The year in gastroenterology literature: 11 essential readings
The literature related to the gastrointestinal (GI) system published this year was, as usual, abundant. As many of us have resumed clinical routines and office hours more typical of the pre-pandemic years, we can be forgiven for having let some of the new publications slip away. Blink and you may have missed updated American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) guidelines, expert reviews on various disorders, or recent clinical trials on prevalent gastrointestinal cancers.
To help us stay current, I scoured the GI literature for 2021 and selected the best papers that I believe have the greatest potential for change in our clinical practices. These items are not listed in any order of preference; rather, they are must read to ensure that we continue to deliver the best possible treatment to our patients in 2022.
AGA Clinical Practice Update on Endoscopic Management of Gastrointestinal Tract Perforations: Expert Review
Obviously, one of the most devastating complications of endoscopic procedures is perforation, given the potentially life-threatening implications it can have. This is why it is so essential for us to quickly recognize and appropriately manage this potential unwanted outcome.
Fortunately, the AGA has responded to this need by commissioning an expert review for those responsible for performing endoscopic procedures. The review provides an easy-to-use guide in the form of 16 separate tips on best practices for managing these complications, if any. As the authors write, “Although perforation is a serious event, with new endoscopic techniques and tools, the endoscopist should no longer be paralyzed when it occurs.”
What to do about a leaky gut
The term “leaky gut” is increasingly used by patients and healthcare providers. Although it describes a blind diagnosis, the leaky gut has widespread associations with a wide range of gastrointestinal and non-gastrointestinal symptoms and diseases.
In an excellent review to help guide discussions with our patients, authors Camilleri and Vella from the Mayo Clinic in Rochester, Minnesota, analyze the latest evidence on the causes of this gut barrier disruption and future pharmacological approaches to treat it. . Of particular value is the comprehensive discussion they include of which foods are deleterious to the barrier as well as which can be supplemented in the diet to promote its integrity.
ACG Clinical Guidelines: Management of Mild Anorectal Disorders
The management of common anorectal pathologies remains a gap in the training of gastroenterologists. This led the ACG to convene a group of experts, which reviewed all the literature on this subject.
The updated guidelines they produced should be a go-to reference for clinicians. The paper summarizes the latest evidence-based definitions, diagnostic criteria and concepts in the assessment and management of these mild disorders.
ACG clinical guidelines: prevention, diagnosis and treatment of Clostridioides difficile Infections
it’s hard Infection (CDI) is a significant event, affecting approximately 500,000 patients each year in the United States and acting as the primary contributor to nosocomial nosocomial nosocomial death.
This ACG guideline is intended to supplement those recently published by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. A notable development is that although infections linked to hospitals and long-term care facilities remain an obvious concern, nosocomial infections now represent 35-48% of CDI. Other recommendations of interest can be found against the use of probiotics for active treatment or for the prevention of recurrence, as well as regarding changes in the antibiotic treatment of the infection and the use of fecal microbial transfer.
Updates on age to start and stop colorectal cancer screening: recommendations from the U.S. multi-company colorectal cancer task force
The US Multi-Company Colorectal Cancer Task Force last published screening recommendations in 2017. In this focused update to those previous recommendations, they are focusing their attention on the age at which to start and stop screening. colorectal cancer in people at medium risk.
In line with the most recent recommendations from the American Cancer Society, the working group also approves the initiation of initial screening in people at average risk at 45 years of age. This was the previous recommendation only for black Americans, but it is now especially recommended for people of all ethnicities. They also recommend that screening decisions between 76 and 85 years be individualized based on life expectancy greater than 10 years, screening history and comorbidities, and advise against screening after 85 years.
AGA Clinical Practice Guideline for the Management of Bleeding Disorders in Patients with Cirrhosis
Patients with cirrhosis usually have an associated coagulopathy. However, the bleeding in these patients is generally balanced, and neither thrombocytopenia nor increased prothrombin time / international normalized ratio (PT / INR) necessarily predict risks.
This superb set of AGA guidelines provides evidence-based / graduated recommendations around specific questions focused on testing strategies, preoperative coagulation-directed prophylaxis, and assessment and management of thrombosis-related issues. in cirrhosis. Of particular interest are the authors’ descriptions of the paradigm shifts that have moved the field away from the standard use of fresh frozen plasma.
Rate and Age Evolution of Gastrointestinal and Non-Gastrointestinal Complications Associated with Screening / Surveillance Colonoscopy
The researchers behind this compelling population study evaluated age-related rates and timing of serious gastrointestinal and non-gastrointestinal adverse events associated with screening or surveillance colonoscopy. They found that for people aged 65 and older, non-gastrointestinal events predominated over gastrointestinal complications for a risk range of 1 to 125 days.
Their analysis highlights the important need to manage vascular complications with antiplatelet and anticoagulant drugs in these elderly patients. Endoscopists should not be the physicians who stop these drugs for procedures without specific approval from the caregiver in charge.
Definition and management of patients with primary biliary cholangitis and incomplete response to treatment
The standard for the initial treatment of patients with primary biliary cholangitis is ursodeoxycholic acid. In this outstanding narrative review, the authors argue that obtaining a biochemical response from this treatment is critical, as consistently high levels of alkaline phosphatase and bilirubin are associated with poor outcomes.
The historical target for alkaline phosphatase has been
Management of gastrointestinal side effects of immune checkpoint inhibitors
The development of immune checkpoint inhibitors has revolutionized the treatment of various types of cancer. They are now used as monotherapy or in combination with chemotherapy as a first or second line treatment for around fifty cancers.
These advances have not been without clinical costs. Adverse events related to the immune system, particularly related to the colon and liver, have important clinical implications, as they may require the interruption or discontinuation of immune checkpoint inhibitors. This in-depth review examines the most recent data and provides specific practical recommendations for the management of these gastrointestinal complications.
Consumption of sugary drinks in adulthood and adolescence and risk of early colorectal cancer in women
Taking advantage of the massive Nurses’ Health Study database, the authors of this compelling study assessed beverage consumption data from 41,272 participants who responded to validated food frequency questionnaires every 4 years. In doing so, they found that each serving / day of sugary drink (SSB) in adolescence (13-18 years) was associated with a 32% increased risk of early-onset colorectal cancer. Compared to consuming less than one serving / week of sugary drinks, higher consumption was associated with a 2.2-fold higher risk. In addition, replacing each serving / day of SSB in adulthood was associated with a reduction in the risk of early-onset colorectal cancer from 17% to 36%.
Virtually all SSBs use high fructose corn syrup rather than cane sugar because it’s sweeter and cheaper, but this ingredient is also associated with several potentially devastating gastrointestinal and non-gastrointestinal illnesses. A 2017 report suggested that the use of high fructose corn syrup is a “public health crisis,” and these latest findings only add to that argument. Clinicians need to be more proactive in educating their patients on how to avoid these and other unwanted dietary components.
AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Disease: Expert Review
Dysplasia and associated colorectal cancer are well-known complications of inflammatory bowel disease (IBD). Recent improvements in medical therapies and endoscopic assessment / intervention have led to dramatic changes in management, and IBD-related dysplasia is no longer a reflex indication for surgical resection of the colon.
This expert review shed light on recent changes in practice for identifying and managing dysplasia associated with IBD. Obviously, this topic is an important paradigm shift for anyone performing colonoscopy monitoring for patients with IBD.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and past president of the American College of Gastroenterology. Its main objective is the clinical practice of gastroenterology. He has published extensively in the internal medicine / gastroenterology literature, with primary research interests in diseases of the esophagus and colon, and more recently on the effects of sleep and the microbiome on health and gastrointestinal diseases.
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