Current Opinion in Gastroenterology最新文献

Purpose of review: The purpose of the review is to critically evaluate the evidence from the literature to establish the current perspective on fluid resuscitation (FR) in acute pancreatitis (AP). We will review the rationale, type of fluid, rate of administration, total volume, duration, monitoring, ideal outcomes to be studied in clinical trials and recommendations for future studies.

Recent findings: FR remains the key component of supportive therapy in AP. The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate FR strategies. Lactated Ringer's remains the preferred fluid for resuscitation. There remain critical gaps in knowledge regarding the end point(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in AP.

Summary: There is insufficient evidence to state that goal-directed therapy, using any of the parameters to guide fluid administration, reduces the risk of persistent organ failure, infected pancreatic necrosis, or mortality in AP, as well as the most appropriate method for the same.

Purpose of review: Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) should be considered in all cases of acute pancreatitis and triglyceride levels measured early, so that appropriate early and long-term treatment can be initiated.

Recent findings: In most cases of HTG-AP, conservative management (nothing by mouth, intravenous fluid resuscitation and analgesia) is sufficient to achieve triglyceride levels less than 500 mg/dl. Intravenous insulin and plasmapheresis are sometimes used, although prospective studies showing clinical benefits are lacking. Pharmacological management of hypertriglyceridemia (HTG) should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk or recurrent acute pancreatitis. In addition to currently used fenofibrate and omega-3 fatty acids, several novel agents are being studied for long-term treatment of HTG. These emerging therapies focus mainly on modifying the action of lipoprotein lipase (LPL) through inhibition of apolipoprotein CIII and angiopoietin-like protein 3. Dietary modifications and avoidance of secondary factors that worsen triglyceride levels should also be pursued. In some cases of HTG-AP, genetic testing may help personalize management and improve outcomes.

Summary: Patients with HTG-AP require acute and long-term management of HTG with the goal of reducing and maintaining triglyceride levels to less than 500 mg/dl.

Purpose of review: Serum levels of amylase and lipase can be elevated in nonpancreatic conditions that may or may not be associated with abdominal pain. This leads to a large proportion of patients being falsely labeled as having acute pancreatitis. In this review, we aim to summarize the existing evidence on pancreatic enzyme elevation in various pancreatic and nonpancreatic conditions and its practical implications in clinical practice and healthcare.

Recent findings: Serum amylase and lipase levels are not specific for pancreatitis. Attempts have been made to validate newer biomarkers including pancreatic elastase, serum trypsin, urinary trypsinogen-activated peptide, phospholipase A2, carboxypeptidase B, activated peptide of carboxypeptidase B, the trypsin 2 alpha 1 activation complex, and circulating cell-free DNA for the diagnosis of acute pancreatitis.

Summary: Serum lipase levels can be elevated in many intra-abdominal inflammatory conditions. Although more sensitive and specific than amylase, serum lipase levels are not sufficient to diagnose acute pancreatitis in patients with abdominal pain. There is a need to increase stress on radiological evidence as well increase cut-off levels of enzyme elevation for a more accurate diagnosis of acute pancreatitis.

Purpose of review: Thermal ablatives therapies have seen an expanding role in gastrointestinal endoscopy during the last years. The aim of this review is to give an overview of the currently available techniques.

Recent findings: In the upper gastrointestinal tract, mainly in early Barrett's neoplasia, endoscopic ablation strategies ranging from RFA to Hybrid-APC are, together with resection strategies, the main part of the armamentarium. In the small intestine, argon plasma coagulation (APC) can be effectively used for the treatment of angiodysplasias. In the lower gastrointestinal tract, APC and RFA are mainly used. In tumour obstruction, thermal ablation is used to reopen the lumen. The selection of available techniques is still increasing.

Summary: The variety of ablation techniques enables the endoscopist to choose the appropriate ablation tool for each individual patient.

Purpose of review: To review the literature within the last 5 years on the current status and future perspectives of the endoscopic management of internal hemorrhoids.

Recent findings: Despite the large burden of hemorrhoidal diseases, research in this area, particularly on endoscopic approaches for treatment, has been slow. Within the last 5 years, data has been published on the novel cap-assisted endoscopic sclerotherapy (CAES), which will continue to gain attention in the future. Rubber band ligation has been adopted by the endoscopist as endoscopic rubber band ligation (ERBL), demonstrating satisfactory results in treating symptomatic hemorrhoids, although mild postprocedure complications are common. Data is needed on head-to-head comparisons between ERBL, endoscopic sclerotherapy, and CAES. Other methods, such as coagulation, are understudied and should be explored further in the endoscopic setting. Meaningful comparisons between treatment methods for internal hemorrhoids have been difficult because of variations in interventional techniques and methods, differences in the grading of hemorrhoids, and lack of standardization of clinical trials. The Goligher classification alone is inadequate for determining the management of symptomatic hemorrhoids and this warrants revision.

Summary: Gastroenterologists are poised to assume a greater role in the management of internal hemorrhoids with flexible endoscopy. Current endoscopic treatment options require further study.

Purpose of review: Lumen apposing metal stents (LAMS) have been increasingly used to manage patients with surgically altered anatomy (SAA), who would have otherwise required percutaneous or surgical interventions. Via the creation of de-novo anastomoses, LAMS provides a conduit to access distal parts of the gastrointestinal tract to perform various interventions.

Recent findings: Pancreatobiliary (PB) and non-PB interventions are challenging in patients with SAA. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and endoscopic ultrasound (EUS)-directed transenteric ERCP (EDEE) are effective procedures that are being increasingly utilized to perform ERCP in patient with Roux-en-Y gastric bypass (RYGB) and non-RYGB SAA, respectively. Furthermore, EUS-directed trans-gastric intervention (EDGI) is a collective term for the non-PB procedures that could be performed in patients with SAA. EDGE/EDEE/EDGI are considered relatively safe procedures, however, intra-procedural stent misdeployement, and long-term ramifications of persistent fistula and stent migration could require endoscopic or, in rare instances, surgical management.

Summary: The advent of LAMS has revolutionized the therapeutic capabilities of EUS, by allowing the creation of new gastrointestinal anastomoses. With the growing body of literature, it is expected that such techniques will be more commonly performed in the community, providing less invasive and more effective treatment options for patients with SAA.

Purpose of review: Rumination syndrome (RS) is a functional gastroduodenal disorder characterized by repeated effortless regurgitation or vomiting of recently ingested food without retching. RS generally has been considered a rare entity. However, it has been increasingly recognized that many RS patients are likely to be underdiagnosed. This review discusses how to recognize and manage RS patients in clinical practice.

Recent findings: A recent epidemiological study that included over 50,000 individuals found that the prevalence of RS around the world is 3.1%. In patients with proton pump inhibitor (PPI)-refractory reflux symptoms, postprandial high-resolution manometry combined with impedance (HRM/Z) reveals that RS accounts for up to 20% of those cases. HRM/Z can be a gold standard for objective RS diagnosis. In addition, off-PPI 24-h impedance pH monitoring can suggest the possibility of RS when it reveals frequent postprandial, non-acid reflux with a high symptom index. Modulated cognitive behavioral therapy (CBT) targeting secondary psychological maintaining mechanisms almost eliminates regurgitation.

Summary: The prevalence of RS is higher than generally thought. For patients suspected of RS, HRM/Z is useful to distinguish RS from gastroesophageal reflux disease. CBT can be a highly effective therapeutic option.

Purpose of review: This review summarizes the most recent literature on older adults with inflammatory bowel diseases (IBD). Additionally, we review geriatric syndromes that may be pertinent to the management of older adults with IBD.

Recent findings: Traditionally chronological age has been used to risk stratify older adults with IBD, however physiologic status, including comorbidities, frailty, and sarcopenia, are more closely associated with clinical outcomes for older adults. Delaying care for and undertreating older adults with IBD based upon advanced chronologic age alone is associated with worse outcomes, including increased mortality. Treatment decisions should be made considering physiologic status, with an understanding of the differential risks associated with both ongoing disease and treatment. As such, there is an increasing recognition of the impact geriatric syndromes have on older adults with IBD, which need to be further explored.

Summary: Older adults with IBD are less likely to receive advanced therapies and timely surgery. They are also more likely to have adverse outcomes despite having similar disease courses to younger adults with IBD. Focusing on biological age as opposed to chronological age can shift this trajectory and improve quality of care for this growing population of patients with IBD.

Purpose of review: This review aims to discuss some of the clinical and epidemiological challenges of risk prediction models; summarize the evidence supporting existing models; and highlight the translational requirements.

Recent findings: A variety of risk prediction models exist to identify prevalent Barrett's esophagus or predict future esophageal adenocarcinoma. External validation studies have investigated performance of these models in a variety of settings. These models appear to be more predictive than use of symptoms alone, but the added complexity means that implementation challenges may require investigation.

Summary: Risk prediction models could be useful for identifying individuals at an increased risk of esophageal adenocarcinoma, which could assist screening decisions. However, risk prediction models must be implemented with care. Implementation science to assist the translation of existing models into practice may be an important next step.