The Year's Top 10 Gastroenterology Articles: Practice-Changing Info You Need to Know

David A. Johnson, MD


December 19, 2018

The gastrointestinal literature did not lack for exciting new science and clinical management recommendations in 2018. This list represents, from my perspective, the 10 most valuable, practice-changing, must-read articles from this year. These articles have changed my approach in several clear and meaningful ways, and I recommend that clinicians see how they too can best apply these disease management paradigms in their own practices.

This list is not presented in numerical order of importance. Instead, each brief summary provided here aims to highlight important new findings in several areas on gastrointestinal care. All 10 articles referenced here are well worth reading in their entirety.

AGA Clinical Practice Update: Surgical Risk Assessment and Perioperative Management in Cirrhosis

Northup PG, Friedman LS, Kamath PS
Clin Gastroenterol Hepatol. 2018 Sep 28. [Epub ahead on print]

Given the increasing prevalence of chronic liver disease due to causes both viral and nonviral (in particular nonalcoholic fatty liver disease), coupled with increasing survival due to improved treatment paradigms, there are more patients who ultimately require surgical intervention for various reasons.

This review provides an excellent evidence-based set of recommendations for preoperative prediction of surgical outcomes and management of cirrhosis in the pre/peri/postoperative period. It serves as a great go-to reference for assessment and management of this complicated patient population.


American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis

Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee Gastroenterology. 2018;154:1096-1101

This expert panel guideline provides the current best practice, evidence-based recommendations for acute pancreatitis. It contains several notable endorsements, such as goal-directed fluid replacement, early (within 24 hours) enteral feeding including for those who are unable to tolerate oral feeding, and cholecystectomy prior to discharge for patients with biliary pancreatitis.

The excellent accompanying technical review[1] is also well worth a read to further expand upon these recommendations.


The Gastroenterologist's Guide to Management of the Post-Liver Transplant Patient

Chascsa DM, Vargas HE
Am J Gastroenterol. 2018;113:819-828

There are approximately 6500 liver transplants performed in the United States annually. Caring for these patients requires an interdisciplinary team at the transplant centers, as well as appropriate management by the primary care gastroenterologist. Accordingly, these providers must be astute regarding the ongoing management of related cardiovascular, metabolic, renal, and skeletal (osteoporosis) post-transplant issues. They also need to be familiar with the initial evaluation of postoperative conditions, complications, immunosuppression, and drug-drug interactions.

This excellent paper provides an up-to-date and concise review of the primary (nontransplant) gastroenterologist's role. It is a must read for all who have exposure to these patients.


ACG Clinical Guideline: Management of Crohn's Disease in Adults

Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE
Am J Gastroenterol. 2018;113:481-517

The approach to Crohn's disease continues to evolve with regard to its diagnosis and medical and surgical management. Advances in biologic and immunologic therapies have provided a broader array of treatment options for patients. This guideline covers the spectrum from mild to complicated disease, and is constructed to be flexible with evidence-based options for best practice that clinicians should find to be an invaluable reference.


Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

Dellon ES, Liacouras CA, Molina-Infante J, et al
Gastroenterology. 2018:155:1022-1033

Once viewed as something seen primarily in the pediatric population, eosinophilic esophagitis (EoE) has since emerged as a prevalent adult disease. More recent data has demonstrated a significant number of patients with mucosal esophageal eosinophilia coupled with typical endoscopic and clinical patterns of EoE who respond entirely to use of proton pump inhibitors (PPIs). Many experts have suggested that such patients should be diagnosed with proton pump-responsive esophageal eosinophilia and not EoE.

This international panel of EoE experts concludes that PPIs are a treatment of esophageal eosinophilia due to EoE and a PPI trial response is not required to identify patients without other causes of esophageal eosinophilia (eg, drug hypersensitivity, Crohn's disease, achalasia, hypereosinophilic syndrome, infections). Therefore, EoE cannot be excluded in patients who have normal endoscopic/histologic findings if PPI therapy was ongoing approximate to the time of endoscopy.


Esomeprazole and Aspirin in Barrett's Oesophagus (AspECT): A Randomized Factorial Trial

Jankowski JAZ, de Caestecker J, Love SB, et al
Lancet. 2018;392:400-408

Barrett's esophagus is well recognized as a premalignant condition. Retrospective analyses have suggested a risk reduction for advanced dysplasia and cancer in patients on chronic PPI therapy.

In this industry-sponsored phase 3 trial, 2500 patients were randomized to low- (20 mg/d) or high- (40 mg bid) dose PPI with or without 325-mg aspirin for at least 8 years. High-dose esomeprazole was superior in time ratio (TR) to low-dose in risk reduction of the composite endpoint of all-cause mortality or progression of Barrett's esophagus to high-grade dysplasia or esophageal cancer (TR, 1.27; 95% confidence interval [CI], 1.01-1.58). Similarly, aspirin was not significantly better compared with no aspirin (TR, 1.24; 95% CI, 0.98-1.57). The combination of both high-dose esomeprazole and aspirin provided the strongest protective effect (TR, 1.59; 95% CI, 1.14-2.23). The numbers needed to treat were 34 for PPIs and 43 for aspirin. Study-related adverse events were rare (1%).

This study provides a compelling argument for a risk-benefit consideration of chemoprevention in patients with Barrett's esophagus.


Transplanting Hepatitis C Virus-Infected Versus Uninfected Kidneys Into Hepatitis C Virus-Infected Recipients: A Cost-Effective Analysis

Eckman MH, Woodle S, Thaker CV, Paterno F, Sherman KE
Ann Intern Med. 2018:169:214-223

Although more than 100,000 patients in the United States start dialysis each year, and there are currently more than 500,000 patients receiving dialysis for end-stage renal disease, only 3.8% receive a renal transplant. Much of this is because of limited organ availability, further compromised by reduction/exclusion of donor infection with hepatitis C virus (HCV). Wait time for HCV-negative donors is approximately double, as an estimated 10%-15% dialysis patients test positive for HCV.

This decision model analysis demonstrated that the transplant of an HCV-infected kidney, followed by HCV treatment, was more cost effective and increased the quality-adjusted life expectancy. Clearly, this is the new standard, given the confidence we have in the near-absolute effectiveness of direct-acting antiviral therapies for curing HCV infection.


Harms Reporting in Randomized Controlled Trials of Interventions Aimed at Modifying Microbiota: A Systematic Review

Bafeta A, Koh M, Riveros C, Ravaud P
Ann Intern Med. 2018;169:240-247

Probiotics are live microorganisms, which when consumed, are intended to provide health benefits improving or restoring a more normative gut flora. Currently, it is estimated that over 4 million adults in the United States use probiotics generally for purported life quality improvement or risk reduction of disease. Additionally, it is estimated that 60% of primary care providers recommend them for patient use. Overall, probiotics have been considered to be generally safe, with rare reports of untoward side effects.

This systematic review analyzed 265 trials, of which 28% reported no harms-related data, 37% reported no safety data, and 80% reported no numbers of serious adverse effects. Overall, 98% of trials did not define adverse or serious adverse effects.

This report concluded that probiotics cannot be viewed as safe, given the absence of qualified harms reporting.


Avatrombopag Before Procedures Reduces Need for Platelet Transfusion in Patients With Chronic Liver Disease and Thrombocytopenia

Terrault N, Chen YC, Izumi N, et al
Gastroenterology. 2018:155:705-718

Cirrhotic patients typically have risks for diagnostic or operative interventions, given their frequent reduction in vitamin K-dependent coagulation factors (reduced international normalized ratio) as well as risk of thrombocytopenia. These patients often may require platelet transfusions prior to these interventions. Avatrombopag is a thrombopoietin-receptor agonist developed to provide platelet count increases as an alternative to platelet transfusions.

This report presents the two randomized, placebo-controlled phase 3 trials for patients with thrombocytopenia (<50,000/mm3) who were stratified as being at low (eg, paracentesis, endoscopy), moderate (eg, liver biopsy, chemoembolization), or high (eg, vascular catheterization, laparoscopic procedures, transjugular intrahepatic portosystemic shunt, dental procedures) risk for bleeding. The primary endpoint was the proportion of patients not requiring platelet transfusion or rescue procedures for bleeding up to 7 days post-intervention.

In these two pivotal studies, compared with those receiving placebo, the primary endpoint was achieved by a significantly higher percentage of those receiving avatrombopag at 60 mg (65.6% vs 22.9%, P < .0001 in ADAPT-1; and 68.6% vs 34.9%, P < .001 in ADAPT-2) and 40 mg (88.1% vs 38.2%, P <.0001 in ADAPT-1; and 87.9% vs 33.3%, P < .001 in ADAPT-2). Thrombotic (including portal vein thrombosis) and thromboembolic complications have been reported with the use of thrombopoietin-receptor agonists, but the risk-benefit of this new agent should be considered for appropriate patients.


Long-term Albumin Administration in Decompensated Cirrhosis (ANSWER): An Open-Label Randomised Trial

Caraceni P, Riggio O, Angeli P, et al; ANSWER Study Investigators
Lancet. 2018:391:2417-2429

Ascites is the most common cause of decompensation in patients with liver disease, and is associated with a poor prognosis and increased related mortality. The role of long-term repeated albumin administration for patients with ascites has been controversial. The scientific premise has been that this would increase plasma colloid oncotic pressure and better regulate the fluid balance between the plasma and interstitial space, as well as increase renal blood flow through the oncotic pressure effect.

In this intent-to-treat analysis, 431 patients were randomized to receive standard diuretic therapies with or without weekly intravenous (IV) albumin infusions. The 18-month survival was significantly higher in the albumin infusion group (77% vs 66%; P = .028). The number needed to treat is 9. This is a profound effect, given that the endpoint is mortality.

Clinicians need to recognize that cirrhosis is associated with upregulation of prostaglandin e2 (PGE2), which has pleiotropic immunomodulatory function. This reduces immune cell trafficking to tissue compartments, blunts antimicrobial T helper cell function, and suppresses bactericidal activity. This is bad for patients with cirrhosis in whom the leading cause of death is infection. Additionally, PGE2 suppresses renal blood flow (four receptor sites on the kidney). However, IV albumin attenuates all these adverse effects and functions as a "sink" for circulating PGE2.

This article has changed my practice. It remains to be defined what the serum albumin threshold target should be for this approach (eg, 3.0 vs 3.5 mg/dL). The costs and availability of parenteral albumin are not insignificant, but the mortality risk reduction and hospital admission reduction is profound.


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