The Year in Gastroenterology Literature: 11 Must-Reads

David A. Johnson, MD


December 23, 2021

This year's published gastrointestinal (GI)-related literature was, as usual, abundant. As many of us resumed clinical routines and office hours more typical of pre-pandemic years, we can be forgiven for letting some of the new publications slip by. Blink and you may have missed updated guidelines from the American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG), expert reviews on various disorders, or recent clinical trials about prevalent GI cancers.

To help us all stay in the loop, I've gone through the 2021 GI literature and selected the top articles that I think have the greatest game-changing potential for our clinical practices. These articles are not listed in any order of preference; rather, they're all "must-reads" for ensuring that we continue to offer the best possible treatment to our patients in 2022.

AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review

Clearly, one of the most devastating complications of endoscopic procedures is perforation, given the life-threatening implications it can have. That's why it's so critical for us to quickly recognize and appropriately manage this potential adverse outcome.

Thankfully, the AGA responded to this need by commissioning an expert review for those tasked with performing endoscopic procedures. The review provides an easy-to-use guide in the form of 16 separate pieces of best-practice advice for managing these complications, should they occur. As the authors write, "Although perforation is a serious event, with novel endoscopic techniques and tools, the endoscopist should no longer be paralyzed when it occurs."

What to Do About the Leaky Gut

The term "leaky gut" is increasingly used by both patients and healthcare providers. Although it describes an indiscriminate diagnosis, leaky gut has widespread associations with a broad spectrum of GI and non-GI symptoms and diseases.

In a great review to help guide discussions with our patients, authors Camilleri and Vella from the Mayo Clinic in Rochester, Minnesota, analyze the latest evidence about what causes this intestinal barrier disruption and future pharmacologic approaches to treating it. Particularly valuable is the comprehensive discussion they include of foods that are deleterious to the barrier as well as those that can be supplemented in the diet to promote its integrity.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

The management of common anorectal disease remains a gap in the training of gastroenterologists. This led the ACG to convene a group of experts, who reviewed the full breadth of literature on this topic.

The updated guidelines they produced should be a go-to reference for clinicians. The document summarizes the latest evidence-based definitions, diagnostic criteria, and concepts in evaluating and managing these benign disorders.

ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

C difficile infection (CDI) is a significant occurrence, affecting approximately 500,000 patients every year in the United States and acting as the leading factor in hospital-acquired nosocomial-related death.

This ACG guideline is intended to supplement those recently issued by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. One notable development is that although hospital- and extended care facility–related infection remains an obvious concern, community-acquired infections now account for 35%-48% of CDI. Other recommendations of interest can be found against the use of probiotics for active treatment or for prevention of recurrence, as well as regarding changes in antibiotic treatment for infection and the use of fecal microbial transfer.

Updates on Age to Start and Stop Colorectal Cancer Screening: Recommendations from the US Multi-Society Task Force on Colorectal Cancer

The US Multi-Society Task Force on Colorectal Cancer last issued screening recommendations in 2017. In this focused update to those previous recommendations, they turn their attention to the age to start and stop colorectal cancer screening in average-risk individuals.

Consistent with the most recent recommendations by the American Cancer Society, the Task Force also endorses initiating initial screening in average-risk individuals at 45 years of age. This was the prior recommendation only for Black Americans but notably is now being advised for persons of all ethnicities. They also recommend that decisions for screening between ages 76 and 85 be individualized on the basis of life expectancy greater than 10 years, prior screening history, and comorbidities, and do not advise screening after 85 years.

AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis

Patients with cirrhosis typically have an associated coagulopathy. However, bleeding in these patients typically has balanced elements, and neither thrombocytopenia nor elevated prothrombin time/international normalized ratio (PT/INR) necessarily predicts risks.

This superb set of guidelines from the AGA provides evidence-based/graded recommendations around specific questions centering on testing strategies, preprocedural coagulation-directed prophylaxis, and the assessment and management of thrombosis-related issues in cirrhosis. Particularly of interest are the authors' descriptions of the paradigm shifts that had the field move away from the standard use of fresh frozen plasma.

Age-Specific Rates and Time-Courses of Gastrointestinal and Nongastrointestinal Complications Associated With Screening/Surveillance Colonoscopy

Investigators behind this compelling population-based study evaluated the age-related rates and timing of serious GI and non-GI adverse events associated with screening or surveillance colonoscopy. They found that for those aged 65 years and older, non-GI events predominated over GI complications during a risk range of 1-125 days.

Their analysis highlights the important need to manage vascular-related complications with antiplatelet and anticoagulant medications in these older patients. Endoscopists should not be the physicians stopping these medications for procedures without the specific approval of the care provider in charge.

Definition and Management of Patients With Primary Biliary Cholangitis and an Incomplete Response to Therapy

The standard for the initial treatment of patients with primary biliary cholangitis is ursodeoxycholic acid. In this standout narrative review, the authors argue that achieving a biochemical response from this treatment is essential, as persistently elevated alkaline phosphatase and bilirubin levels are associated with poor outcomes.

The historical target for alkaline phosphatase has been < 1.67 upper limit of normal (ULN) at 1 year (although the authors cite some studies suggesting that the timeline for incomplete response should be 6 months), but lower appears better. Normalization of alkaline phosphatase and attaining bilirubin levels ≤ 0.6 ULN has been associated with the lowest risk for liver transplantation or death.

Management of Gastrointestinal Side Effects of Immune Checkpoint Inhibitors

The development of immune checkpoint inhibitors has revolutionized the treatment of various types of cancer. They are now used as single agents or in combination with chemotherapies as first- or second-line treatment for approximately 50 cancers.

This progress hasn't come without clinical costs. Immune-related adverse events, particularly colonic- and hepatic-related, have significant clinical implications, as they may necessitate interruption or cessation of the immune checkpoint inhibitors. This in-depth review discusses the most recent data and provides practical specific recommendations for the management of these GI complications.

Sugar-Sweetened Beverage Intake in Adulthood and Adolescence and Risk of Early-Onset Colorectal Cancer Among Women

Taking advantage of the massive Nurses' Health Study database, the authors behind this persuasive study evaluated data on beverage consumption from 41,272 participants who responded to validated food frequency questionnaires every 4 years. In doing so, they found that each serving/day increment of sugar-sweetened beverage (SSB) in adolescence (13-18 years) was associated with a 32% increased risk for early-onset colorectal cancer. Compared with consumption of less than 1 serving/week of SSB, a higher intake was associated with a 2.2 times increased risk. Furthermore, replacing each serving/day of SSB in adulthood was associated with a risk reduction for early-onset colorectal cancer of 17%-36%.

Virtually all of the SSBs use high-fructose corn syrup rather than cane sugar, as it is sweeter and cheaper, yet this ingredient is also associated with several potentially devastating GI diseases and non-GI conditions. A 2017 report suggested that the use of high-fructose corn syrup is a "public health crisis," and these latest results only add to that argument. Clinicians need to be more proactive in educating their patients about avoiding these and other adverse dietary components.

AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Diseases: Expert Review

Dysplasia and related colorectal cancer are well-recognized complications of inflammatory bowel disease (IBD). Recent improvements in medical therapies and endoscopic evaluation/intervention have led to dramatic shifts in management, and IBD-related dysplasia is no longer a reflex indication for surgical colonic resection.

This expert review put a much needed spotlight on the recent shifts in practice for identifying and managing IBD-related dysplasia. Clearly, this topic is a significant paradigm shift for anyone performing colonoscopic surveillance for patients with IBD.

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 the 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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