What's new in gastroenterology and hepatology

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.

ENDOSCOPY

Updated guidelines on preventing post-ERCP pancreatitis (March 2023)

The American Society of Gastrointestinal Endoscopy (ASGE) has published updated guidelines on preventing pancreatitis related to endoscopic retrograde cholangiopancreatography (ERCP) [1]. The guidelines endorse several preventive strategies including use of nonsteroidal anti-inflammatory drugs administered rectally prior to ERCP, a guidewire-assisted cannulation technique, and peri-and post-procedural intravenous hydration. For patients at higher risk for pancreatitis, ASGE recommends temporary pancreatic stent placement. Our approach is generally consistent with these guidelines. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis", section on 'Rectal nonsteroidal anti-inflammatory drugs'.)

ESOPHAGEAL AND GASTRIC DISEASE

Monitoring patients with eosinophilic esophagitis (February 2023)

Eosinophilic esophagitis (EoE) is a chronic condition; however, the optimal strategy for long-term monitoring is unclear. A panel of international experts recently published recommendations for monitoring patients with clinically stable EoE [2]. The recommendations included follow-up visits every 12 to 24 months and individualizing the decision to perform upper endoscopy based on symptoms, prior esophageal pathology, medication adjustments, and clinician and patient preferences. Our approach to monitoring patients with EoE is consistent with the expert recommendations. (See "Treatment of eosinophilic esophagitis (EoE)", section on 'Introduction'.)

Dupilumab for eosinophilic esophagitis (January 2023)

Therapeutic options for eosinophilic esophagitis (EoE) are expanding. In a two-part trial in patients with EoE that had not responded to proton pump inhibitor therapy, weekly dupilumab resulted in higher rates of histologic improvement after 24 weeks relative to placebo (part A [weekly dupilumab]: 60 versus 5 percent, and part B [dupilumab every 2 weeks]: 59 versus 6 percent) [3]. Dupilumab also improved dysphagia symptom scores. Based on these findings, the US Food and Drug Administration approved dupilumab for EoE in patients ≥12 years of age who weigh ≥40 kg [4]. Future studies will help to inform the role of dupilumab in EoE management. (See "Treatment of eosinophilic esophagitis (EoE)", section on 'Options for nonresponders'.)

HEPATOLOGY

Liver transplantation for severe alcohol-associated hepatitis (January 2023)

Liver transplantation (LT) can be lifesaving for patients with severe alcohol-associated hepatitis (AH), but studies evaluating patient selection are limited. In a study including 241 patients with AH who underwent LT, a prior history of liver decompensation was associated with higher risks of post-LT mortality and harmful alcohol use compared with no prior decompensation (adjusted hazard ratios 2.72 and 1.77, respectively) [5]. Additional studies with long-term follow-up are needed to optimize criteria for patient selection. (See "Liver transplantation for alcohol-associated liver disease", section on 'Patients with severe alcohol-associated hepatitis (AH)'.)

Obeticholic acid for primary biliary cholangitis (January 2023)

Obeticholic acid is a second-line therapy for primary biliary cholangitis (PBC) in the absence of cirrhosis. However, the long-term benefits of obeticholic acid are uncertain. In a recent study, 209 patients treated with obeticholic acid were compared with untreated patients from two disease registries (Global PBC and PBC-UK) [6]. After six years of follow-up, obeticholic acid was associated with lower rates of mortality or liver transplantation compared with no obeticholic acid use (2 versus 10 and 13 percent, respectively). These data lend support for long-term therapy with obeticholic acid. (See "Overview of the management of primary biliary cholangitis", section on 'Subsequent therapy'.)

Markers of liver fibrosis and risk of surgical mortality (December 2022)

The benefit of checking preoperative liver biochemistries in healthy individuals is uncertain because most patients with abnormal biochemistries do not have advanced liver disease. However, emerging data suggested that an elevated FIB-4 score, which consists of age, aminotransferases, and platelet count, may be associated with increased surgical mortality. In a large cohort study of individuals without known liver disease, a preoperative FIB-4 score ≥2.67 (defined as the threshold for advanced fibrosis) was associated with increased risk of intraoperative mortality, mortality during hospitalization, and 30-day mortality [7]. While biochemical markers of liver disease may have a future role for assessing surgical risk, additional studies are needed to confirm these findings. (See "Assessing surgical risk in patients with liver disease", section on 'Screening for liver disease before surgery'.)

PANCREATIC AND BILIARY DISEASE

Fluid resuscitation in acute pancreatitis (October 2022)

Fluid therapy is central to the management of acute pancreatitis, but recommendations on the volume of intravenous fluid required have varied. In a randomized trial, 249 patients with acute pancreatitis were assigned to aggressive fluid resuscitation (lactated Ringer solution bolus of 20 mL/kg followed by 3 mL/kg/hour) versus moderate resuscitation (1.5 mL/kg/hour with a 10 mL/kg bolus in patients with hypovolemia) with subsequent goal-directed management [8]. There was no difference in rates of moderately severe or severe pancreatitis or duration of hospitalization, but the trial was terminated early due to higher rates of fluid overload in the aggressive resuscitation group (20 versus 6 percent). This study supports our approach to use moderate fluid resuscitation with goal-directed therapy in patients with acute pancreatitis. (See "Management of acute pancreatitis", section on 'Fluid replacement'.)

SMALL BOWEL AND COLONIC DISEASE

New guidelines on the role of biomarkers in ulcerative colitis (March 2023)

The American Gastroenterological Association has published new guidelines on using biomarkers for monitoring patients with ulcerative colitis [9]. The guidelines emphasize that noninvasive biomarkers may serve as surrogates for endoscopic evaluation and may complement a symptom-based monitoring strategy. The recommendations include measuring fecal calprotectin, fecal lactoferrin, and/or C-reactive protein periodically to screen for colonic inflammation in asymptomatic patients. Abnormal biomarkers prompt further assessment with lower endoscopy and may guide adjustments in therapy. Our approach to using biomarkers in ulcerative colitis is consistent with these guidelines. (See "Medical management of low-risk adult patients with mild to moderate ulcerative colitis", section on 'Monitoring during remission'.)

Fecal microbiota rectal suspension for preventing recurrent Clostridioides difficile infection (March 2023)

In 2022, the US Food and Drug Administration approved a fecal microbiota rectal suspension live biotherapeutic product (Rebyota) for preventing recurrent Clostridioides difficile infection (CDI) in adults with ≥2 prior episodes [10]. It is administered rectally via an enema 24 to 72 hours after the last dose of antibiotics for CDI treatment. In clinical trials of this product, 71 percent of participants did not have a recurrence within eight weeks of their prior CDI and none had a serious adverse event [11]. It remains to be seen how this new fecal microbiota rectal suspension will compare with traditional methods of fecal microbiota transplantation and with bezlotoxumab and whether it is a cost-effective preventive tool for CDI recurrences. (See "Fecal microbiota transplantation for treatment of Clostridioides difficile infection", section on 'Stool-based products'.)

Updated guidelines on celiac disease (January 2023)

The diagnosis of celiac disease in adults with elevated celiac serologies usually requires duodenal biopsies for confirmation. However, updated American College of Gastroenterology celiac disease guidelines state that a non-biopsy approach may be used in selected situations [12]. For example, symptomatic adults who are unwilling or unable to undergo upper endoscopy but have a high level of tissue transglutaminase immunoglobulin A (>10-fold elevation above the upper limit of normal) with a positive endomysial antibody in a second blood sample can be diagnosed as likely celiac disease. (See "Diagnosis of celiac disease in adults", section on 'Patients unable/unwilling to undergo upper endoscopy'.)

Use of anti-tumor necrosis factor therapy for inflammatory bowel disease in pregnancy (November 2022)

Data on the use of anti-tumor necrosis factor (TNF) agents for treatment of inflammatory bowel disease (IBD) during pregnancy are accumulating. In a population-based study including >5000 pregnancies exposed to these agents from conception, use beyond 24 weeks of gestation was associated with a 7 percent reduction in the relative risk of an IBD flare between 32 weeks of gestation and 6 months postpartum compared with stopping therapy, after adjusting for factors such as IBD type and glucocorticoid use [13]. In addition, anti-TNF therapy was not associated with increased risk of adverse pregnancy outcomes. These data support our approach of continuing anti-TNF therapy throughout pregnancy in patients with IBD. (See "Fertility, pregnancy, and nursing in inflammatory bowel disease", section on 'Anti-tumor necrosis factor agents'.)

Therapeutic drug monitoring for patients with inflammatory bowel disease (October 2022)

For patients with inflammatory bowel disease (IBD) in remission, the benefits of therapeutic drug monitoring (ie, measuring serum concentrations of anti-tumor necrosis factor [TNF] agents and antidrug antibodies) are uncertain. In a meta-analysis of nine trials including 1405 patients with IBD in remission with anti-TNF therapy, there were no significant differences in rates of sustained remission, antidrug antibodies, or serious adverse events between patients who had therapeutic drug monitoring versus those managed conventionally [14]. We reserve drug monitoring for patients with IBD in clinical remission who are at higher risk of complications from a disease flare, rather than performing it routinely in all patients. (See "Treatment of Crohn disease in adults: Dosing and monitoring of tumor necrosis factor-alpha inhibitors", section on 'Patients in remission'.)