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What's new in gastroenterology and hepatology
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: Apr 4, 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

Fecal DNA testing for colorectal cancer screening (March 2014)

A newer stool DNA test that also incorporates stool hemoglobin testing is in development, after withdrawal from the market of a previous stool DNA assay. 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 [1]. 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'.)

Updated ASCO guidelines for follow-up of colorectal cancer survivors (November 2013)

In 2013, the American Society of Clinical Oncology (ASCO) updated its prior 2005 recommendations for follow-up care, surveillance protocols, and secondary prevention measures for survivors of colorectal cancer [2], endorsing the previously published recommendations of Cancer Care Ontario [3]. Important changes included tailoring surveillance to the individual patient’s risk and functional status, emphasis on surveillance during the first two to four years following diagnosis and treatment, specific recommendations for the elements of surveillance (table 1), and integration of care with the primary care physician. In addition, there is more emphasis on maintaining a healthy body weight, being physically active, and eating a healthy diet. (See "Surveillance after colorectal cancer resection", section on 'Recommendations from major groups'.)

ENDOSCOPY

Advanced imaging techniques in patients with Barrett's esophagus (January 2014)

Dysplasia in Barrett's esophagus is often patchy in extent and severity. Endoscopists traditionally have relied on random biopsy sampling techniques to identify dysplasia and, consequently, dysplastic areas can easily be missed because of biopsy sampling error. Advanced imaging techniques (eg, chromoendoscopy or narrow band imaging [NBI]) have been proposed to enhance the identification of dysplastic areas. A meta-analysis of 14 studies found that advanced imaging techniques increased the diagnostic yield for dysplasia or cancer by 34 percent compared with random biopsy sampling [4]. The increase in yield was similar for chromoendoscopy and virtual chromoendoscopy (eg, NBI). Whether this increase in diagnostic yield leads to improved patient outcomes is unclear. (See "Management of Barrett's esophagus", section on 'Endoscopic techniques'.)

ESOPHAGEAL AND GASTRIC DISEASE

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 [5]. 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'.)

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) [6]. 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'.)

HEPATOLOGY

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 [7]. The risk of decompensation in HIV/HCV coinfected patients is even greater in the absence of antiretroviral therapy [8]. 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 [9]. 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 [10]. 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".)

Ultrasound-based transient elastography in chronic liver disease (January 2014)

Several models have been developed to predict outcomes in patients with cirrhosis, such as the Model for End-stage Liver Disease and the Child-Pugh score. The liver stiffness measurements obtained using ultrasound-based transient elastography may also help predict the risk of developing adverse outcomes. In a meta-analysis of prospective studies in patients with chronic liver disease, baseline liver stiffness was associated with an increased risk of hepatic decompensation, hepatocellular carcinoma development, and death [11]. (See "Tests used for the noninvasive assessment of hepatic fibrosis", section on 'Ultrasound-based transient elastography'.)

Diagnostic paracentesis for cirrhosis and ascites (February 2014)

Diagnostic paracentesis at the time of hospitalization may be associated with decreased mortality in patients with cirrhosis and ascites. A database study that included 17,711 such patients hospitalized for the management of ascites or encephalopathy found that in-hospital mortality rates were 24 percent lower in patients who underwent paracentesis compared with those who did not [12]. This study supports the practice of performing diagnostic paracentesis in patients with ascites and cirrhosis who are admitted to the hospital for the management of ascites or hepatic encephalopathy. (See "Diagnostic and therapeutic abdominal paracentesis", section on 'Indications'.)

Potential for interferon-free regimens in chronic HCV genotype 1 infection (January 2014)

Rapid progress is being made towards developing all-oral, interferon-free regimens that achieve excellent rates of sustained virologic response (SVR), and thus effective cure, for genotype 1 hepatitis C virus (HCV) infection, even among patients who had not previously responded to peginterferon and ribavirin. Genotype 1 infection is the most common in North America and Europe and has traditionally been difficult to treat. In two trials of different interferon-free regimens in genotype 1 infected patients without cirrhosis, including both treatment-naive and experienced individuals, SVR was achieved in 83 to 98 percent, depending on the specific regimen [13,14]. Although most of the agents in these regimens are not currently available, these results highlight the feasibility of cure of genotype 1 HCV infection without the need for interferon and should thus inform the decision on whether to defer antiviral treatment to wait for these new agents. (See "Treatment regimens for chronic hepatitis C virus genotype 1", section on 'Deciding when to treat' and "Investigational therapies for hepatitis C virus infection", section on 'Interferon-free DAA combinations'.)

IDSA guidelines for vaccination of immunocompromised hosts (January 2014)

The Infectious Diseases Society of America has published new guidelines for vaccination of immunocompromised hosts, including hematopoietic cell transplant recipients, solid organ transplant recipients, as well as patients with cancer, asplenia, primary immunodeficiency disorders, chronic inflammatory conditions, HIV infection, and chronic inflammatory diseases receiving immunosuppressive agents [15]. The document includes recommendations about the appropriate use (and avoidance) of specific vaccines in immunocompromised hosts. (See "Immunizations in hematopoietic cell transplant candidates and recipients" and "Immunizations in solid organ transplant candidates and recipients" and "Immunizations in patients with cancer" and "Prevention of sepsis in the asplenic patient".)

Pregnancy outcomes in women with primary sclerosing cholangitis (January 2014)

Data are limited with regard to pregnancy in women with primary sclerosing cholangitis (PSC). In a population-based study from Sweden, 229 singleton births from women with PSC were compared with over two million births from mothers without PSC [16]. PSC was associated with increases in the risks of preterm birth and need for cesarian delivery, but not with small for gestational age, congenital anomalies, stillbirth, or neonatal death. This study suggests that pregnancy should not be discouraged in women with PSC. (See "Pregnancy in women with pre-existing chronic liver disease", section on 'Primary sclerosing cholangitis'.)

Sofosbuvir and simeprevir for genotype 1 chronic hepatitis C infection (December 2013)

Sofosbuvir, a hepatitis C virus (HCV) polymerase inhibitor, and simeprevir, a HCV protease inhibitor, are currently becoming available in the United States and elsewhere for treatment of chronic genotype 1 HCV infection. Regimens that include these agents offer high sustained virological response (SVR) rates, more favorable adverse effect profiles than earlier regimens, ease of administration, and relatively short treatment durations [17-20]. However, regimens for genotype 1 infection generally continue to include interferon. Interferon-free regimens are expected in the near future, and it is reasonable for many patients to defer treatment while awaiting newer therapies. Most patients with chronic genotype 1 HCV infection who are candidates for and desire therapy at this time should be treated with peginterferon, weight-based ribavirin, and a direct-acting antiviral (DAA). If available, we recommend the DAAs sofosbuvir or simeprevir rather than telaprevir or boceprevir. Choice of regimens for specific populations of patients are further discussed in the topic. A joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America has also released guidelines on the use of these agents for the treatment of chronic hepatitis C infection [21]. (See "Treatment regimens for chronic hepatitis C virus genotype 1".)

Sofosbuvir for genotype 2 and 3 chronic hepatitis C infection (December 2013)

Sofosbuvir, a hepatitis C virus (HCV) polymerase inhibitor, is becoming available in the United States and elsewhere for the treatment of genotype 2 and genotype 3 chronic HCV infection. Despite relatively high sustained virologic response (SVR) rates with only 24 weeks of peginterferon and ribavirin among most patients with genotype 2 or 3 infection, the many contraindications and side effects associated with interferon have precluded therapy for many patients. Thus, the introduction of sofosbuvir, which offers the possibility of an effective, well-tolerated, all-oral, interferon-free regimen for most genotype 2 and 3 infected patients [17,22,23], represents a major milestone in the management of chronic HCV infection. Where available, for most patients with genotype 2 and 3 chronic HCV infection, we recommend the combination of sofosbuvir and ribavirin, rather than peginterferon and ribavirin. Choice of regimens for specific populations of patients are further discussed in the topic. A joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America has also released guidelines on the use of these agents for the treatment of chronic hepatitis C infection [21]. (See "Treatment regimens for chronic hepatitis C virus genotypes 2 and 3".)

Antidepressants as prophylaxis for interferon alfa induced depression (November 2013)

For patients who are treated with interferon, the common side effect of depression can be prevented with antidepressants. Randomized trials have previously yielded conflicting results about the benefits of prophylactic antidepressants, but meta-analyses have found that prophylaxis is beneficial. A new analysis of eight trials including nearly 600 patients compared antidepressants (selective serotonin reuptake inhibitors) with placebo for preventing depression in patients who were about to start interferon for hepatitis C or malignant melanoma [24]. Major depression was less likely to occur during interferon treatment in patients who received antidepressants (odds ratio 0.4). (See "Neuropsychiatric side effects associated with interferon-alfa plus ribavirin therapy: Treatment and prevention", section on 'When to treat for interferon psychiatric side effects'.)

PANCREATIC AND BILIARY DISEASE

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 [25]. 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'.)

Open versus minimally-invasive pancreaticoduodenectomy (February 2014)

Laparoscopic pancreaticoduodenectomy for pancreatic head tumors is a complex procedure suited only for select patients treated at high volume centers experienced with minimally-invasive techniques. A systematic review identified six retrospective studies that compared outcomes of open versus minimally-invasive pancreaticoduodenectomy in more than 500 patients [26]. Overall morbidity was similar between the groups, and differences in other outcomes were likely attributable to differences in patient selection; larger tumors and those with vascular involvement were generally treated with an open procedure. Longer-term studies are needed to assess late oncologic outcomes. (See "Surgical resection of lesions of the head of the pancreas", section on 'Open versus minimally-invasive'.)

SMALL BOWEL AND COLONIC DISEASE

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 [27]. 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 [28]. 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 strong placebo effect. However, a small 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 [29]. 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'.)

Physical activity and risk of inflammatory bowel disease (December 2013)

In two large prospective cohort studies (Nurse’s Health Study I and II) that included 194,711 women, the risk of Crohn disease but not ulcerative colitis was inversely associated with physical activity [30]. The absolute risk of Crohn disease among women in the highest and lowest fifth of physical activity was 6 and 16 events per 100,000 person-years, respectively. However, the mechanism of the association between physical activity and Crohn disease and whether physical activity is associated with a reduction in disease activity in patients with existing Crohn disease are unknown. (See "Definition, epidemiology, and risk factors in inflammatory bowel disease", section on 'Physical activity'.)

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REFERENCES

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