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Abstract

Medical therapy is the mainstay of treatment for gastroesophageal reflux disease (GERD). However, up to 40% of patients do not respond well to medical therapy or are tired of lifelong treatment.1Everhart J.E. Ruhl C.E. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases.Gastroenterology. 2009; 136: 376-386Abstract Full Text Full Text PDF PubMed Scopus (423) Google Scholar Surgical fundoplication is an alternative to maintenance treatment with a proton-pump inhibitor.2Lundell L. Miettinen P. Myrvold H.E. et al.Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis.Clin Gastroenterol Hepatol. 2009; 7: 1292-1298Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar For patients who do not want surgery, various endoscopic treatment modalities have been advocated for the treatment of GERD, such as radiofrequency augmentation to the lower esophageal sphincter (LES), endoscopic suturing of the LES, and silicone injection into the LES. However, these endoscopic techniques have produced mixed results, and many have been withdrawn from the market. Stretta, a form of radiofrequency ablation to the LES, has been reintroduced to the market since 2010. Its clinical efficacy remains controversial.3Katz P.O. Gerson L.B. Vela M.F. Guidelines for the diagnosis and management of gastroesophageal reflux disease.Am J Gastroenterol. 2013; 108: 308-328Crossref PubMed Scopus (1143) Google Scholar, 4Franciosa M. Triadafilopoulos G. Mashimo H. Stretta Radiofrequency Treatment for GERD: A Safe and Effective Modality.Gastroenterol Res Pract. 2013; : 783815PubMed Google Scholar To date, the American College of Gastroenterology has not recommended Stretta for the treatment of GERD.5Kahrilas P.J. Shaheen N.J. Vaezi M.F. et al.American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease.Gastroenterology. 2008; 135: 1383-1391Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar On the contrary, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has adopted a positive attitude towards Stretta as a therapeutic modality in patients with GERD.6Auyang E.D. Carter P. Rauth T. et al.SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).Surg Endosc. 2013; 27: 2658-2672Crossref PubMed Scopus (54) Google Scholar This recommendation was largely based upon a meta-analysis of pooled data from 20 studies.7Perry K.A. Banerjee A. Melvin W.S. Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis.Surg Laparosc Endosc Percutan Tech. 2012; 22: 283-288Crossref PubMed Scopus (79) Google Scholar However, there are doubts about the quality of this meta-analysis. For example, some of the studies included were of poor quality. In this issue of Clinical Gastroenterology and Hepatology, Lipka et al8Lipka S. Kumar A. Richter J.E. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: A systematic review and meta-analysis.Clin Gastroenterol Hepatol. 2015; 13: 1058-1067Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar searched MEDLINE and The Cochrane Library, along with other databases, for randomized controlled trials of Stretta in patients with GERD. Primary outcomes were physiologic parameters of GERD, including normalization of esophageal pH values and augmentation of LES pressure. Secondary outcomes were health-related quality of life and reduced use of proton pump inhibitors. They reviewed data from 4 trials that involved a total of 165 patients. The pooled results showed no difference between Stretta and sham or treatment with PPI in patients with GERD for both primary and secondary outcomes. Furthermore, they also found serious complications associated with the Stretta procedure, including pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and at least deaths. Clinicians and policy makers should revisit the true efficacy and safety of Stretta after reading this article. See page 1058. Diarrhea is a common indication for colonoscopy. Although most patients with endoscopically normal looking colon have functional bowel disorder, a small proportion of patients may suffer from microscopic colitis. The latter is characterized by 3 distinct features, namely, a history of chronic watery diarrhea, normal endoscopic appearance of the colon, and a distinct histologic pattern (2 subtypes: collagenous and lymphocytic colitis).1Magro F. Langner C. Driessen A. et al.European consensus on the histopathology of inflammatory bowel disease.J Crohns Colitis. 2013; 7: 827-851Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Microscopic colitis is a rare disease, with a reported incidence is only up to 21 per 100,000 per year.2Gentile N.M. Khanna S. Loftus Jr., E.V. et al.The epidemiology of microscopic colitis in Olmsted County from 2002 to 2010: a population-based study.Clin Gastroenterol Hepatol. 2014; 12: 838-842Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar However, endoscopists should not overlook this condition because it responds well to treatment with budesonide.3Stewart M.J. Seow C.H. Storr M.A. Prednisolone and budesonide for short- and long-term treatment of microscopic colitis: systematic review and meta-analysis.Clin Gastroenterol Hepatol. 2011; 9: 881-890Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar While the diagnosis of microscopic colitis relies on taking random biopsies of normal looking colonic mucosa for histologic assessment, it is not cost-effective to do routine biopsies on patients with normal colonoscopy. In this issue, Kane et al4Kane J.S. Rotimi O. Everett S.M. et al.Development and validation of a scoring system to identify patients with microscopic colitis.Clin Gastroenterol Hepatol. 2015; 13: 1125-1131Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar reported a validated scoring system to predict microscopic colitis that aimed to reduce need for random biopsies. They retrospectively analyzed the colonoscopy data of all subjects with chronic diarrhea referred for colonoscopy in Leeds Teaching Hospitals NHS Trust between 2011 and 2012. Patients with macroscopically normal colonic mucosa and random colonic biopsies available were reviewed. A total of 476 patients in 2011 were included in the derivation cohort, 17.9% of patients had microscopic colitis. They found that age ≥50, female gender, proton pump inhibitor or nonsteroidal anti-inflammatory drug use, presence of weight loss, and absence of abdominal pain were significantly associated with microscopic colitis. Using these predictors to create a diagnostic scoring system, the investigators identified an optimal cut-off point of ≥+8 that correctly identified 90.5% of microscopic colitis in the validation cohort. They estimated that this strategy would have avoided over 45% of random colonic biopsies. From healthcare provider’s perspective, this scoring system may help reduce unnecessary colonic biopsies and saves cost. This study reminds endoscopists about the predictors of microscopic colitis in an apparently normal colonoscopic examination. Previous studies also identified other predicting factors such as use of selective serotonin re-uptake inhibitors, statins, and angiotensin converting enzyme inhibitors.5Beaugerie L. Pardi D.S. Review article: drug-induced microscopic colitis - proposal for a scoring system and review of the literature.Aliment Pharmacol Ther. 2005; 22: 277-284Crossref PubMed Scopus (198) Google Scholar Using the proposed scoring system, however, endoscopists need to be aware of the fact that up to 10% of microscopic colitis will be missed. This article is highlighted by an editorial by Darrell S. Pardi (page 1132). See page 1125. Vertical transmission of viral hepatitis B continues to be the most important route of infection in many endemic countries such as China. While vaccination plus administration of hepatitis B immune globulin to newborns from hepatitis B positive mothers has been widely adopted to prevent perinatal transmission, up to 10% of infants still fail to be protected by this strategy.1Deng M. Zhou X. Gao S. et al.The effects of telbivudine in late pregnancy to prevent intrauterine transmission of the hepatitis B virus: a systematic review and meta-analysis.Virol J. 2012; 9: 185Crossref PubMed Scopus (67) Google Scholar Previous studies attempted to explore different strategies to reduce mother-to-infant transmission. For examples, the use of elective caesarian section reduces perinatal transmission as compared to vaginal delivery.2Pan C.Q. Zou H.B. Chen Y. et al.Cesarean Section Reduces Perinatal Transmission of Hepatitis B Virus Infection From Hepatitis B Surface Antigen-Positive Women to Their Infants.Clin Gastroenterol Hepatol. 2013; 11: 1349-1355Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar One key factor in predicting failure of active-passive immunoprophylaxis is high maternal viral load.3del Canho R. Grosheide P.M. Mazel J.A. et al.Ten-year neonatal hepatitis vaccination program, The Netherlands, 1982-1992: protective efficacy and long-ter immunogenicity.Vaccine. 1997; 15: 1624-1630Crossref PubMed Scopus (168) Google Scholar Oral anti-viral drugs therefore have been evaluated to further reduce the risk of perinatal transmission. Lamivudine was the first oral nucleoside analog used in hepatitis B positive mothers. Subsequent studies showed that Telbivudine is more potent than Lamivudine and is safe in pregnancy.4Pan C.Q. Han G.R. Jiang H.X. et al.Telbivudine prevents vertical transmission from HBeAg-positive women with chronic hepatitis B.Clin Gastroenterol Hepatol. 2012; 10: 520-526Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar According to the US Food and Drug Administration, telbivudine and tenofovir belong to category B whereas lamivudine, entecavir and adefovir belong to category C.5Fontana R.J. Side effects of long-term oral antiviral therapy for hepatitis B.Hepatology. 2009; 49: S185-195Crossref PubMed Scopus (215) Google Scholar However, there are limited prospective data on the efficacy and safety of telbivudine in preventing perinatal transmission of hepatitis B infection. In this issue, Wu et al6Wu Q. Huang H. Sun X. et al.Telbivudine prevents vertical transmission of Hepatitis B virus from women with high viral loads: A prospective long-term study.Clin Gastroenterol Hepatol. 2015; 13: 1170-1176Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar conducted a nonrandomized prospective study of telbivudine 600 mg daily from 24th to 32th weeks of gestation in 279 HBeAg-positive pregnant women with levels of HBV DNA >106 IU/mL. One hundred seventy one women who were unwilling to take anti-viral drugs participated as controls. All newborns were vaccinated with a recombinant HBV vaccine and hepatitis B immune globulin. Mother to child transmission of HBV was determined by the presence of HBsAg and HBV DNA in the infant at 6 months. The results were impressive. None of infants whose mothers received telbivudine were tested positive for HBsAg at 6 months, compared to 14.7% of infants in the control group. Over 99% of cord blood had undetectable HBV DNA in the telbivudine group, compared to only 61.5% had undetectable HBV DNA in in the control group. No severe adverse events or complications were observed. A number of issues remain unresolved. First, although the levels of HBV DNA were significantly lower among women given telbivudine, there was no long-term data on virological or biochemical flare-up of hepatitis B infection after withdrawal of Telbivudine. Second, long-term treatment with Telbivudine is associated with a considerable risk of YMDD mutation. It is uncertain whether short-term therapy during pregnancy will have any consequence on the emergence of drug resistant mutation in case the mother requires prolonged treatment in the future. This article is highlighted by an editorial by F. Blaine Hollinger (page 1177). See page 1170. Telbivudine Prevents Vertical Transmission of Hepatitis B Virus From Women With High Viral Loads: A Prospective Long-Term StudyClinical Gastroenterology and HepatologyVol. 13Issue 6PreviewHepatitis B virus (HBV) infection is a leading cause of liver diseases. We investigated the efficacy and safety of telbivudine in preventing transmission of HBV from hepatitis B e antigen–positive pregnant women with high viral loads to their infants in an open-label study. Full-Text PDF No Evidence for Efficacy of Radiofrequency Ablation for Treatment of Gastroesophageal Reflux Disease: A Systematic Review and Meta-AnalysisClinical Gastroenterology and HepatologyVol. 13Issue 6PreviewA radiofrequency ablation technique known as Stretta was recommended by the Society of American Gastrointestinal and Endoscopic Surgeons as an alternative treatment for gastroesophageal reflux disease (GERD). However, randomized controlled trials of the efficacy of Stretta have produced conflicting findings, and those from previous systematic reviews were compromised as a result of deficiencies in study conduct and reporting of findings. We performed a systematic review to evaluate all evidence on the efficacy of Stretta for the management of GERD. Full-Text PDF Development and Validation of a Scoring System to Identify Patients With Microscopic ColitisClinical Gastroenterology and HepatologyVol. 13Issue 6PreviewDiarrhea is a common indication for colonoscopy. Biopsies are collected and analyzed from patients with a macroscopically normal colon to exclude microscopic colitis (MC), but the diagnostic yield is low because most patients have functional disease. We developed and validated a diagnostic scoring system to identify patients with MC to reduce the need to collect biopsies from all patients. Full-Text PDF