As in past years, 2023 featured an abundance of engaging literature. Expert panels, professional societies like American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA), and groundbreaking international researchers all weighed in on a range of gastrointestinal (GI) conditions.
Surveying this wide array of articles and picking the top contributions was a difficult task. Yet, in considering the totality of 2023, I felt that these 10 articles had the greatest game-changing implications.
The articles are not listed in order of importance; all of them are equally invaluable resources for gastroenterologists looking to stay current with best practices in their field.
Acute Liver Failure Guidelines
Acute liver failure (ALF) is a critical condition that occurs in patients with no preexisting liver disease and is characterized by elevated liver enzymes (reflecting hepatic injury), coagulopathy, and hepatic encephalopathy. Given the broad array of etiologies and presentations of ALF, it is essential that clinicians have the information needed to recognize it early so they can initiate potentially life-saving treatment.
This guideline represents the official ALF practice recommendations put forward by the ACG. Its expert authors weighed and graded the most current data to provide guidance on diagnosing and managing ALF, including an overview of the relevant factors when considering liver transplantation.
ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions
It is not uncommon to encounter subepithelial lesions (SEL) of the GI tract during endoscopic and cross-sectional radiologic evaluations. SEL can represent benign or malignant lesions and occur anywhere along the GI tract. This can often create a conundrum for clinicians, particularly as these lesions may frequently represent only incidental findings.
In another set of clinical guidelines from ACG, authors provide their recommendations for evaluation, monitoring, and/or resection of SEL, and advice on how to also tailor the risk vs benefit of these interventions so that we adopt the best patient-centered approach.
Long-Term Safety Outcomes of Fecal Microbiota Transplantation: Real-World Data Over 8 Years From the Hong Kong FMT Registry
Although the short-term safety and effectiveness of fecal microbiota transplantation (FMT) for the prevention of recurrent Clostridioides difficile infection (CDI) is well documented, our knowledge of the long-term safety outcomes is relatively limited. Patient registries are therefore particularly valuable, as they can help facilitate systematic collection of prospective, long-term safety data, including from patients often excluded from clinical trials.
This report from the first and largest FMT registry in Asia is a fantastic example of such real-world data. Investigators behind this analysis reported that there were no significant safety signals identified. Notably, most of the FMTs in this registry were not performed for CDI but rather for clinical trials evaluating its efficacy for type 2 diabetes, obesity, inflammatory bowel disease, and irritable bowel syndrome. FMT administration occurred via upper endoscopy (67%) or rectal enema (20%), differing from the typical approaches used currently in the United States.
This report provides yet more comfort that FMT can be safely administered, although additional evaluation of the two new US Food and Drug Administration–approved formulations — Rebyota and Vowst — is needed.
Noninvasive Assessment of Postoperative Disease Recurrence in Crohn's Disease: A Multicenter, Prospective Cohort Study on Behalf of the Italian Group for Inflammatory Bowel Disease
Colonoscopy is firmly established as the gold standard for assessing postoperative recurrence in Crohn's disease.
In this multicenter study, a group of Italian researchers evaluated the efficacy of another option for determining postoperative recurrence: noninvasive ultrasonography. They demonstrated that with the use of this noninvasive technique, the presence of lymph nodes or the combination of bowel wall thickening (BWT) ≥ 3 mm and fecal calprotectin (FC) values ≥ 50 µg/g correctly classified 56% and 75% of patients, with less than 5% of patients falsely classified as having endoscopic recurrence. Conversely, the combination of BWT < 3 mm and FC < 50 µg/g correctly classified 74%, with only 4.5% falsely classified as not having endoscopic recurrence.
This approach has great appeal for on-site evaluation at the time of clinic visit, providing more expedited treatment if needed. It is already a standard in several centers of excellence for inflammatory bowel disease, but encouraging its expansion to even more clinics will surely enhance the care of patients.
Bile Acid Sequestrants in Microscopic Colitis: Clinical Outcomes and Utility of Bile Acid Testing
The standard approach for treatment of microscopic colitis is the use of oral budesonide. Albeit quite safe, there are clearly potential risks associated with the use of long-term steroids of any formulation. Additionally, the relapse rate following discontinuance ranges from 40% to 81%.
This led investigators to design one of the largest cohorts evaluating treatment with bile acid sequestrants (BAS) in patients with microscopic colitis. They assessed the response of 282 patients to cholestyramine (64.9%), colesevelam (21.6%), and colestipol (13.5%). Prior to BAS therapy, 99% were treated with another medication or combination for microscopic colitis, including loperamide (78.4%), budesonide (69.9%), bismuth subsalicylate (41.1%), and mesalamine (11.0%).
With a median follow-up of 4.5 years, clinical response rates to BAS were 49.3% complete, 16.3% partial, 24.8% nonresponse, and 9.6% intolerance. No predictors of response to BAS were identified, including measurement of fecal bile acids. After discontinuation, 41.6% had recurrence at a median of 21 weeks (range, 1-172 weeks).
These groundbreaking results should lead the way to a safer and effective treatment approach beyond the use of steroids.
Updates to the Modern Diagnosis of GERD: Lyon Consensus 2.0
This update to the Lyon Consensus provides evidence-based changes to the criteria for the diagnosis of gastroesophageal reflux disease (GERD). Compared with the original Lyon Consensus 1.0, these new criteria include changes made to objective endoscopic findings, notably the removal of LA grade A erosive esophagitis as conclusive evidence of GERD.
The paper's authors also provide new thresholds and metrics to be used with prolonged wireless pH monitoring, a discussion of parameters useful in the evaluation of "refractory GERD," and guidance on when testing should be performed on or off antisecretory therapy — all beneficial information for clinicians who evaluate this common disease.
Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations
Although gastroenterologists commonly evaluate constipation, fecal incontinence, obstipation, and anorectal pain, anorectal motility (ARM) is not widely utilized, for reasons that remain unclear.
This paper is the result of a roundtable discussion held by experts, who were tasked with examining the current clinical practices of physicians and surgeons in both academic and community settings as it relates to ARM and biofeedback therapy. Roundtable participants discussed in detail how ARM identifies key pathophysiologic abnormalities, such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction. They noted that ARM is a critical component of biofeedback therapy, as well as directed treatment for patients with dyssynergic defecation and fecal incontinence.
Clinicians from all specialties, as well as primary care, should read this excellent review and compendium of recommendations for the expanded use of ARM. Patient outcomes will assuredly be enhanced by better understanding of this valuable, yet underutilized, tool.
AGA Clinical Practice Update on the Use of Vasoactive Drugs and Intravenous Albumin in Cirrhosis: Expert Review
Cirrhosis is a major cause of morbidity and mortality worldwide. The estimated median survival for those with cirrhosis depends on the stage: > 15 years in the compensated stage, 2 years in the decompensated stage, and 9 months in the further decompensated stage.
This outstanding expert review from AGA represents a comprehensive survey of the latest relevant literature. Its authors provide recommendations about the use of vasoactive drugs (eg, terlipressin, norepinephrine, and combination of octreotide and midodrine) in the treatment of hepatorenal syndrome and acute kidney injury. They also provide direction on the appropriate use of IV albumin and an expanded discussion on the use of IV terlipressin.
As most clinicians probably have not used terlipressin, which is the best drug for selected indications, this information will be invaluable. It's just one reason this article should be a must-read for those providing care for patients with all stages of cirrhosis.
AGA Clinical Practice Update on Management of Ostomies: Commentary
Enteral ostomies are not uncommon in patients with inflammatory and/or neoplastic GI disease. In the United States, approximately 750,000 people have an ostomy and 130,000 new ostomy surgeries are performed annually. Despite this, most clinicians do not have a good foundation of how to care for these surgical changes.
This AGA Institute Clinical Practice Update represents the work of an expert multidisciplinary panel, which was compromised of a gastroenterologist, colorectal surgeon, wound ostomy nurse, and ostomate (person who has had an ostomy). The panel's work focused on ileostomy or colostomy, and provides an outstanding overview of the specific types of ostomies, as well as the management of short- and long-term complications. It serves as a persuasive reminder that when it comes to the management of ostomies, a true multidisciplinary approach is needed.
EASL Clinical Practice Guidelines on the Management of Liver Diseases in Pregnancy
Liver diseases in pregnancy include gestational liver disorders, as well as the acute and chronic disorders occurring coincidentally. Such diseases are associated with significant risk for maternal and fetal morbidity and mortality.
It was therefore quite welcome when the European Association for the Study of the Liver (EASL) published this set of clinical guidelines on the topic. Put together by an expert panel, this comprehensive tome provides timely recommendations for evaluating and managing a range of liver diseases in pregnancy, including both preterm and postpartum implications. Additional topics covered range from drugs best used to treat these patients, to perinatal transmission of infectious hepatitis, to preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.
All ten of these publications are notable and have potentially significant clinical impacts. I recommend keeping these valued resources close at hand, which can be resources to guide current "best care practice" for your patients.
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 a past president of American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.
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Cite this: The 10 Best GI Studies From 2023 That You Need to Know - Medscape - Dec 20, 2023.
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