American Gastroenterological Association Recommends Research Articles

The latest recommendations for the pharmacological treatment of irritable bowel syndrome with diarrhea. Review

Irritable bowel syndrome (IBS) is a common disorder resulting from disturbances in gut‑brain interactions, with a worldwide prevalence of 4.1 % to 10.1 % in adults. Although IBS is not life‑threatening, it is associated with a significant disease burden, including reduced quality of life, increased rates of comorbid psychological disorders, and high economic costs. One of the main subtypes of IBS is IBS with diarrhea (IBS‑D). Recently published guidelines of the American Gastroenterological Association (AGA) for pharmacologic treatment of patients with IBS‑D have just been released, based on evidence from a systematic and comprehensive review of the literature, while considering only randomized controlled trials conducted in adults with IBS. A positive diagnosis of IBS‑D can be made on the basis of medical history and physical examination, evaluation of gastrointestinal symptoms (especially presence or absence of worrisome features), limited diagnostic testing, and use of symptom‑based Rome IV criteria. The presence of alarming signs, such as the onset of new symptoms after age 50 years, rectal bleeding not associated with hemorrhoids or anal fissures, unintentional weight loss, iron deficiency anemia, nocturnal diarrhea, a family history of colon cancer, inflammatory bowel disease, or celiac disease, requires a thorough evaluation. In the treatment of IBS‑D, drugs with different mechanisms of action and different effectiveness are used. According to the latest AGA recommendations, most of the drugs, widely used in the treatment of IBS‑D (in particular, antispasmodics, loperamide, antidepressants), have a low reliability of efficacy evidence. Drugs with significant evidence of effectiveness include rifaximin‑a, eluxadoline, and alosetron, but the last two are not registered and are not used in Ukraine. Thus, until now, the only drug available in Ukraine for the treatment of IBS‑D and its relapses with well‑proven efficacy, is rifaximin‑a (Alfa Normix, Xifaxan). Selective serotonin reuptake inhibitors are not recommended for patients with IBS‑D.

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

American Gastroenterological Association Institute and College of American Pathologists Quality Measure Development for Detection of Mismatch Repair Deficiency and Lynch Syndrome Management

American Gastroenterological Association Institute and College of American Pathologists Quality Measure Development for Detection of Mismatch Repair Deficiency and Lynch Syndrome Management

Early Feeding Shortens Hospital Stay in Patients with Mild or Moderate Pancreatitis

Based on moderate-quality evidence from several previous clinical trials, the American Gastroenterological Association recommends that oral feeding be

Comparing accuracy of high-risk features for detecting advanced neoplasia in pancreatic cystic lesions: a systematic review and meta-analysis.

BackgroundThe American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF), whereas the American College of Gastroenterology recommends EUS for ≥1 HRF. This systematic review and meta-analysis compared the diagnostic accuracy of using ≥1 vs. ≥2 HRF for assessing the risk of advanced neoplasia (AN) and performing EUS in PCL.MethodsAn electronic database search was performed for eligible studies. AN was defined as pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm or mucinous cystadenoma with high-grade dysplasia, pancreatic intraepithelial neoplasia and pancreatic neuroendocrine tumors. HRF included cyst size ≥3 cm, solid component, and dilated pancreatic duct ≥5 mm. The primary outcome was the sensitivity and specificity of using ≥1 vs. ≥2 HRF as an indication for EUS to detect AN in PCL.ResultsOf 38 studies initially screened, 8 were included in the final analysis. Seven studies assessed the accuracy of ≥2 HRF and 4 studies assessed ≥1 HRF. The pooled sensitivity, specificity, positive and negative predictive values of EUS for detecting AN were 41.7% (95% confidence interval 19.5-67.8%), 90.8% (81.9-95.5%), 30.4% (19.4-44.2%) and 94.3% (89.6-97.0%) with ≥2HRFs, and 77.1% (66.1-85.3%), 72.7% (50.4-87.5%), 17.95% (10.3-29.4%), 98.1% (90.8-99.6%), respectively, with ≥1 HRF.ConclusionPerforming EUS for PCL with ≥1 HRF could offer greater sensitivity in detecting AN compared to ≥2 HRF, with a similar negative predictive value.

Therapeutic drug monitoring of anti-tumour necrosis factor-α agents in inflammatory bowel disease: Limits and improvements.

Since the publication of the American Gastroenterological Association's recommendations in 2017, there have been no significant changes in the biological monitoring recommendations in inflammatory bowel disease. Possible limitations are the lack of evidence to recommend proactive therapeutic drug monitoring (pTDM) over reactive TDM (rTDM), and the limited information about individualized dosing methods. This article aims to review the TDM strategy updates and the use of individualized dosing methods. For the analysis of the TDM strategies and individualized dosing method, a search was carried out in PubMed and Cochrane Central. In the TDM case, since August 2017. A total of 263 publications were found, but only 7 related to proactive TDM. Five of these publications directly compared pTDM vs rTDM and 2 were randomized clinical trials. Six studies found benefits of pTDM and 1 found no differences. Regarding the individualized dosing method, 229 distinct results were found. Population pharmacokinetics was the most widely used method to develop individual dosage models and to analyse the influence of factors on drug concentrations (albumin concentration, weight, presence of anti-drug antibodies etc). We have found no major changes in TDM strategies. There is a growing trend towards the use of pTDM because it has shown a longer duration of treatment response, lower rates of discontinuation and relapses. However, the available evidence is limited and of low quality. Despite the common use of population pharmacokinetic methods to analyse pharmacokinetic factors, they are not commonly used for personalized dosing.

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

AGA Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic

Abbreviations used in this paper AGAAmerican Gastroenterological AssociationCDCCenters for Disease Control and PreventionCIconfidence intervalCOVID-19coronavirus disease 2019GIgastrointestinalGRADEGrading of Recommendations Assessment, Development and EvaluationMERS-CoVMiddle East respiratory syndrome–related coronavirusORodds ratioPAPRpowered air-purifying respiratorPPEpersonal protective equipmentRRrisk ratioSARS-CoV-2severe acute respiratory syndrome coronavirus 2WHOWorld Health Organization

To resect or not to resect: a review of pancreatic cyst disease management.

With recent advances in radiographic testing, there have been increases in the incidental identification of pancreatic cysts. Determining management, specifically, which cysts can be watched versus intervened upon has significant impact on at the patient-physician level as well as globally on resource allocation and healthcare expenditures. This review focuses on the three main guidelines (Fukuoka guidelines, European consensus, and American Gastroenterological Association recommendations) for management of pancreatic cystic disease after incidental identification. There are iterant revisions to each set of recommendations every few years as new data is published on the subject. This review encompasses the most up-to-date recommendations for management while also providing a framework for conceptualizing work-up for varying types of pancreatic cystic disease before and after incidental identification. Pancreatic cystic disease should be approached in thoughtful clinical manner, and each cyst should be evaluated in the context of patient's health and healthcare goals. All cysts, however, should be considered malignant until proven otherwise. Applications of different diagnostic modalities like MRI and EUS with FNA can better characterize cystic lesions and assess malignant potential. Resection should always be considered in cysts with concerning features. If deferred, surveillance should be continued indefinitely. Early termination of surveillance risks future malignant progression.

58-Year-Old Woman With Melena

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (T.G.C., B.A.-B.); Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (C.G.L.). A 58-year-old woman presented to the emergency department with a 3-day history of passing dark, tarry stools. Her medical history was notable for symptomatic hemophilia A carrier state, gastroesophageal reflux disease, internal hemorrhoids, papillary thyroid cancer treated with thyroidectomy and radioactive iodine for nodal metastasis with secondary hypothyroidism, and obesity with a recent intentional 22.5-kg weight loss. She reported a 3-day history of passing black, tarry stools, averaging 3 stools per day. She did not have light-headedness on standing, any previous episodes, abdominal pain, vomiting, hematochezia, hematemesis, or history of liver or renal disease or alcohol abuse. She was not taking nonsteroidal anti-inflammatory drugs, iron, bismuth subsalicylate, or antiplatelet or anticoagulant medications. Her family history was notable for adenomatous colonic polyposis (at age 17 years, her son was diagnosed as having adenomatous colonic polyps that necessitated a subtotal colectomy). The patient’s last colonoscopy was 4 years before the current presentation and was negative for masses or polyps. On presentation, she had sinus tachycardia at 110 beats/min with a blood pressure of 111/ 51 mmHg. Examination findings were remarkable for conjunctival pallor and positive results on a fecal occult blood test with melenic stool noted on rectal examination. Examination revealed no abdominal tenderness or stigmata of chronic liver disease. Laboratory testing revealed the following notable results (reference ranges provided parenthetically): hemoglobin, 5.5 g/dL (12.015.5 g/dL); platelets, 179 10/L (150450 10/L); international normalized ratio, 1.0 (0.8-1.2); activated partial thromboplastin time, 27 seconds (28-38 seconds); factor VIII activity, 86% (55%-200%); sodium, 139 mmol/L (135-145 mmol/L); potassium, 4.2 mmol/L (3.6-5.2 mmol/L); serum urea nitrogen, 28 mg/dL (6-21 mg/dL); and creatinine, 0.7 mg/dL (0.6-1.1 mg/dL).

Screening and surveillance for Barrett esophagus.

Screening and surveillance for Barrett esophagus.

Endoscopic assessment and management of early esophageal adenocarcinoma.

Esophageal carcinoma affects more than 450000 people worldwide and the incidence is rapidly increasing. In the United States and Europe, esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence. Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages. Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett's esophagus. These risk factors include chronic gastroesophageal reflux disease, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa. The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option. The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia. Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation, photodynamic therapy and cryoablation. Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion. Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor, positive lymph node and submucosal invasion. Surgical resection should be offered to patients with deep submucosal invasion.

Gastric Biopsies: The Gap between Evidence-Based Medicine and Daily Practice in the Management of GastricHelicobacter pyloriInfection

Many consider histology to be the gold standard for Helicobacter pylori detection. Because the number and distribution of H pylori organisms vary, particularly in patients taking proton pump inhibitors (PPIs), the American Gastroenterological Association recommends discontinuing PPIs two weeks before endoscopy, and taking biopsies from both the body and antrum. To assess the influence of clinical practice on the histopathological detection of H pylori infection. Electronic patient records were evaluated for the sites of gastric sampling and PPI use at endoscopy. One hundred fifty cases with biopsies taken from both antrum and body were randomly selected for pathological re-review with special stains. The gastric regions sampled, H pylori distribution and influence of clinical factors on pathological interpretation were assessed. Between 2005 and 2010, 10,268 biopsies were taken to detect H pylori. Only one region was sampled in 60% of patients (antrum 47%, body 13%). Re-review of biopsies taken from both antrum and body indicated that the correct regions were sampled in only 85 (57%) patients. Of these, 54 were H pylori positive and 96 were H pylori negative. H pylori was present in the antrum in only 15% of the patients and body only in 21%. Of 96 H pylori-negative patients, two were reinterpreted as positive. Forty-seven per cent of patients were taking PPIs at endoscopy, contributing to both false-negative and false-positive diagnoses. Despite national and international guidelines for managing H pylori infection, the American Gastroenterological Association guidelines are infrequently adhered to, with PPIs frequently contributing to false diagnosis; sampling one region only increases the likelihood of missing active infection by at least 15%.

Patients With Celiac Disease Are Not Followed Up Adequately

Adherence to a gluten-free diet is the only effective treatment for celiac disease. It has been recommended that patients be followed up, make regular visits to the clinic, and undergo serologic analysis for markers of celiac disease, although a follow-up procedure has not been standardized. We determined how many patients with celiac disease are actually followed up. We collected data on 122 patients with biopsy-proven celiac disease, diagnosed between 1996 and 2006 in Olmsted County, Minnesota (70% women; median age, 42 y), for whom complete medical records and verification of residency were available. We determined the frequency at which patients received follow-up examinations, from 6 months to 5 years after diagnosis. The Kaplan-Meier method was used to estimate event rates at 1 and 5 years. Patients were classified according to categories of follow-up procedures recommended by the American Gastroenterological Association (AGA). We estimated that by 1 and 5 years after diagnosis with celiac disease, 41.0% and 88.7% of the patients had follow-up visits, 33.6% and 79.8% were assessed for compliance with a gluten-free diet, 3.3% and 15.8% met with a registered dietitian, 2.5% and 18.1% had an additional intestinal biopsy, and 22.1% and 65.6% received serologic testing for markers of celiac disease, respectively. Among 113 patients (93%) who were followed up for more than 4 years, only 35% received follow-up analyses that were consistent with AGA recommendations. Patients with celiac disease are not followed up consistently. Follow-up examinations often are inadequate and do not follow AGA recommendations. Improving follow-up strategies for patients with celiac disease could improve management of this disease.