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What's new in gastroenterology and hepatology

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2014. | This topic last updated: Oct 16, 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

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'.)

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 [2]. 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 [3]. 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'.)

ENDOSCOPY

Infection associated with contaminated endoscopes (October 2014)

In January 2014, the Centers for Disease Control and Prevention (CDC) reported that since January 2013, 69 cases of New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae (CRE) had been identified in the United States, 44 of which were from northeastern Illinois [4]. Further investigation identified 39 cases from one hospital [5]. The source of infection was subsequently traced to the elevator channel of a single duodenoscope (the endoscopes used for endoscopic retrograde cholangiopancreatography [ERCP]). No lapses in the cleaning protocol were identified. It is theorized that the complex design of the elevator mechanism makes it more difficult to clean than other parts of endoscopes [5,6]. After changing duodenoscope reprocessing from high-level disinfection to gas sterilization with ethylene oxide, no new cases have been identified. Duodenoscopes should be considered as possible sources for CRE outbreaks in healthcare facilities. (See "Endoscope disinfection", section on 'Carbapenem-resistant Enterobacteriaceae'.)

Preprocedure testing for endoscopic procedures (July 2014)

The American Society for Gastrointestinal Endoscopy has released guidelines regarding testing prior to endoscopic procedures [7]. 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'.)

ESOPHAGEAL AND GASTRIC DISEASE

Intermittent dosing of proton pump inhibitors for peptic ulcer bleeding (October 2014)

Treatment with proton pump inhibitors (PPIs) leads to elevation of gastric pH levels, which stabilizes blood clots and improves clinical outcomes. As a result, PPIs are recommended for all patients with peptic ulcer bleeding. High-dose continuous infusions of intravenous (IV) PPIs have traditionally been recommended for patients presenting with upper gastrointestinal bleeding. However, several meta-analyses of randomized trials have failed to show superior outcomes with high-dose continuous IV proton pump administration compared with intermittent dosing (eg, 40 mg IV twice daily). In addition, intermittent dosing could lead to decreased resource utilization and cost. In the most recent meta-analysis, intermittent dosing was not inferior to high-dose continuous infusions with regard to rebleeding, mortality, need for surgery or repeat intervention, or the need for urgent intervention in patients with peptic ulcers with high-risk stigmata (active bleeding, adherent clot, or a visible vessel) [8]. There was also a trend toward a decreased risk of rebleeding with intermittent dosing. Based on this cumulative evidence, for patients presenting with upper gastrointestinal bleeding, we now recommend treatment with IV pantoprazole, esomeprazol, or omeprazole (where available) at a dose of 40 mg twice daily rather than a high-dose continuous infusion. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Summary and recommendations' and "Overview of the treatment of bleeding peptic ulcers", section on 'Continuous versus intermittent dosing'.)

HEPATOLOGY

Ledipasvir-sofosbuvir for genotype 1 chronic hepatitis C infection (December 2013, MODIFIED October 2014)

Interferon-free options for chronic genotype 1 hepatitis C virus (HCV) infection are increasing. A once-daily combination pill of two direct-acting antiviral agents, ledipasvir and sofosbuvir, is becoming available in the United States and elsewhere. In several large open-label trials, ledipasvir-sofosbuvir achieved sustained virologic response (SVR) rates exceeding 90 percent in genotype 1 infected patients regardless of treatment history or presence of cirrhosis [9-11]. For all patients with chronic genotype 1 HCV infection, we favor the regimen of ledipasvir-sofosbuvir because of its efficacy, its favorable adverse effect profile, its ease of administration, and extensive data to support its use. For treatment-naïve patients, treatment duration is eight weeks for those without cirrhosis and a viral level <6 million international units/mL, and 12 weeks for those with cirrhosis or a higher viral level. For treatment-experienced patients, treatment duration is 12 weeks for those without cirrhosis and 24 weeks for those with cirrhosis. (See "Treatment regimens for chronic hepatitis C virus genotype 1", section on 'Selection of treatment regimens'.)

Granulocyte colony-stimulating factor for severe alcoholic hepatitis (September 2014)

Granulocyte colony-stimulating factor (GCSF) has been proposed as a possible treatment for severe alcoholic hepatitis because it may mobilize bone marrow-derived stem cells and promote hepatic regeneration. In a randomized, nonblinded trial, 46 patients with severe alcoholic hepatitis were assigned to receive standard medical care (pentoxifylline with supportive care) plus GCSF or standard medical care alone [12]. Survival at 90 days was higher in the patients who received GCSF than in those who did not (78 versus 30 percent). However, the survival rate in patients who received standard medical care alone was lower than has been seen in other trials of pentoxifylline, so the role of GCSF in the treatment of severe alcoholic hepatitis remains unclear. (See "Alcoholic hepatitis: Natural history and management", section on 'Possibly effective treatments'.)

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 [13]. 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 [14]. 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 [15]. 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 [16]. 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'.)

PANCREATIC AND BILIARY DISEASE

Imaging prior to laparoscopic cholecystectomy (October 2014)

In patients who need to undergo cholecystectomy but are at intermediate-risk for having a common bile duct stone, imaging (endoscopic ultrasound [EUS] or magnetic resonance cholangiopancreatography) is typically obtained prior to surgery to exclude a stone. An alternative is to proceed to laparoscopic cholecystectomy with intraoperative cholangiography. This approach was examined in a randomized trial with 100 patients at intermediate risk of having a common bile duct stone [17]. Patients were assigned to either laparoscopic cholecystectomy with intraoperative cholangiography or initial EUS (followed by ERCP if positive) and subsequent laparoscopic cholecystectomy. Patients who proceeded directly to surgery had a shorter median length of stay, without a difference in complication rates or mortality. If a surgeon experienced with intraoperative cholangiography is available, proceeding directly to laparoscopic cholecystectomy is a reasonable alternative to obtaining preoperative imaging. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management", section on 'Intermediate-risk patients'.)

Postoperative antibiotics following cholecystectomy (October 2014)

Antibiotics are often given to patients with acute cholecystitis to prevent infectious complications, but few studies are available to guide the use of postoperative antibiotics following cholecystectomy in this setting. In a multicenter trial that randomly assigned 414 patients with mild or moderate calculous cholecystitis to continue their preoperative antibiotic regimen or to receive no antibiotics following cholecystectomy, there were no differences in postoperative infection rates [18]. The results of this trial support the common practice of discontinuing antibiotics after cholecystectomy in patients with uncomplicated cholecystitis. Clinical judgment should dictate antibiotic management in complicated cases. (See "Treatment of acute calculous cholecystitis", section on 'Antibiotics'.)

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 [19]. 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'.)

SMALL BOWEL AND COLONIC DISEASE

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) [20]. 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 [21]. 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 [22]. (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'.)

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REFERENCES

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