions in near future.

Purpose of review: This review aims to provide an up-to-date overview of the expanding role of endoscopic ultrasound (EUS) in endohepatology, highlighting its potential to transform the diagnostic and therapeutic landscape for liver diseases. Given the increasing complexity of liver disease management, this review discusses both established and emerging applications of EUS in liver parenchyma assessment, portal hypertension diagnosis and related complications treatment and liver biopsy techniques.

Recent findings: Recent studies demonstrate that EUS can accurately assess liver fibrosis, detect focal lesions, and evaluate portal hypertension, with significant advancements in EUS-guided liver biopsy and treatment of gastric varices. Key findings include improved diagnostic accuracy with EUS-FNB over traditional methods and the potential for endoscopic ultrasound portal pressure gradient (EUS-PPG) in portal pressure measurements.

Summary: EUS holds significant promise in diagnosing and treating liver diseases, with applications in assessing liver fibrosis, identifying focal liver lesions, and managing portal hypertension. Future research will likely focus on enhancing EUS's role in therapeutic procedures, such as managing portal vein thrombosis and creating intrahepatic portosystemic shunts, offering a new avenue for minimally invasive treatment options.

Purpose of review: The rising prevalence of obesity, now affecting over 40% of U.S. adults, poses critical implications for colorectal cancer screening, as obesity increases the risk of both colorectal adenomas and cancer. Despite these elevated risks, patients with obesity have lower colonoscopy screening participation and face unique barriers that compromise procedural quality. This review aims to highlight the challenges encountered during colonoscopy in obese patients and examine emerging solutions that may enhance screening effectiveness and patient outcomes.

Recent findings: Obesity is associated with suboptimal bowel preparation, prolonged cecal intubation times, lower adenoma detection rates, and increased sedation-related complications. These challenges stem from altered gastrointestinal physiology, body habitus, and comorbid conditions. Recent innovations in bowel preparation strategies, sedation protocols, and endoscopic technologies-such as robotic-assisted colonoscopy and artificial intelligence-enhanced visualization-have demonstrated promise in addressing these limitations. Institutional initiatives, including tailored protocols and endoscopy team training, are also contributing to improved outcomes.

Summary: As obesity rates climb, adapting colonoscopy practices to meet the needs of this population is essential. Incorporating evidence-based strategies and emerging technologies can help overcome procedural barriers, improve detection rates, and reduce disparities in colorectal cancer screening. Continued research and guideline refinement are needed to optimize care delivery for patients with obesity.

Purpose of review: The prevalence of inflammatory bowel disease (IBD) amongst older adults (≥60 years old) is rising, encompassing individuals with a preexisting diagnosis and those newly diagnosed. Projections estimate that by 2030, one-third of patients with IBD will be older adults. Managing older adults with IBD poses unique challenges, including frailty, multimorbidity and polypharmacy. This review summarises the approach to managing older adults with small bowel Crohn's disease (SBCD), a distinct IBD sub-type.

Recent findings: The 2024 "State of IBD care in the United Kingdom (UK)" report revealed a median delay of 8 months from onset of Crohn's disease symptoms to diagnosis. Diagnostic delay in Crohn's disease is associated with stricturing and penetrating complications. Diagnostic challenges in SBCD include its insidious presentation in older adults and the poor utility of calprotectin as a biomarker, with a positive predictive value of only 23.1% with a calprotectin over 200 μg/g. Management should be tailored to patient preference and frailty, given the paucity of evidence pertaining to nutritional, medical and surgical treatment approaches in older adults.

Summary: Older adults with IBD represent a heterogenous cohort. Optimising the recruitment of older adults to clinical trials and stratifying outcomes according to frailty are key research priorities.