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What's new in gastroenterology and hepatology

Disclosures: Peter A L Bonis, MD Employee of UpToDate, Inc. Anne C Travis, MD, MSc, FACG, AGAF Employee of UpToDate, Inc. Equity Ownership/Stock Options: Proctor & Gamble. Shilpa Grover, MD, MPH Employee of UpToDate, Inc.

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2014. | This topic last updated: Sep 15, 2014.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.


Colorectal cancer mortality after adenoma resection (August 2014)

There are limited data regarding the incidence and mortality from colorectal cancer in patients who have had colorectal adenomas resected. In a study that included approximately 40,000 patients from a Norwegian population based registry who had undergone resection of a colorectal adenoma, 1273 patients were diagnosed with colorectal cancer during a median follow up of nearly eight years [1]. As compared with the general population, individuals who had undergone resection of one tubular adenoma of any size had a lower colorectal cancer mortality, while those with two or more adenomas, high grade dysplasia, or villous histology had a higher colorectal cancer mortality. Studies are needed to determine if intensive colorectal cancer surveillance reduces colorectal cancer mortality among individuals with high-risk adenomas. (See "Approach to the patient with colonic polyps", section on 'Surveillance'.)

Fecal DNA testing for colorectal cancer screening (March 2014, MODIFIED August 2014)

A newer stool DNA test that also incorporates stool hemoglobin testing and DNA methylation was approved by the US Food and Drug Administration in August 2014. In a comparison of the new assay with one round of a fecal immunochemical test (FIT) in nearly 10,000 people at average risk for colorectal cancer who also underwent colonoscopy, the sensitivity for colorectal cancer of the stool DNA and FIT tests were 92.3 percent and 73.8 percent respectively [2]. Nearly 10 percent of individuals with an entirely negative colonoscopy had a positive stool DNA test; the implications of "false-positive" DNA tests is uncertain. Since screening tests are performed at regular intervals, and intervals for performing repeat FIT testing are likely shorter than for stool DNA testing, results of one round of screening may not represent comparative effectiveness over a period of time. (See "Tests for screening for colorectal cancer: Stool tests, radiologic imaging and endoscopy", section on 'Fecal DNA tests'.)

Colorectal cancer screening in older adults who have never been screened (July 2014)

For most older adults, it is reasonable to stop screening for colorectal cancer (CRC) at age 75 years, or 85 years at the latest. However, for older adults who have never been screened for CRC (23 percent of US elderly individuals), one-time screening appears to be cost-effective up to age 86 years, based on results of a modeling study [3]. In this simulation study, assuming a willingness to pay $100,000 per quality-adjusted life-year gained, colonoscopy was cost-effective to age 83 years, sigmoidoscopy to 84 years, and fecal immunochemistry testing to 86 years for patients without comorbidity and at average risk for CRC. Colonoscopy was the most effective, and most expensive, strategy for one-time screening. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Older adults with no prior screening'.)

Screening colonoscopy and adenoma detection rate (April 2014)

Detection rates for colonic adenomas during screening colonoscopy depend upon the experience and technique of the colonoscopist, and so may be an important marker of quality. In a study of over 300,000 colonoscopies, rates of adenoma detection among 136 gastroenterologists varied from 7.4 to 52.5 percent [4]. Patients who had screening colonoscopy performed by gastroenterologists with higher rates of detecting adenomas were at lower risk for both interval advanced-stage colorectal cancer (CRC) and fatal interval CRC. (See "Tests for screening for colorectal cancer: Stool tests, radiologic imaging and endoscopy", section on 'Sensitivity of colonoscopy'.)


Preprocedure testing for endoscopic procedures (July 2014)

The American Society for Gastrointestinal Endoscopy has released guidelines regarding testing prior to endoscopic procedures [5]. The guidelines recommend that patients not undergo routine preprocedure laboratory testing, chest radiography, or electrocardiography. Instead, preprocedure testing should be obtained selectively based upon the patient’s medical history, physical examination findings, and procedural risk factors. (See "Overview of colonoscopy in adults", section on 'Preprocedure testing'.)


Lower infectious risk with restrictive blood transfusion strategy (April 2014)

A restrictive blood transfusion strategy (eg, transfusion at a hemoglobin level of 7 to 8 g/dL) is associated with a trend towards lower mortality compared with a liberal strategy (transfusion for a hemoglobin level <10 g/dL) in many medical and surgical settings. A new meta-analysis of randomized trials found that a restrictive, compared with a liberal, strategy was associated with a lower risk of serious infections (12 versus 17 percent, respectively) in hospitalized patients [6]. The greatest benefit was seen in patients undergoing orthopedic surgery and those who presented with sepsis. The safety of restrictive transfusion in patients with acute coronary syndromes (eg, myocardial infarction) has not been evaluated adequately, and higher thresholds may be needed in this population. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Overview of our approach'.)

Radiofrequency ablation for low-grade dysplasia in Barrett's esophagus (March 2014)

Patients with low-grade dysplasia in the setting of Barrett's esophagus are often managed with surveillance endoscopy. An alternative approach is to treat with radiofrequency ablation (RFA). A randomized trial compared RFA with endoscopic surveillance in such patients [7]. RFA increased rates of complete eradication of dysplasia and complete eradication of intestinal metaplasia. RFA also reduced the risk of progression to high-grade dysplasia or adenocarcinoma. However, patients included in this trial underwent RFA procedures at expert centers and dysplasia was confirmed by an expert pathologist. Thus, whether the results seen in this trial would be seen with more widespread adoption of RFA for the treatment of low-grade dysplasia is unclear. (See "Management of Barrett's esophagus", section on 'Radiofrequency ablation'.)

Acid suppression and pneumonia (March 2014)

Previous observational studies reported an association between proton pump inhibitor (PPI) use and community acquired pneumonia (CAP), but a new meta-analysis suggests the observation might have been due to confounding. The meta-analysis included eight cohort studies with over 4 million new users of nonsteroidal antiinflammatory drugs (NSAIDs), of which nearly 100,000 were treated prophylactically with PPIs and about 50,000 were treated with histamine 2 receptor antagonists (H2RAs) [8]. On adjusted analysis, neither the use of PPIs nor H2RAs was associated with an increased risk of hospitalization for CAP during the six months following initiation of NSAIDs. (See "Overview and comparison of the proton pump inhibitors for the treatment of acid-related disorders", section on 'Pneumonia'.)


Risk of perinatal transmission of HBV in the United States (June 2014)

Administration of hepatitis B virus (HBV) vaccination and hepatitis B immune globulin (HBIG) to newborns of women with chronic HBV infection significantly reduces the risk of perinatal HBV transmission but does not eradicate it. In an observational study of over 4000 infants born to HBV-infected mothers in the United States between 1997 and 2010, over 95 percent received HBV vaccination and HBIG [9]. Perinatal transmission occurred in 3.40 percent of births to hepatitis B e antigen (HBeAg) positive mothers and 0.04 percent of births to HBeAg negative mothers. Among women whose HBV DNA results and HBeAg status were known, no HBV transmission occurred with a viral load less than 5 x107 IU/mL, regardless of the HBeAg status. (See "Hepatitis B and pregnancy", section on 'HBV DNA level'.)

Screening for Hepatitis B virus infection in the United States (June 2014)

Infection with Hepatitis B virus (HBV) can lead to chronic liver disease and is preventable with vaccination. The US Preventive Services Task Force (USPSTF) has updated its statement on screening for HBV infection in nonpregnant adolescents and adults to recommend that individuals at high-risk for HBV infection be screened if they have not been vaccinated or if they were vaccinated without prior screening [10]. High-risk populations include persons born in regions with a prevalence of HBV ≥2 percent, US–born persons whose parents were born in regions with a prevalence ≥8 percent, injection drug users, men who have sex with men, household contacts of persons with HBV infection, and individuals with HIV infection. Existing guidelines from the Centers for Disease Control and Prevention and the American Association for the Study of Liver Disease also support screening of high-risk individuals in the US. (See "Diagnosis of hepatitis B virus infection", section on 'Who should be tested or screened'.)

Glucocorticoids after hepatoportoenterostomy for biliary atresia (June 2014)

New clinical evidence demonstrates that glucocorticoids are not useful in the treatment of biliary atresia after hepatoportoenterostomy (Kasai procedure). In a multicenter randomized trial that included 140 infants with biliary atresia, compared with placebo, glucocorticoid treatment improved neither bile drainage six months postoperatively nor survival with the native liver at two years of age [11]. Moreover, infants treated with glucocorticoids had earlier onset of serious adverse events. This trial resolves questions about the utility of glucocorticoid treatment that were raised by previous retrospective or under-powered studies, which had conflicting results. (See "Biliary atresia", section on 'Glucocorticoids'.)

Nonselective beta blockers in patients with cirrhosis and spontaneous bacterial peritonitis (May 2014)

Nonselective beta blockers are used routinely to prevent variceal bleeding in patients with cirrhosis and esophageal varices. However, among patients with spontaneous bacterial peritonitis (SBP), beta blocker use is associated with worse outcomes compared with not using a beta blocker. This was examined in a retrospective study of 607 patients with cirrhosis and ascites [12]. Once SBP developed, patients receiving a nonselective beta blocker had decreased transplant-free survival rates, increased rates of hepatorenal syndrome, and more days of hospitalization. Because of these worse outcomes, we permanently discontinue nonselective beta blockers once SBP has developed. (See "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis", section on 'Discontinue nonselective beta blockers'.)

Risk of hepatic decompensation in HIV/HCV coinfected patients (April 2014)

In patients with chronic hepatitis C virus (HCV) infection, concomitant HIV infection is associated with higher rates of liver-related morbidity and mortality. In a retrospective study of over 10,000 HCV-infected male US veterans, the estimated 10-year incidence of hepatic decompensation was 7.4 percent among antiretroviral treated HIV/HCV coinfected men compared with 4.8 percent among HCV monoinfected men [13]. The risk of decompensation in HIV/HCV coinfected patients is even greater in the absence of antiretroviral therapy [14]. These findings argue for early treatment of chronic HCV, which can prevent liver complications if successful, in HIV infected patients. (See "Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected patient", section on 'Hepatic decompensation'.)

Ribavirin for chronic hepatitis E infection in transplant recipients (March 2014)

Transplant recipients are at increased risk for chronic hepatitis E virus (HEV) and there is currently no established therapy. A multicenter retrospective case series included 59 patients with a solid organ transplant who had received ribavirin for a median of three months, beginning a median of nine months after the diagnosis of HEV infection [15]. At the end of therapy, HEV clearance was observed in 95 percent of patients. A sustained virologic response, defined as undetectable serum HEV RNA at least six months after cessation of ribavirin, was observed in 78 percent of patients. Anemia was the most common side effect. Prospective studies are needed to confirm these findings and to determine the dose, duration, and timing of ribavirin therapy. (See "Hepatitis E virus infection", section on 'Treatment'.)

Chronic hepatitis C virus infection in the United States (March 2014)

An estimated 1 percent of the United States population, or approximately 2.7 million individuals, has chronic hepatitis C virus (HCV) infection, based on an analysis of the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2010 [16]. Peak prevalence was observed among those born between 1945 and 1965, who accounted for 80 percent of all chronically infected individuals. One-time screening for HCV infection is recommended by UpToDate, consistent with recommendations from the Centers for Disease Control and Prevention, for all US adults in this birth cohort, regardless of risk factors. (See "Epidemiology and transmission of hepatitis C virus infection", section on 'United States' and "Screening for chronic hepatitis C virus infection".)


Biliary sphincterotomy for type III sphincter of Oddi dysfunction (May 2014)

Patients with type III biliary sphincter of Oddi dysfunction (SOD; defined as biliary-type pain without objective findings such as abnormal liver blood tests or a dilated common bile duct) are difficult to diagnose and manage. Some of these patients will have undergone cholecystectomy but continue to have pain. Whether biliary sphincterotomy benefits such patients was examined in a randomized, sham-controlled trial with 214 patients [17]. There was no difference between those who had a sphincterotomy and those who had a sham procedure with regard to pain relief. In addition, there were no subgroups that appeared to benefit from sphincterotomy, including those with abnormal sphincter of Oddi manometry. This trial suggests that biliary sphincterotomy should not be performed for treatment of patients with possible type III SOD whose pain persists following cholecystectomy. (See "Treatment of sphincter of Oddi dysfunction", section on 'Biliary pain'.)

Identification of potentially malignant pancreatic cystic neoplasms (March 2014)

The major challenge in the evaluation of pancreatic cystic neoplasms (PCNs) is identifying lesions with malignant potential. In a study that performed proteomic mucin profiling on cyst fluid, proteomic analysis was more accurate than cytology or cyst fluid carcinoembryonic antigen (CEA) level for identifying lesions with malignant potential and could predict risk of malignant transformation [18]. If validated in other studies, proteomic mucin profiling of cyst fluid may prove a valuable method for identifying cysts that require surgical resection. (See "Pancreatic cystic neoplasms", section on 'Other markers'.)


Posttreatment surveillance colonoscopy in older adults (August 2014)

Expert guidelines for surveillance of patients with treated colorectal cancer (CRC) or adenomatous polyps do not specifically address when, if ever, surveillance endoscopy should be stopped. In a retrospective cohort study of more than 25,000 patients ≥50 years of age (nearly 5,000 aged 75 or older) undergoing surveillance colonoscopy at a single integrated California health system for a history of CRC or adenomatous polyps, older age was independently associated with a higher risk of post-procedure hospitalization, as was the presence of a Charlson comorbidity score of 2 or higher (table 1) [19]. The risk of post-procedure hospitalization and the impact of comorbidity should be taken into account when assessing the relative risks and benefits of periodic surveillance colonoscopy in patients with advanced age or comorbidities and a history of treated CRC or colonic adenoma. (See "Surveillance after colorectal cancer resection", section on 'Guidelines from major groups' and "Approach to the patient with colonic polyps", section on 'Surveillance'.)

Lack of increased cancer risk from TNF inhibitors in patients with inflammatory bowel disease (June 2014)

There is some uncertainty whether the use of tumor necrosis factor (TNF) inhibitors increases the risk of cancer, particularly in patients with rheumatoid arthritis. Less information has been available regarding such risk in patients with other disorders. The cancer risk of TNF inhibitors in patients with inflammatory bowel disease (IBD) was examined in a study using a nationwide registry in Denmark, involving over 56,000 patients with IBD, of whom about 4600 were exposed to TNF inhibitor therapy with median follow-up of 3.7 years [20]. After adjustment for multiple potential confounders, there was no evidence that patients exposed to TNF inhibitors experienced an increased risk for cancer compared with unexposed patients. There was also no evidence of increased risk with cumulative dose, although risk with a greater duration of exposure or follow-up than in the study could not be excluded. (See "Tumor necrosis factor-alpha inhibitors: Risk of malignancy", section on 'Evidence of no increased long-term risk'.)

Vedolizumab for moderate to severe inflammatory bowel disease (May 2014)

Vedolizumab is a recombinant humanized, anti alpha-4-beta-7 integrin monoclonal antibody, an integrin relatively specific to the gastrointestinal tract and involved in inflammation. Vedolizumab has been studied for the treatment of inflammatory bowel disease and in May 2014 was approved by the US Food and Drug Administration for use in patients with moderate to severe Crohn disease or ulcerative colitis [21]. (See "Approach to adults with steroid-refractory and steroid-dependent ulcerative colitis", section on 'Vedolizumab' and "Overview of the medical management of severe or refractory Crohn disease in adults", section on 'Vedolizumab'.)

Combination methotrexate and infliximab in Crohn disease (March 2014)

Combination therapy with methotrexate and infliximab in patients with Crohn disease has not been previously evaluated. In a randomized trial of 126 patients with Crohn disease who had initiated induction therapy with prednisone within the preceding six weeks, all patients were treated with infliximab and further assigned to receive either methotrexate or placebo [22]. Prednisone was then tapered at week 1 and discontinued by week 14. Although combination therapy with methotrexate and infliximab was well tolerated, there were no differences in the rates of treatment failure between the two groups. (See "Immunomodulator therapy in Crohn disease", section on 'Efficacy of methotrexate in combination with anti-TNF therapy'.)

Low FODMAP diet in irritable bowel syndrome (March 2014)

A diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) has been recommended in patients with irritable bowel syndrome (IBS) but evidence to support this recommendation has been limited. In a randomized, single-blind, cross-over trial, 30 patients with IBS and 8 healthy controls were assigned to 21 days of either a diet low in FODMAPs or a moderate FODMAP Australian (Western) diet [23]. Subjects with IBS but not controls had significantly lower overall gastrointestinal symptoms scores with improvement in scores for abdominal pain, bloating, flatulence, and dissatisfaction with stool consistency while on a low FODMAP diet as compared with both the moderate FODMAP diet and their usual diet. This study supports our current approach, which incorporates a low-FODMAP diet (table 2) early in management of IBS. (See "Treatment of irritable bowel syndrome in adults", section on 'Low FODMAP diet'.)

Non-celiac gluten sensitivity (March 2014)

It remains unclear whether there is a category of patients with symptomatic response to gluten but without serologic evidence of celiac disease, termed “non-celiac gluten sensitivity.” In most cases the gastrointestinal symptoms are not replicated on double-blind food challenge, suggesting a placebo effect. However, a minority of patients may have a true non-celiac gluten sensitivity. This was suggested by a study in a group of children without serologic evidence of celiac disease, but documented gastrointestinal symptoms in response to open challenge with gluten [24]. In this selected group of patients, the symptoms were reproduced after a partially-blinded gluten challenge, in which the child but not the parents were blinded to the gluten. The findings may reflect a true gluten sensitivity, biased expectations of the parent, or symptoms caused by non-gluten carbohydrates in the diet. (See "Clinical manifestations and diagnosis of celiac disease in children", section on 'Non-celiac gluten sensitivity'.)

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