From the AGA Journals

Bariatric surgery resolved nonalcoholic steatohepatitis (NASH) without worsening fibrosis in 84% of patients with evaluable biopsies, according to the findings of a prospective study.

The study included 180 severely or morbidly obese adults (body mass index >35 kg/m²) with NASH who underwent bariatric surgery at a center in France. Among 94 patients evaluated 5 years later, 68% had follow-up liver biopsies, of whom 84% (95% confidence interval, 73.1%-92.2%) met the primary endpoint of resolution of NASH without worsening of fibrosis. All histologic aspects of NASH had improved, median nonalcoholic fatty liver disease scores (NAS) fell from 5 (interquartile range, 4 to 5) to 1 (IQR, 0-2; P < .001), and 90% of patients achieved at least a 2-point NAS improvement. Hepatocellular ballooning also improved in 87.5% of patients. Baseline severity of NASH did not affect the chances of it resolving at 5 years. “The reduction of fibrosis [was] progressive, beginning during the first year and continuing through 5 years,” Guillaume Lassailly, MD, and associates wrote in Gastroenterology.

NASH is a priority for clinical research because of the substantial risk for subsequent cirrhosis, added Dr. Lassailly of CHU Lille (France). For NASH to resolve, most patients need to lose at least 7%-10% of their body weight, but “only 10% of patients reach this objective with lifestyle therapy at 1 year, and less than half maintain the weight loss 5 years later.” Despite ongoing drug development efforts, no medications have been approved for treating NASH. Although weight loss after bariatric surgery has been reported to resolve NASH in approximately 80% of patients at 1 year, longer-term data have been unavailable, and it has remained unclear whether bariatric surgery can slow or halt fibrosis progression.

All patients in this study had biopsy-confirmed NASH and at least a 5-year history of severe or morbid obesity as well as at least one comorbidity, such as diabetes mellitus or arterial hypertension. Patients were not heavy drinkers, and none had detectable markers of chronic liver disease.

Bariatric surgery produced a median 12-kg/m² drop in body mass index. At 5-year follow-up, 93% of patients meeting or exceeding this threshold who had biopsies performed showed resolution of NASH without worsening of fibrosis. Furthermore, 56% of patients (95% CI, 42.4%-69.3%) had no histologic evidence of fibrosis, including 45.5% of patients who had bridging fibrosis at baseline.

Participants in this study received intensive preoperative support, including evaluations by numerous specialists, a nutrition plan, and a 6- to 12-month therapeutic education program. Bariatric surgery techniques included Roux-en-Y gastric bypass, gastric banding, and sleeve gastrectomy. A subgroup analysis linked gastric bypass to a significantly higher probability of meeting the primary endpoint, compared with gastric banding. Refusal was the most common reason for not having a follow-up biopsy, the researchers said. “Patients without liver biopsy after bariatric surgery were not significantly different from those with a histological follow-up except for a lower BMI at 1 year. Baseline fibrosis did not influence the probability of undergoing histological reevaluation at 5 years.”

Two study participants died from surgical complications within 1 month after surgery, and one patient died from cardiac dysfunction 4 years later. No fatality was deemed liver related.

The study was funded by the French Ministry of Health, Conseil Régional Nord-Pas de Calais, National de la Recherche, and the European commission (FEDER). The researchers reported having no conflicts of interest.

SOURCE: Lassailly G et al. Gastroenterology. 2020 Jun 15. doi: 10.1053/j.gastro.2020.06.006.

Bariatric surgery resolved nonalcoholic steatohepatitis (NASH) without worsening fibrosis in 84% of patients with evaluable biopsies, according to the findings of a prospective study.

The study included 180 severely or morbidly obese adults (body mass index >35 kg/m²) with NASH who underwent bariatric surgery at a center in France. Among 94 patients evaluated 5 years later, 68% had follow-up liver biopsies, of whom 84% (95% confidence interval, 73.1%-92.2%) met the primary endpoint of resolution of NASH without worsening of fibrosis. All histologic aspects of NASH had improved, median nonalcoholic fatty liver disease scores (NAS) fell from 5 (interquartile range, 4 to 5) to 1 (IQR, 0-2; P < .001), and 90% of patients achieved at least a 2-point NAS improvement. Hepatocellular ballooning also improved in 87.5% of patients. Baseline severity of NASH did not affect the chances of it resolving at 5 years. “The reduction of fibrosis [was] progressive, beginning during the first year and continuing through 5 years,” Guillaume Lassailly, MD, and associates wrote in Gastroenterology.

NASH is a priority for clinical research because of the substantial risk for subsequent cirrhosis, added Dr. Lassailly of CHU Lille (France). For NASH to resolve, most patients need to lose at least 7%-10% of their body weight, but “only 10% of patients reach this objective with lifestyle therapy at 1 year, and less than half maintain the weight loss 5 years later.” Despite ongoing drug development efforts, no medications have been approved for treating NASH. Although weight loss after bariatric surgery has been reported to resolve NASH in approximately 80% of patients at 1 year, longer-term data have been unavailable, and it has remained unclear whether bariatric surgery can slow or halt fibrosis progression.

All patients in this study had biopsy-confirmed NASH and at least a 5-year history of severe or morbid obesity as well as at least one comorbidity, such as diabetes mellitus or arterial hypertension. Patients were not heavy drinkers, and none had detectable markers of chronic liver disease.

Bariatric surgery produced a median 12-kg/m² drop in body mass index. At 5-year follow-up, 93% of patients meeting or exceeding this threshold who had biopsies performed showed resolution of NASH without worsening of fibrosis. Furthermore, 56% of patients (95% CI, 42.4%-69.3%) had no histologic evidence of fibrosis, including 45.5% of patients who had bridging fibrosis at baseline.

Participants in this study received intensive preoperative support, including evaluations by numerous specialists, a nutrition plan, and a 6- to 12-month therapeutic education program. Bariatric surgery techniques included Roux-en-Y gastric bypass, gastric banding, and sleeve gastrectomy. A subgroup analysis linked gastric bypass to a significantly higher probability of meeting the primary endpoint, compared with gastric banding. Refusal was the most common reason for not having a follow-up biopsy, the researchers said. “Patients without liver biopsy after bariatric surgery were not significantly different from those with a histological follow-up except for a lower BMI at 1 year. Baseline fibrosis did not influence the probability of undergoing histological reevaluation at 5 years.”

Two study participants died from surgical complications within 1 month after surgery, and one patient died from cardiac dysfunction 4 years later. No fatality was deemed liver related.

The study was funded by the French Ministry of Health, Conseil Régional Nord-Pas de Calais, National de la Recherche, and the European commission (FEDER). The researchers reported having no conflicts of interest.

SOURCE: Lassailly G et al. Gastroenterology. 2020 Jun 15. doi: 10.1053/j.gastro.2020.06.006.

Bariatric surgery resolved nonalcoholic steatohepatitis (NASH) without worsening fibrosis in 84% of patients with evaluable biopsies, according to the findings of a prospective study.

The study included 180 severely or morbidly obese adults (body mass index >35 kg/m²) with NASH who underwent bariatric surgery at a center in France. Among 94 patients evaluated 5 years later, 68% had follow-up liver biopsies, of whom 84% (95% confidence interval, 73.1%-92.2%) met the primary endpoint of resolution of NASH without worsening of fibrosis. All histologic aspects of NASH had improved, median nonalcoholic fatty liver disease scores (NAS) fell from 5 (interquartile range, 4 to 5) to 1 (IQR, 0-2; P < .001), and 90% of patients achieved at least a 2-point NAS improvement. Hepatocellular ballooning also improved in 87.5% of patients. Baseline severity of NASH did not affect the chances of it resolving at 5 years. “The reduction of fibrosis [was] progressive, beginning during the first year and continuing through 5 years,” Guillaume Lassailly, MD, and associates wrote in Gastroenterology.

NASH is a priority for clinical research because of the substantial risk for subsequent cirrhosis, added Dr. Lassailly of CHU Lille (France). For NASH to resolve, most patients need to lose at least 7%-10% of their body weight, but “only 10% of patients reach this objective with lifestyle therapy at 1 year, and less than half maintain the weight loss 5 years later.” Despite ongoing drug development efforts, no medications have been approved for treating NASH. Although weight loss after bariatric surgery has been reported to resolve NASH in approximately 80% of patients at 1 year, longer-term data have been unavailable, and it has remained unclear whether bariatric surgery can slow or halt fibrosis progression.

All patients in this study had biopsy-confirmed NASH and at least a 5-year history of severe or morbid obesity as well as at least one comorbidity, such as diabetes mellitus or arterial hypertension. Patients were not heavy drinkers, and none had detectable markers of chronic liver disease.

Bariatric surgery produced a median 12-kg/m² drop in body mass index. At 5-year follow-up, 93% of patients meeting or exceeding this threshold who had biopsies performed showed resolution of NASH without worsening of fibrosis. Furthermore, 56% of patients (95% CI, 42.4%-69.3%) had no histologic evidence of fibrosis, including 45.5% of patients who had bridging fibrosis at baseline.

Participants in this study received intensive preoperative support, including evaluations by numerous specialists, a nutrition plan, and a 6- to 12-month therapeutic education program. Bariatric surgery techniques included Roux-en-Y gastric bypass, gastric banding, and sleeve gastrectomy. A subgroup analysis linked gastric bypass to a significantly higher probability of meeting the primary endpoint, compared with gastric banding. Refusal was the most common reason for not having a follow-up biopsy, the researchers said. “Patients without liver biopsy after bariatric surgery were not significantly different from those with a histological follow-up except for a lower BMI at 1 year. Baseline fibrosis did not influence the probability of undergoing histological reevaluation at 5 years.”

Two study participants died from surgical complications within 1 month after surgery, and one patient died from cardiac dysfunction 4 years later. No fatality was deemed liver related.

The study was funded by the French Ministry of Health, Conseil Régional Nord-Pas de Calais, National de la Recherche, and the European commission (FEDER). The researchers reported having no conflicts of interest.

SOURCE: Lassailly G et al. Gastroenterology. 2020 Jun 15. doi: 10.1053/j.gastro.2020.06.006.

A new model of gastric cancer screening suggests that, for Asian Americans, endoscopic screening alongside colonoscopy and follow-up surveillance of gastric preneoplasia is a cost-effective strategy. Incremental cost-effectiveness ratios (ICERs) were lowest for Chinese, Japanese, and Korean Americans. The model simulated results for asymptomatic 50-year-old subjects.

Gastric cancer risk is highest in Asian Pacific, Latin American, and Eastern European countries. Asia Pacific countries alone represent about half of all new cases. Helicobacter pylori–related gastritis is the strongest known risk factor for intestinal-type noncardia gastric adenocarcinoma (NCGA), which is the most common gastric cancer, and this chronic inflammation can lead to gastric intestinal metaplasia (GIM). Individuals with GIM have a 0.16% increased annual risk of NCGA, which makes them good candidates for endoscopic screening that could catch new cancers at an early stage.

In a previous study (Gastroenterology. 2018 May 17;155[3]:648-60), researchers at Vanderbilt University Medical Center in Durham, N.C., at Boston University School of Medicine, and at the University of Pennsylvania in Philadelphia showed that, in asymptomatic 50-year-old Asian Americans, Hispanic patients, and non-Hispanic Black patients, performing a single esophagogastroduodenoscopy (EGD) concomitantly with a colonoscopy, followed by screening EGDs if indicated (such as for a GIM diagnosis), is a cost-effective strategy. They found ongoing screening was not cost effective if the original results were normal.

In the new study published in Gastroenterology and Hepatology, the researchers followed up this finding with an attempt to tease out the cost-effectiveness of screening in different subgroups, as well as by sex. They built a Markov decision model focusing on the six most common Asian groups in the United States: Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

Model inputs were based on the published literature, and the outputs were compared with data from the Surveillance, Epidemiology, and End Results (SEER) data for disaggregated Asian Americans between 2001 and 2014 and separately with the California Cancer Registry (2011-2015). The model produced a good fit to the epidemiological data.

The model then compared cost-effectiveness of three hypothetical screening strategies in asymptomatic 50-year-old Asian Americans: one-time upper EGD with biopsies conducted at the time of colonoscopies for colorectal cancer screening, followed by EGDs every 3 years if GIM was detected (or other appropriate management of higher-grade pathology); EGD with biopsy at a colonoscopy for CRC screening followed by EGD biennially regardless of initial findings; and no endoscopy screening.

The one-time EGD strategy was the most cost-effective, regardless of sex, with an ICER of $75,959 per quality-adjusted life-year (QALY) in males and $74,329/QALY in females. The lowest ICER was found for Chinese Americans (males and females, $68,256/QALY), followed by Japanese Americans (males, $69,011/QALY; females, $73,748/QALY), and Korean Americans (males, $70,739/ QALY; females, $70,236/QALY). The highest ICERs were among Filipino American males and females, but the strategy was still cost-effective at the predetermined willingness-to-pay threshold of $100,000 ($83,732/QALY).

In all ethnic groups, the biennial screening strategy produced more harm than good and was costlier.

The authors believe that the strategy could be applied to other ethnic groups that come from countries with populations at higher relative risk of gastric cancer, such as Central and Latin American countries.

Asked to comment on the study, Mimi Tan, MD, an assistant professor of gastroenterology at Baylor College of Medicine in Houston, suggested that the estimates of precancerous lesions used in the Markov model were quite high because they were based on pathology databases. These sources tend to be biased toward symptomatic individuals since these are the patients typically referred for upper endoscopy biopsies. “Therefore, these probabilities may not represent true probability of these precancerous lesions among asymptomatic screening populations,” Dr. Tan said in an interview. She also questioned whether the study represented the true risk in female populations since the literature for women is sparse.

Dr. Tan suggested that a more cost-effective screening strategy might be one-time H. pylori immunoglobulin G testing in Asian Americans. The Houston Consensus Conference on Testing for H. pylori Infection already recommends testing for first-generation immigrants from high prevalence areas and Latino and African American racial or ethnic groups (Clin Gastroenterol Hepatol. 2018 Jul;16[7]:992-1002). “Future studies should compare cost-effectiveness of one-time upper endoscopy, which is more costly but able to detect premalignant lesions, to one-time H. pylori testing,” said Dr. Tan.

SOURCE: Shah SC et al. Clin Gastroenterol Hepatol. 2020 July 21. doi: 10.1016/j.cgh.2020.07.031.

A new model of gastric cancer screening suggests that, for Asian Americans, endoscopic screening alongside colonoscopy and follow-up surveillance of gastric preneoplasia is a cost-effective strategy. Incremental cost-effectiveness ratios (ICERs) were lowest for Chinese, Japanese, and Korean Americans. The model simulated results for asymptomatic 50-year-old subjects.

Gastric cancer risk is highest in Asian Pacific, Latin American, and Eastern European countries. Asia Pacific countries alone represent about half of all new cases. Helicobacter pylori–related gastritis is the strongest known risk factor for intestinal-type noncardia gastric adenocarcinoma (NCGA), which is the most common gastric cancer, and this chronic inflammation can lead to gastric intestinal metaplasia (GIM). Individuals with GIM have a 0.16% increased annual risk of NCGA, which makes them good candidates for endoscopic screening that could catch new cancers at an early stage.

In a previous study (Gastroenterology. 2018 May 17;155[3]:648-60), researchers at Vanderbilt University Medical Center in Durham, N.C., at Boston University School of Medicine, and at the University of Pennsylvania in Philadelphia showed that, in asymptomatic 50-year-old Asian Americans, Hispanic patients, and non-Hispanic Black patients, performing a single esophagogastroduodenoscopy (EGD) concomitantly with a colonoscopy, followed by screening EGDs if indicated (such as for a GIM diagnosis), is a cost-effective strategy. They found ongoing screening was not cost effective if the original results were normal.

In the new study published in Gastroenterology and Hepatology, the researchers followed up this finding with an attempt to tease out the cost-effectiveness of screening in different subgroups, as well as by sex. They built a Markov decision model focusing on the six most common Asian groups in the United States: Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

Model inputs were based on the published literature, and the outputs were compared with data from the Surveillance, Epidemiology, and End Results (SEER) data for disaggregated Asian Americans between 2001 and 2014 and separately with the California Cancer Registry (2011-2015). The model produced a good fit to the epidemiological data.

The model then compared cost-effectiveness of three hypothetical screening strategies in asymptomatic 50-year-old Asian Americans: one-time upper EGD with biopsies conducted at the time of colonoscopies for colorectal cancer screening, followed by EGDs every 3 years if GIM was detected (or other appropriate management of higher-grade pathology); EGD with biopsy at a colonoscopy for CRC screening followed by EGD biennially regardless of initial findings; and no endoscopy screening.

The one-time EGD strategy was the most cost-effective, regardless of sex, with an ICER of $75,959 per quality-adjusted life-year (QALY) in males and $74,329/QALY in females. The lowest ICER was found for Chinese Americans (males and females, $68,256/QALY), followed by Japanese Americans (males, $69,011/QALY; females, $73,748/QALY), and Korean Americans (males, $70,739/ QALY; females, $70,236/QALY). The highest ICERs were among Filipino American males and females, but the strategy was still cost-effective at the predetermined willingness-to-pay threshold of $100,000 ($83,732/QALY).

In all ethnic groups, the biennial screening strategy produced more harm than good and was costlier.

The authors believe that the strategy could be applied to other ethnic groups that come from countries with populations at higher relative risk of gastric cancer, such as Central and Latin American countries.

Asked to comment on the study, Mimi Tan, MD, an assistant professor of gastroenterology at Baylor College of Medicine in Houston, suggested that the estimates of precancerous lesions used in the Markov model were quite high because they were based on pathology databases. These sources tend to be biased toward symptomatic individuals since these are the patients typically referred for upper endoscopy biopsies. “Therefore, these probabilities may not represent true probability of these precancerous lesions among asymptomatic screening populations,” Dr. Tan said in an interview. She also questioned whether the study represented the true risk in female populations since the literature for women is sparse.

Dr. Tan suggested that a more cost-effective screening strategy might be one-time H. pylori immunoglobulin G testing in Asian Americans. The Houston Consensus Conference on Testing for H. pylori Infection already recommends testing for first-generation immigrants from high prevalence areas and Latino and African American racial or ethnic groups (Clin Gastroenterol Hepatol. 2018 Jul;16[7]:992-1002). “Future studies should compare cost-effectiveness of one-time upper endoscopy, which is more costly but able to detect premalignant lesions, to one-time H. pylori testing,” said Dr. Tan.

SOURCE: Shah SC et al. Clin Gastroenterol Hepatol. 2020 July 21. doi: 10.1016/j.cgh.2020.07.031.

A new model of gastric cancer screening suggests that, for Asian Americans, endoscopic screening alongside colonoscopy and follow-up surveillance of gastric preneoplasia is a cost-effective strategy. Incremental cost-effectiveness ratios (ICERs) were lowest for Chinese, Japanese, and Korean Americans. The model simulated results for asymptomatic 50-year-old subjects.

Gastric cancer risk is highest in Asian Pacific, Latin American, and Eastern European countries. Asia Pacific countries alone represent about half of all new cases. Helicobacter pylori–related gastritis is the strongest known risk factor for intestinal-type noncardia gastric adenocarcinoma (NCGA), which is the most common gastric cancer, and this chronic inflammation can lead to gastric intestinal metaplasia (GIM). Individuals with GIM have a 0.16% increased annual risk of NCGA, which makes them good candidates for endoscopic screening that could catch new cancers at an early stage.

In a previous study (Gastroenterology. 2018 May 17;155[3]:648-60), researchers at Vanderbilt University Medical Center in Durham, N.C., at Boston University School of Medicine, and at the University of Pennsylvania in Philadelphia showed that, in asymptomatic 50-year-old Asian Americans, Hispanic patients, and non-Hispanic Black patients, performing a single esophagogastroduodenoscopy (EGD) concomitantly with a colonoscopy, followed by screening EGDs if indicated (such as for a GIM diagnosis), is a cost-effective strategy. They found ongoing screening was not cost effective if the original results were normal.

In the new study published in Gastroenterology and Hepatology, the researchers followed up this finding with an attempt to tease out the cost-effectiveness of screening in different subgroups, as well as by sex. They built a Markov decision model focusing on the six most common Asian groups in the United States: Chinese, Filipino, Southeast Asian, Vietnamese, Korean, and Japanese Americans.

Model inputs were based on the published literature, and the outputs were compared with data from the Surveillance, Epidemiology, and End Results (SEER) data for disaggregated Asian Americans between 2001 and 2014 and separately with the California Cancer Registry (2011-2015). The model produced a good fit to the epidemiological data.

The model then compared cost-effectiveness of three hypothetical screening strategies in asymptomatic 50-year-old Asian Americans: one-time upper EGD with biopsies conducted at the time of colonoscopies for colorectal cancer screening, followed by EGDs every 3 years if GIM was detected (or other appropriate management of higher-grade pathology); EGD with biopsy at a colonoscopy for CRC screening followed by EGD biennially regardless of initial findings; and no endoscopy screening.

The one-time EGD strategy was the most cost-effective, regardless of sex, with an ICER of $75,959 per quality-adjusted life-year (QALY) in males and $74,329/QALY in females. The lowest ICER was found for Chinese Americans (males and females, $68,256/QALY), followed by Japanese Americans (males, $69,011/QALY; females, $73,748/QALY), and Korean Americans (males, $70,739/ QALY; females, $70,236/QALY). The highest ICERs were among Filipino American males and females, but the strategy was still cost-effective at the predetermined willingness-to-pay threshold of $100,000 ($83,732/QALY).

In all ethnic groups, the biennial screening strategy produced more harm than good and was costlier.

The authors believe that the strategy could be applied to other ethnic groups that come from countries with populations at higher relative risk of gastric cancer, such as Central and Latin American countries.

Asked to comment on the study, Mimi Tan, MD, an assistant professor of gastroenterology at Baylor College of Medicine in Houston, suggested that the estimates of precancerous lesions used in the Markov model were quite high because they were based on pathology databases. These sources tend to be biased toward symptomatic individuals since these are the patients typically referred for upper endoscopy biopsies. “Therefore, these probabilities may not represent true probability of these precancerous lesions among asymptomatic screening populations,” Dr. Tan said in an interview. She also questioned whether the study represented the true risk in female populations since the literature for women is sparse.

Dr. Tan suggested that a more cost-effective screening strategy might be one-time H. pylori immunoglobulin G testing in Asian Americans. The Houston Consensus Conference on Testing for H. pylori Infection already recommends testing for first-generation immigrants from high prevalence areas and Latino and African American racial or ethnic groups (Clin Gastroenterol Hepatol. 2018 Jul;16[7]:992-1002). “Future studies should compare cost-effectiveness of one-time upper endoscopy, which is more costly but able to detect premalignant lesions, to one-time H. pylori testing,” said Dr. Tan.

SOURCE: Shah SC et al. Clin Gastroenterol Hepatol. 2020 July 21. doi: 10.1016/j.cgh.2020.07.031.

The rising incidence of colorectal cancer in adults younger than 50 years heightens the need to evaluate the colon and rectum of any patient, regardless of age, who presents with symptoms such as rectal bleeding, weight loss, abdominal pain, iron-deficiency anemia, or changes in bowel habits, according to a new American Gastroenterological Association clinical practice update.

In addition to receiving cancer staging or being referred to an oncologist, newly diagnosed patients should be counseled about both germline genetic testing and fertility preservation, wrote Lisa A. Boardman, MD, of Mayo Clinic in Rochester, Minn., with associates in Clinical Gastroenterology and Hepatology. “Clinicians should present the role of fertility preservation prior to [administering] cancer-directed therapy, including surgery, pelvic radiation, or chemotherapy.”

It remains unclear why the incidence of young adult–onset colorectal cancer is rising, but the trend is not limited to the United States. Implicated risk factors include inflammatory bowel disease, prior irradiation, harboring a pathogenic germline mutation for a known hereditary cancer syndrome, and having a first- or second-degree relative with colorectal cancer. Indeed, the odds of developing young adult–onset disease are nearly 4 times higher if a parent has colorectal cancer and nearly 12 times higher if a sibling is affected.

For newly diagnosed young adults, it is important to collect a family cancer history but vital, regardless of history, to discuss targeted or multiplex germline mutation testing. Detecting hereditary colorectal cancer syndromes is crucial because their nature informs surgical options for treatment. “Roughly one in five young adult–onset colorectal cancers will be caused by a germline mutation, and among those with a detectable hereditary condition, half of those patients with young adult–onset colorectal cancer will have Lynch syndrome,” the experts noted. For these patients (who have mutations involving MSH2, EPCAM, MLH1, MSH6, and PMS2), ileorectostomy (IRA) for colorectal cancer should be considered.

For patients with the classic subtype of familial adenomatous polyposis, ileal pouch anal anastomosis is recommended after the polyp burden can no longer be managed endoscopically, although initial IRA with subsequent conversion to IPAA is an option for women of child-bearing age, according to the clinical practice update. Patients with the attenuated subtype of familial adenomatous polyposis should consider IRA or colectomy if colorectal cancer develops or if the polyp burden exceeds endoscopic control. In contrast, colectomy is the only type of surgery recommended for patients with serrated polyposis syndrome requiring surgical treatment.

Finally, clinicians should offer only screening for hereditary cancer syndromes if young adults cancer have been diagnosed with a hereditary colorectal cancer syndrome. “For patients with sporadic young adult–onset colorectal cancer, extracolonic screening and colorectal cancer surveillance intervals are the same as for patients with older adult–onset colorectal cancer,” the experts wrote. For young patients without an apparent underlying genetic syndrome, molecular studies may eventually help tailor treatment options, “but at this point, more extensive surgery or more aggressive chemotherapy cannot be recommended. As cancer treatments evolve to use patient tumor specific therapeutics, our management of patients with young adult–onset colorectal cancer will improve.”

Dr. Boardman and associates reported having no relevant conflicts of interest.

SOURCE: Boardman LA et al. Clin Gastroenterol Hepatol. 2020 Jun 7. doi: 10.1016/j.cgh.2020.05.058.
 

The rising incidence of colorectal cancer in adults younger than 50 years heightens the need to evaluate the colon and rectum of any patient, regardless of age, who presents with symptoms such as rectal bleeding, weight loss, abdominal pain, iron-deficiency anemia, or changes in bowel habits, according to a new American Gastroenterological Association clinical practice update.

In addition to receiving cancer staging or being referred to an oncologist, newly diagnosed patients should be counseled about both germline genetic testing and fertility preservation, wrote Lisa A. Boardman, MD, of Mayo Clinic in Rochester, Minn., with associates in Clinical Gastroenterology and Hepatology. “Clinicians should present the role of fertility preservation prior to [administering] cancer-directed therapy, including surgery, pelvic radiation, or chemotherapy.”

It remains unclear why the incidence of young adult–onset colorectal cancer is rising, but the trend is not limited to the United States. Implicated risk factors include inflammatory bowel disease, prior irradiation, harboring a pathogenic germline mutation for a known hereditary cancer syndrome, and having a first- or second-degree relative with colorectal cancer. Indeed, the odds of developing young adult–onset disease are nearly 4 times higher if a parent has colorectal cancer and nearly 12 times higher if a sibling is affected.

For newly diagnosed young adults, it is important to collect a family cancer history but vital, regardless of history, to discuss targeted or multiplex germline mutation testing. Detecting hereditary colorectal cancer syndromes is crucial because their nature informs surgical options for treatment. “Roughly one in five young adult–onset colorectal cancers will be caused by a germline mutation, and among those with a detectable hereditary condition, half of those patients with young adult–onset colorectal cancer will have Lynch syndrome,” the experts noted. For these patients (who have mutations involving MSH2, EPCAM, MLH1, MSH6, and PMS2), ileorectostomy (IRA) for colorectal cancer should be considered.

For patients with the classic subtype of familial adenomatous polyposis, ileal pouch anal anastomosis is recommended after the polyp burden can no longer be managed endoscopically, although initial IRA with subsequent conversion to IPAA is an option for women of child-bearing age, according to the clinical practice update. Patients with the attenuated subtype of familial adenomatous polyposis should consider IRA or colectomy if colorectal cancer develops or if the polyp burden exceeds endoscopic control. In contrast, colectomy is the only type of surgery recommended for patients with serrated polyposis syndrome requiring surgical treatment.

Finally, clinicians should offer only screening for hereditary cancer syndromes if young adults cancer have been diagnosed with a hereditary colorectal cancer syndrome. “For patients with sporadic young adult–onset colorectal cancer, extracolonic screening and colorectal cancer surveillance intervals are the same as for patients with older adult–onset colorectal cancer,” the experts wrote. For young patients without an apparent underlying genetic syndrome, molecular studies may eventually help tailor treatment options, “but at this point, more extensive surgery or more aggressive chemotherapy cannot be recommended. As cancer treatments evolve to use patient tumor specific therapeutics, our management of patients with young adult–onset colorectal cancer will improve.”

Dr. Boardman and associates reported having no relevant conflicts of interest.

SOURCE: Boardman LA et al. Clin Gastroenterol Hepatol. 2020 Jun 7. doi: 10.1016/j.cgh.2020.05.058.
 

The rising incidence of colorectal cancer in adults younger than 50 years heightens the need to evaluate the colon and rectum of any patient, regardless of age, who presents with symptoms such as rectal bleeding, weight loss, abdominal pain, iron-deficiency anemia, or changes in bowel habits, according to a new American Gastroenterological Association clinical practice update.

In addition to receiving cancer staging or being referred to an oncologist, newly diagnosed patients should be counseled about both germline genetic testing and fertility preservation, wrote Lisa A. Boardman, MD, of Mayo Clinic in Rochester, Minn., with associates in Clinical Gastroenterology and Hepatology. “Clinicians should present the role of fertility preservation prior to [administering] cancer-directed therapy, including surgery, pelvic radiation, or chemotherapy.”

It remains unclear why the incidence of young adult–onset colorectal cancer is rising, but the trend is not limited to the United States. Implicated risk factors include inflammatory bowel disease, prior irradiation, harboring a pathogenic germline mutation for a known hereditary cancer syndrome, and having a first- or second-degree relative with colorectal cancer. Indeed, the odds of developing young adult–onset disease are nearly 4 times higher if a parent has colorectal cancer and nearly 12 times higher if a sibling is affected.

For newly diagnosed young adults, it is important to collect a family cancer history but vital, regardless of history, to discuss targeted or multiplex germline mutation testing. Detecting hereditary colorectal cancer syndromes is crucial because their nature informs surgical options for treatment. “Roughly one in five young adult–onset colorectal cancers will be caused by a germline mutation, and among those with a detectable hereditary condition, half of those patients with young adult–onset colorectal cancer will have Lynch syndrome,” the experts noted. For these patients (who have mutations involving MSH2, EPCAM, MLH1, MSH6, and PMS2), ileorectostomy (IRA) for colorectal cancer should be considered.

For patients with the classic subtype of familial adenomatous polyposis, ileal pouch anal anastomosis is recommended after the polyp burden can no longer be managed endoscopically, although initial IRA with subsequent conversion to IPAA is an option for women of child-bearing age, according to the clinical practice update. Patients with the attenuated subtype of familial adenomatous polyposis should consider IRA or colectomy if colorectal cancer develops or if the polyp burden exceeds endoscopic control. In contrast, colectomy is the only type of surgery recommended for patients with serrated polyposis syndrome requiring surgical treatment.

Finally, clinicians should offer only screening for hereditary cancer syndromes if young adults cancer have been diagnosed with a hereditary colorectal cancer syndrome. “For patients with sporadic young adult–onset colorectal cancer, extracolonic screening and colorectal cancer surveillance intervals are the same as for patients with older adult–onset colorectal cancer,” the experts wrote. For young patients without an apparent underlying genetic syndrome, molecular studies may eventually help tailor treatment options, “but at this point, more extensive surgery or more aggressive chemotherapy cannot be recommended. As cancer treatments evolve to use patient tumor specific therapeutics, our management of patients with young adult–onset colorectal cancer will improve.”

Dr. Boardman and associates reported having no relevant conflicts of interest.

SOURCE: Boardman LA et al. Clin Gastroenterol Hepatol. 2020 Jun 7. doi: 10.1016/j.cgh.2020.05.058.
 

For patients with gastroesophageal reflux disease (GERD), endoscopic and minimally invasive surgical techniques may be viable alternatives to proton pump inhibitor (PPI) therapy, according to investigators.

Still, their exact role in the treatment process remains undetermined, reported Michael F. Vaezi, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues.

“The frequent incomplete response to PPI therapy, in addition to recent studies suggesting chronic complications with PPI therapy, have fueled discussion of alternative strategies for treating patients with GERD,” the investigators wrote in Gastroenterology. “For a substantial number of patients and providers with the above concerns who are unwilling to pursue the traditional surgical gastric fundoplication, endoscopic or less invasive surgical strategies have gained some traction.”

Dr. Vaezi and colleagues noted that they conducted the scoping review with intentions of being more descriptive than prescriptive.

“Our goal is not to recommend the utility of any of the discussed techniques in specific clinical scenarios,” they wrote. “Rather, it is to summarize the currently available evidence and identify where more research may be helpful.”

Across 22 randomized, controlled trials and observational studies, objective and symptomatic improvement varied between modalities. Measured outcomes also varied; most studies reported symptoms, health-related quality of life, and PPI use; fewer studies (but still a majority) reported intraesophageal acid exposure and/or lower esophageal sphincter (LES) pressure. Conclusions drawn by Dr. Vaezi and colleagues are summarized below.
 

Magnetic sphincter augmentation of the LES

In multiple trials, magnetic sphincter augmentation demonstrated a “high degree of efficacy” in the short or midterm, and a favorable safety profile. Dr. Vaezi and colleagues highlighted significant improvements in disease-related quality of life, with “a substantial proportion” of patients achieving normalization or at least 50% improvement in acid exposure. While some patients required esophageal dilation after the procedure, this was not needed any more frequently than after surgical fundoplication.

Radiofrequency ablation

Across five trials, radiofrequency ablation, which involves delivery of energy to the LES and gastric cardia, improved GERD-related quality of life, and reduced, but did not normalize, acid exposure. The technique lessened short-term need for PPIs, but long-term relief was not observed. Compared with observational studies, efficacy signals were weaker in randomized, controlled trials. The procedure was generally safe.

Surgical implantation of LES pacemaker

Limited data were available for LES sphincter stimulation among patients with GERD, and the most recent study, involving a comparison of device placement with or without stimulation, was terminated early. Still, available data suggest that the technique is generally well tolerated, with reduced need for PPIs, improved symptoms, and lessened acid exposure. Dr. Vaezi and colleagues noted that the manufacturing company, EndoStim, is in receivership, putting U.S. availability in question.

Full-thickness fundoplication

Endoscopic full-thickness fundoplication was associated with improvement of symptoms and quality of life, and a favorable safety profile. Although the procedure generally reduced PPI use, most patients still needed PPIs long-term. Reflux improved after the procedure, but not to the same degree as laparoscopic plication.

Transoral incisionless fundoplication

Based on a number of studies, including five randomized, controlled trials, transoral incisionless fundoplication appears safe and effective, with reduced need for PPIs up to 5 years. According to Dr. Vaezi and colleagues, variable results across studies are likely explained by variations in the technique over time and heterogeneous patient populations. Recent studies in which the “TIF 2.0 technique” has been performed on patients with hiatal hernias less than 2 cm have met objective efficacy outcomes.

Incisionless fundoplication with magnetic ultrasonic surgical endostapler

The magnetic ultrasonic surgical endostapler, which allows for incisionless fundoplication, had more limited data. Only two studies have been conducted, and neither had sham-controlled nor comparative-trial data. Furthermore, multiple safety signals have been encountered, with “substantial” complication rates and serious adverse events that were “noticeable and concerning,” according to Dr. Vaezi and colleagues.

Concluding their discussion, the investigators suggested that some endoscopic and minimally invasive approaches to GERD are “promising” alternatives to PPI therapy.

“However, their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially the durability of their effect, are understood,” they wrote.

The investigators reported no conflicts of interest.

SOURCE: Vaezi MF et al. Gastroenterology. 2020 Jul 1. doi: 10.1053/j.gastro.2020.05.097.

For patients with gastroesophageal reflux disease (GERD), endoscopic and minimally invasive surgical techniques may be viable alternatives to proton pump inhibitor (PPI) therapy, according to investigators.

Still, their exact role in the treatment process remains undetermined, reported Michael F. Vaezi, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues.

“The frequent incomplete response to PPI therapy, in addition to recent studies suggesting chronic complications with PPI therapy, have fueled discussion of alternative strategies for treating patients with GERD,” the investigators wrote in Gastroenterology. “For a substantial number of patients and providers with the above concerns who are unwilling to pursue the traditional surgical gastric fundoplication, endoscopic or less invasive surgical strategies have gained some traction.”

Dr. Vaezi and colleagues noted that they conducted the scoping review with intentions of being more descriptive than prescriptive.

“Our goal is not to recommend the utility of any of the discussed techniques in specific clinical scenarios,” they wrote. “Rather, it is to summarize the currently available evidence and identify where more research may be helpful.”

Across 22 randomized, controlled trials and observational studies, objective and symptomatic improvement varied between modalities. Measured outcomes also varied; most studies reported symptoms, health-related quality of life, and PPI use; fewer studies (but still a majority) reported intraesophageal acid exposure and/or lower esophageal sphincter (LES) pressure. Conclusions drawn by Dr. Vaezi and colleagues are summarized below.
 

Magnetic sphincter augmentation of the LES

In multiple trials, magnetic sphincter augmentation demonstrated a “high degree of efficacy” in the short or midterm, and a favorable safety profile. Dr. Vaezi and colleagues highlighted significant improvements in disease-related quality of life, with “a substantial proportion” of patients achieving normalization or at least 50% improvement in acid exposure. While some patients required esophageal dilation after the procedure, this was not needed any more frequently than after surgical fundoplication.

Radiofrequency ablation

Across five trials, radiofrequency ablation, which involves delivery of energy to the LES and gastric cardia, improved GERD-related quality of life, and reduced, but did not normalize, acid exposure. The technique lessened short-term need for PPIs, but long-term relief was not observed. Compared with observational studies, efficacy signals were weaker in randomized, controlled trials. The procedure was generally safe.

Surgical implantation of LES pacemaker

Limited data were available for LES sphincter stimulation among patients with GERD, and the most recent study, involving a comparison of device placement with or without stimulation, was terminated early. Still, available data suggest that the technique is generally well tolerated, with reduced need for PPIs, improved symptoms, and lessened acid exposure. Dr. Vaezi and colleagues noted that the manufacturing company, EndoStim, is in receivership, putting U.S. availability in question.

Full-thickness fundoplication

Endoscopic full-thickness fundoplication was associated with improvement of symptoms and quality of life, and a favorable safety profile. Although the procedure generally reduced PPI use, most patients still needed PPIs long-term. Reflux improved after the procedure, but not to the same degree as laparoscopic plication.

Transoral incisionless fundoplication

Based on a number of studies, including five randomized, controlled trials, transoral incisionless fundoplication appears safe and effective, with reduced need for PPIs up to 5 years. According to Dr. Vaezi and colleagues, variable results across studies are likely explained by variations in the technique over time and heterogeneous patient populations. Recent studies in which the “TIF 2.0 technique” has been performed on patients with hiatal hernias less than 2 cm have met objective efficacy outcomes.

Incisionless fundoplication with magnetic ultrasonic surgical endostapler

The magnetic ultrasonic surgical endostapler, which allows for incisionless fundoplication, had more limited data. Only two studies have been conducted, and neither had sham-controlled nor comparative-trial data. Furthermore, multiple safety signals have been encountered, with “substantial” complication rates and serious adverse events that were “noticeable and concerning,” according to Dr. Vaezi and colleagues.

Concluding their discussion, the investigators suggested that some endoscopic and minimally invasive approaches to GERD are “promising” alternatives to PPI therapy.

“However, their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially the durability of their effect, are understood,” they wrote.

The investigators reported no conflicts of interest.

SOURCE: Vaezi MF et al. Gastroenterology. 2020 Jul 1. doi: 10.1053/j.gastro.2020.05.097.

For patients with gastroesophageal reflux disease (GERD), endoscopic and minimally invasive surgical techniques may be viable alternatives to proton pump inhibitor (PPI) therapy, according to investigators.

Still, their exact role in the treatment process remains undetermined, reported Michael F. Vaezi, MD, PhD, of Vanderbilt University Medical Center in Nashville, Tenn., and colleagues.

“The frequent incomplete response to PPI therapy, in addition to recent studies suggesting chronic complications with PPI therapy, have fueled discussion of alternative strategies for treating patients with GERD,” the investigators wrote in Gastroenterology. “For a substantial number of patients and providers with the above concerns who are unwilling to pursue the traditional surgical gastric fundoplication, endoscopic or less invasive surgical strategies have gained some traction.”

Dr. Vaezi and colleagues noted that they conducted the scoping review with intentions of being more descriptive than prescriptive.

“Our goal is not to recommend the utility of any of the discussed techniques in specific clinical scenarios,” they wrote. “Rather, it is to summarize the currently available evidence and identify where more research may be helpful.”

Across 22 randomized, controlled trials and observational studies, objective and symptomatic improvement varied between modalities. Measured outcomes also varied; most studies reported symptoms, health-related quality of life, and PPI use; fewer studies (but still a majority) reported intraesophageal acid exposure and/or lower esophageal sphincter (LES) pressure. Conclusions drawn by Dr. Vaezi and colleagues are summarized below.
 

Magnetic sphincter augmentation of the LES

In multiple trials, magnetic sphincter augmentation demonstrated a “high degree of efficacy” in the short or midterm, and a favorable safety profile. Dr. Vaezi and colleagues highlighted significant improvements in disease-related quality of life, with “a substantial proportion” of patients achieving normalization or at least 50% improvement in acid exposure. While some patients required esophageal dilation after the procedure, this was not needed any more frequently than after surgical fundoplication.

Radiofrequency ablation

Across five trials, radiofrequency ablation, which involves delivery of energy to the LES and gastric cardia, improved GERD-related quality of life, and reduced, but did not normalize, acid exposure. The technique lessened short-term need for PPIs, but long-term relief was not observed. Compared with observational studies, efficacy signals were weaker in randomized, controlled trials. The procedure was generally safe.

Surgical implantation of LES pacemaker

Limited data were available for LES sphincter stimulation among patients with GERD, and the most recent study, involving a comparison of device placement with or without stimulation, was terminated early. Still, available data suggest that the technique is generally well tolerated, with reduced need for PPIs, improved symptoms, and lessened acid exposure. Dr. Vaezi and colleagues noted that the manufacturing company, EndoStim, is in receivership, putting U.S. availability in question.

Full-thickness fundoplication

Endoscopic full-thickness fundoplication was associated with improvement of symptoms and quality of life, and a favorable safety profile. Although the procedure generally reduced PPI use, most patients still needed PPIs long-term. Reflux improved after the procedure, but not to the same degree as laparoscopic plication.

Transoral incisionless fundoplication

Based on a number of studies, including five randomized, controlled trials, transoral incisionless fundoplication appears safe and effective, with reduced need for PPIs up to 5 years. According to Dr. Vaezi and colleagues, variable results across studies are likely explained by variations in the technique over time and heterogeneous patient populations. Recent studies in which the “TIF 2.0 technique” has been performed on patients with hiatal hernias less than 2 cm have met objective efficacy outcomes.

Incisionless fundoplication with magnetic ultrasonic surgical endostapler

The magnetic ultrasonic surgical endostapler, which allows for incisionless fundoplication, had more limited data. Only two studies have been conducted, and neither had sham-controlled nor comparative-trial data. Furthermore, multiple safety signals have been encountered, with “substantial” complication rates and serious adverse events that were “noticeable and concerning,” according to Dr. Vaezi and colleagues.

Concluding their discussion, the investigators suggested that some endoscopic and minimally invasive approaches to GERD are “promising” alternatives to PPI therapy.

“However, their place in the treatment algorithm for GERD will be better defined when important clinical parameters, especially the durability of their effect, are understood,” they wrote.

The investigators reported no conflicts of interest.

SOURCE: Vaezi MF et al. Gastroenterology. 2020 Jul 1. doi: 10.1053/j.gastro.2020.05.097.

Mounting data support acute pancreatitis as one possible GI manifestation of COVID-19, according to investigators.

While previous case reports suggested that infection with SARS-CoV2 may lead to pancreatitis, this retrospective analysis, which is the largest to date, is the first to offer substantial evidence for this claim, reported lead author Sumant Inamdar, MBBS, of the University of Arkansas, Little Rock, and colleagues.

“It has become increasingly clear that COVID-19 has systemic effects that also includes the gastrointestinal and pancreaticobiliary systems,” the investigators wrote in Gastroenterology. “As islet cells of the pancreas contain ACE2 receptor proteins, SARS-CoV2 can bind to these receptors and cause pancreatic injury.”

For the present analysis, Dr. Inamdar and colleagues reviewed charts from 48,012 patients who were hospitalized in New York between March and June of this year. While pancreatitis is usually diagnosed based on two out of three criteria, disease classification in the study required all three: characteristic upper abdominal pain upon admission, lipase greater than three times the upper limit of normal, and evidence of pancreatitis on cross-sectional imaging.

“[B]y including all three criteria for pancreatitis in our definition, we may be underestimating the rate of pancreatitis,” the investigators wrote. “However, we felt including diagnostic lipase levels and imaging was important for the accuracy of the diagnosis.”

Primary outcomes included mechanical ventilation, length of stay, development of pancreatic necrosis, and mortality. Outcomes were compared between patients with and without COVID-19.

Out of 48,012 hospitalized patients, 11,883 (24.75%) tested positive for SARS-CoV2. Across the entire population, 189 patients had pancreatitis (0.39%), and of these, 32 (17%) also had COVID-19. This translates to a point prevalence for pancreatitis of 0.27% for patients hospitalized with COVID-19.

Among patients with pancreatitis who did not have COVID-19, the most common etiologies for pancreatitis were gallstones (34%) and alcohol (37%), compared with just 16% and 6% of SARS-CoV2-positive cases of pancreatitis, respectively. Idiopathic pancreatitis was significantly more common among patients with COVID-19 than those without (69% vs 21%; P less than .0001).

Black or Hispanic patients with pancreatitis were 4-5 times more likely to have COVID-19 than patients with pancreatitis who were white. Across all races/ethnicities, patients with pancreatitis and COVID-19 more often required mechanical ventilation (odds ratio [OR], 5.65) and longer hospital stays (OR, 3.22), compared with those who had pancreatitis alone. While rates of mortality and pancreatic necrosis showed similar trends, associations with COVID-19 were not statistically significant.

“These findings support the notion that pancreatitis should be included in the list of GI manifestations of COVID-19,” the investigators wrote.

When caring for patients with COVID-19, Dr. Inamdar and colleagues recommended that clinicians pay close attention to any history of abdominal pain, and consider testing serum lipase levels.

“Further large studies are needed to confirm our findings,” they concluded.

Avinash Ketwaroo, MD, of Baylor College of Medicine in Houston, agreed that more work is needed; in the meantime, he suggested that evidence is now strong enough for clinicians to take notice.

SOURCE: Inamdar S et al. Gastroenterology. 2020 Aug 26. doi: 10.1053/j.gastro.2020.08.044.

Share AGA GI Patient Center content to help your patients understand the symptoms and complications of pancreatitis at http://ow.ly/j1AN30r8ZDa.

This story was updated on 9/14/2020.

Mounting data support acute pancreatitis as one possible GI manifestation of COVID-19, according to investigators.

While previous case reports suggested that infection with SARS-CoV2 may lead to pancreatitis, this retrospective analysis, which is the largest to date, is the first to offer substantial evidence for this claim, reported lead author Sumant Inamdar, MBBS, of the University of Arkansas, Little Rock, and colleagues.

“It has become increasingly clear that COVID-19 has systemic effects that also includes the gastrointestinal and pancreaticobiliary systems,” the investigators wrote in Gastroenterology. “As islet cells of the pancreas contain ACE2 receptor proteins, SARS-CoV2 can bind to these receptors and cause pancreatic injury.”

For the present analysis, Dr. Inamdar and colleagues reviewed charts from 48,012 patients who were hospitalized in New York between March and June of this year. While pancreatitis is usually diagnosed based on two out of three criteria, disease classification in the study required all three: characteristic upper abdominal pain upon admission, lipase greater than three times the upper limit of normal, and evidence of pancreatitis on cross-sectional imaging.

“[B]y including all three criteria for pancreatitis in our definition, we may be underestimating the rate of pancreatitis,” the investigators wrote. “However, we felt including diagnostic lipase levels and imaging was important for the accuracy of the diagnosis.”

Primary outcomes included mechanical ventilation, length of stay, development of pancreatic necrosis, and mortality. Outcomes were compared between patients with and without COVID-19.

Out of 48,012 hospitalized patients, 11,883 (24.75%) tested positive for SARS-CoV2. Across the entire population, 189 patients had pancreatitis (0.39%), and of these, 32 (17%) also had COVID-19. This translates to a point prevalence for pancreatitis of 0.27% for patients hospitalized with COVID-19.

Among patients with pancreatitis who did not have COVID-19, the most common etiologies for pancreatitis were gallstones (34%) and alcohol (37%), compared with just 16% and 6% of SARS-CoV2-positive cases of pancreatitis, respectively. Idiopathic pancreatitis was significantly more common among patients with COVID-19 than those without (69% vs 21%; P less than .0001).

Black or Hispanic patients with pancreatitis were 4-5 times more likely to have COVID-19 than patients with pancreatitis who were white. Across all races/ethnicities, patients with pancreatitis and COVID-19 more often required mechanical ventilation (odds ratio [OR], 5.65) and longer hospital stays (OR, 3.22), compared with those who had pancreatitis alone. While rates of mortality and pancreatic necrosis showed similar trends, associations with COVID-19 were not statistically significant.

“These findings support the notion that pancreatitis should be included in the list of GI manifestations of COVID-19,” the investigators wrote.

When caring for patients with COVID-19, Dr. Inamdar and colleagues recommended that clinicians pay close attention to any history of abdominal pain, and consider testing serum lipase levels.

“Further large studies are needed to confirm our findings,” they concluded.

Avinash Ketwaroo, MD, of Baylor College of Medicine in Houston, agreed that more work is needed; in the meantime, he suggested that evidence is now strong enough for clinicians to take notice.

SOURCE: Inamdar S et al. Gastroenterology. 2020 Aug 26. doi: 10.1053/j.gastro.2020.08.044.

Share AGA GI Patient Center content to help your patients understand the symptoms and complications of pancreatitis at http://ow.ly/j1AN30r8ZDa.

This story was updated on 9/14/2020.

Mounting data support acute pancreatitis as one possible GI manifestation of COVID-19, according to investigators.

While previous case reports suggested that infection with SARS-CoV2 may lead to pancreatitis, this retrospective analysis, which is the largest to date, is the first to offer substantial evidence for this claim, reported lead author Sumant Inamdar, MBBS, of the University of Arkansas, Little Rock, and colleagues.

“It has become increasingly clear that COVID-19 has systemic effects that also includes the gastrointestinal and pancreaticobiliary systems,” the investigators wrote in Gastroenterology. “As islet cells of the pancreas contain ACE2 receptor proteins, SARS-CoV2 can bind to these receptors and cause pancreatic injury.”

For the present analysis, Dr. Inamdar and colleagues reviewed charts from 48,012 patients who were hospitalized in New York between March and June of this year. While pancreatitis is usually diagnosed based on two out of three criteria, disease classification in the study required all three: characteristic upper abdominal pain upon admission, lipase greater than three times the upper limit of normal, and evidence of pancreatitis on cross-sectional imaging.

“[B]y including all three criteria for pancreatitis in our definition, we may be underestimating the rate of pancreatitis,” the investigators wrote. “However, we felt including diagnostic lipase levels and imaging was important for the accuracy of the diagnosis.”

Primary outcomes included mechanical ventilation, length of stay, development of pancreatic necrosis, and mortality. Outcomes were compared between patients with and without COVID-19.

Out of 48,012 hospitalized patients, 11,883 (24.75%) tested positive for SARS-CoV2. Across the entire population, 189 patients had pancreatitis (0.39%), and of these, 32 (17%) also had COVID-19. This translates to a point prevalence for pancreatitis of 0.27% for patients hospitalized with COVID-19.

Among patients with pancreatitis who did not have COVID-19, the most common etiologies for pancreatitis were gallstones (34%) and alcohol (37%), compared with just 16% and 6% of SARS-CoV2-positive cases of pancreatitis, respectively. Idiopathic pancreatitis was significantly more common among patients with COVID-19 than those without (69% vs 21%; P less than .0001).

Black or Hispanic patients with pancreatitis were 4-5 times more likely to have COVID-19 than patients with pancreatitis who were white. Across all races/ethnicities, patients with pancreatitis and COVID-19 more often required mechanical ventilation (odds ratio [OR], 5.65) and longer hospital stays (OR, 3.22), compared with those who had pancreatitis alone. While rates of mortality and pancreatic necrosis showed similar trends, associations with COVID-19 were not statistically significant.

“These findings support the notion that pancreatitis should be included in the list of GI manifestations of COVID-19,” the investigators wrote.

When caring for patients with COVID-19, Dr. Inamdar and colleagues recommended that clinicians pay close attention to any history of abdominal pain, and consider testing serum lipase levels.

“Further large studies are needed to confirm our findings,” they concluded.

Avinash Ketwaroo, MD, of Baylor College of Medicine in Houston, agreed that more work is needed; in the meantime, he suggested that evidence is now strong enough for clinicians to take notice.

SOURCE: Inamdar S et al. Gastroenterology. 2020 Aug 26. doi: 10.1053/j.gastro.2020.08.044.

Share AGA GI Patient Center content to help your patients understand the symptoms and complications of pancreatitis at http://ow.ly/j1AN30r8ZDa.

This story was updated on 9/14/2020.

For patients with suspected small-bowel bleeding, a three-variable scoring system predicted the diagnostic outcomes of video capsule endoscopy, according to the findings of a multicenter study.

“Admission to the hospital with overt bleeding and having a hemoglobin [level] of less than 6.4 g/dL were two positive predictors of a diagnosis. Being younger than 54 years old at the time of the video capsule endoscopy exam was a significant negative predictor of a diagnosis,” Neil B. Marya, MD, of the University of California, Los Angeles, and associates wrote in Techniques and Innovations in Gastrointestinal Endoscopy.

To develop the scoring system, they analyzed retrospective data from 162 adults with suspected small-bowel bleeding who received video capsule endoscopies at the University of Massachusetts or the University of California, Los Angeles, in 2016 or 2017. Most of these individuals were outpatients with occult gastrointestinal bleeding, but nearly one-third were inpatients with overt bleeding.

In all, 70 (43%) patients had a relevant finding on video capsule endoscopy, most frequently arteriovenous malformation (26%), blood (10.5%), or ulceration (10.5%). On multivariable analysis, the odds of positive video capsule endoscopy were significantly higher when patients had been admitted to the hospital with overt bleeding (adjusted odds ratio, 2.38; 95% confidence interval, 1.05-5.39) or had a baseline hemoglobin level less than or equal to 6.4 g/dL (aOR, 2.68; 95% CI, 1.11-6.48). In contrast, patients who were younger than 54 years were significantly less likely to have diagnostic lesions (aOR, 0.25; 95% CI, 0.11-0.58). After designating these variables as A, B, and C, respectively, the researchers derived the following equation to produce the score: (0.87 x A) + (0.99 x B) – (1.38 x C). Each variable was scored as 1 (present) or 0 (absent). Based on this equation, the highest score possible score was 1.86, and the lowest possible score was –1.38.

The researchers validated this scoring system by analyzing data from 152 adults with suspected small-bowel bleeding who were examined prospectively at the two centers. The development and validation cohorts resembled each other except that the validation cohort had lower mean hemoglobin levels (8.2 g/dL versus 9.0 g/dL in the development cohort; P < .01) and higher mean blood urea nitrogen levels (25.3 mg/dL vs. 19.9 mg per dL; P =.03). Receiver operating curves were similar between the two groups (respective C-statistics, 0.70 and 0.69; P = .91).

However, the scoring system’s maximum specificity was only 30.6%, yielding a positive predictive value of only 48.6%. The associated cutoff score was greater than or equal to 0. At this cutoff, sensitivity was “at least 90%,” and negative predictive value was 83.6%. Thus, the scoring system is best suited for identifying patients who are unlikely to have a diagnostic lesion found on video capsule endoscopy, the researchers said.

“Patients with scores of less than 0 could conceivably have capsule examinations deferred,” they concluded. “For example, consider a clinician taking care of a hospitalized patient who meets criteria for undergoing video capsule endoscopy for the indication of suspected small intestinal bleeding, but finds that the patient has a suspected small-bowel bleeding capsule diagnosis score of less than 0. The clinician could decide to have their patient undergo the video capsule endoscopy as an outpatient, since the likelihood of detecting an actionable lesion is low. This decision could have a [beneficial] financial impact.”

No external funding sources were reported. Dr. Marya disclosed a recent consulting relationship with AnX Robotica. Two coinvestigators disclosed a consulting relationship with Medtronic and research support from Olympus and Medtronic.

SOURCE: Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Jun 19. doi: 10.1016/j.tige.2020.06.001.

For patients with suspected small-bowel bleeding, a three-variable scoring system predicted the diagnostic outcomes of video capsule endoscopy, according to the findings of a multicenter study.

“Admission to the hospital with overt bleeding and having a hemoglobin [level] of less than 6.4 g/dL were two positive predictors of a diagnosis. Being younger than 54 years old at the time of the video capsule endoscopy exam was a significant negative predictor of a diagnosis,” Neil B. Marya, MD, of the University of California, Los Angeles, and associates wrote in Techniques and Innovations in Gastrointestinal Endoscopy.

To develop the scoring system, they analyzed retrospective data from 162 adults with suspected small-bowel bleeding who received video capsule endoscopies at the University of Massachusetts or the University of California, Los Angeles, in 2016 or 2017. Most of these individuals were outpatients with occult gastrointestinal bleeding, but nearly one-third were inpatients with overt bleeding.

In all, 70 (43%) patients had a relevant finding on video capsule endoscopy, most frequently arteriovenous malformation (26%), blood (10.5%), or ulceration (10.5%). On multivariable analysis, the odds of positive video capsule endoscopy were significantly higher when patients had been admitted to the hospital with overt bleeding (adjusted odds ratio, 2.38; 95% confidence interval, 1.05-5.39) or had a baseline hemoglobin level less than or equal to 6.4 g/dL (aOR, 2.68; 95% CI, 1.11-6.48). In contrast, patients who were younger than 54 years were significantly less likely to have diagnostic lesions (aOR, 0.25; 95% CI, 0.11-0.58). After designating these variables as A, B, and C, respectively, the researchers derived the following equation to produce the score: (0.87 x A) + (0.99 x B) – (1.38 x C). Each variable was scored as 1 (present) or 0 (absent). Based on this equation, the highest score possible score was 1.86, and the lowest possible score was –1.38.

The researchers validated this scoring system by analyzing data from 152 adults with suspected small-bowel bleeding who were examined prospectively at the two centers. The development and validation cohorts resembled each other except that the validation cohort had lower mean hemoglobin levels (8.2 g/dL versus 9.0 g/dL in the development cohort; P < .01) and higher mean blood urea nitrogen levels (25.3 mg/dL vs. 19.9 mg per dL; P =.03). Receiver operating curves were similar between the two groups (respective C-statistics, 0.70 and 0.69; P = .91).

However, the scoring system’s maximum specificity was only 30.6%, yielding a positive predictive value of only 48.6%. The associated cutoff score was greater than or equal to 0. At this cutoff, sensitivity was “at least 90%,” and negative predictive value was 83.6%. Thus, the scoring system is best suited for identifying patients who are unlikely to have a diagnostic lesion found on video capsule endoscopy, the researchers said.

“Patients with scores of less than 0 could conceivably have capsule examinations deferred,” they concluded. “For example, consider a clinician taking care of a hospitalized patient who meets criteria for undergoing video capsule endoscopy for the indication of suspected small intestinal bleeding, but finds that the patient has a suspected small-bowel bleeding capsule diagnosis score of less than 0. The clinician could decide to have their patient undergo the video capsule endoscopy as an outpatient, since the likelihood of detecting an actionable lesion is low. This decision could have a [beneficial] financial impact.”

No external funding sources were reported. Dr. Marya disclosed a recent consulting relationship with AnX Robotica. Two coinvestigators disclosed a consulting relationship with Medtronic and research support from Olympus and Medtronic.

SOURCE: Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Jun 19. doi: 10.1016/j.tige.2020.06.001.

For patients with suspected small-bowel bleeding, a three-variable scoring system predicted the diagnostic outcomes of video capsule endoscopy, according to the findings of a multicenter study.

“Admission to the hospital with overt bleeding and having a hemoglobin [level] of less than 6.4 g/dL were two positive predictors of a diagnosis. Being younger than 54 years old at the time of the video capsule endoscopy exam was a significant negative predictor of a diagnosis,” Neil B. Marya, MD, of the University of California, Los Angeles, and associates wrote in Techniques and Innovations in Gastrointestinal Endoscopy.

To develop the scoring system, they analyzed retrospective data from 162 adults with suspected small-bowel bleeding who received video capsule endoscopies at the University of Massachusetts or the University of California, Los Angeles, in 2016 or 2017. Most of these individuals were outpatients with occult gastrointestinal bleeding, but nearly one-third were inpatients with overt bleeding.

In all, 70 (43%) patients had a relevant finding on video capsule endoscopy, most frequently arteriovenous malformation (26%), blood (10.5%), or ulceration (10.5%). On multivariable analysis, the odds of positive video capsule endoscopy were significantly higher when patients had been admitted to the hospital with overt bleeding (adjusted odds ratio, 2.38; 95% confidence interval, 1.05-5.39) or had a baseline hemoglobin level less than or equal to 6.4 g/dL (aOR, 2.68; 95% CI, 1.11-6.48). In contrast, patients who were younger than 54 years were significantly less likely to have diagnostic lesions (aOR, 0.25; 95% CI, 0.11-0.58). After designating these variables as A, B, and C, respectively, the researchers derived the following equation to produce the score: (0.87 x A) + (0.99 x B) – (1.38 x C). Each variable was scored as 1 (present) or 0 (absent). Based on this equation, the highest score possible score was 1.86, and the lowest possible score was –1.38.

The researchers validated this scoring system by analyzing data from 152 adults with suspected small-bowel bleeding who were examined prospectively at the two centers. The development and validation cohorts resembled each other except that the validation cohort had lower mean hemoglobin levels (8.2 g/dL versus 9.0 g/dL in the development cohort; P < .01) and higher mean blood urea nitrogen levels (25.3 mg/dL vs. 19.9 mg per dL; P =.03). Receiver operating curves were similar between the two groups (respective C-statistics, 0.70 and 0.69; P = .91).

However, the scoring system’s maximum specificity was only 30.6%, yielding a positive predictive value of only 48.6%. The associated cutoff score was greater than or equal to 0. At this cutoff, sensitivity was “at least 90%,” and negative predictive value was 83.6%. Thus, the scoring system is best suited for identifying patients who are unlikely to have a diagnostic lesion found on video capsule endoscopy, the researchers said.

“Patients with scores of less than 0 could conceivably have capsule examinations deferred,” they concluded. “For example, consider a clinician taking care of a hospitalized patient who meets criteria for undergoing video capsule endoscopy for the indication of suspected small intestinal bleeding, but finds that the patient has a suspected small-bowel bleeding capsule diagnosis score of less than 0. The clinician could decide to have their patient undergo the video capsule endoscopy as an outpatient, since the likelihood of detecting an actionable lesion is low. This decision could have a [beneficial] financial impact.”

No external funding sources were reported. Dr. Marya disclosed a recent consulting relationship with AnX Robotica. Two coinvestigators disclosed a consulting relationship with Medtronic and research support from Olympus and Medtronic.

SOURCE: Marya NB et al. Tech Innov Gastrointest Endosc. 2020 Jun 19. doi: 10.1016/j.tige.2020.06.001.

The American Gastroenterological Association (AGA) has published a clinical practice update for endoscopic management of nonvariceal upper GI bleeding (NVUGIB).

The update includes 10 best practice recommendations based on clinical experience and a comprehensive literature review, reported lead author Daniel K. Mullady, MD, of Washington University in St. Louis.

“Numerous endoscopic devices have been developed over the past 30 years with demonstrated effectiveness in treating NVUGIB,” Dr. Mullady and colleagues wrote in Gastroenterology. “The purpose of this clinical practice update is to review the key concepts, new devices, and therapeutic strategies in endoscopically combating this age-old clinical dilemma.”

According to the investigators, endoscopy is central to management of NVUGIB, but only after patients are appropriately triaged and stabilized.

“[E]ndoscopy should be performed to determine the source of bleeding, to assess rebleeding risk, and to treat lesions at high risk for rebleeding,” they wrote. “Exactly when the endoscopy should be performed is a clinical judgment made by the gastroenterologist in consultation with the primary service.”

The investigators recommended that endoscopy be performed within 12 hours for emergent cases and within 24 hours for urgent cases, whereas elective cases could wait longer.

They noted that NVUGIB can range from mild and self-limiting, allowing for outpatient management, to severe and life-threatening, necessitating intensive care. Because of this broad range, the investigators recommended familiarity with triage scoring systems, including the Glasgow-Blatchford Score, the Rockall Score, and AIMS-65.

“A common decision is deciding whether or not to wait until the next morning to perform endoscopy on a patient presenting after hours with suspected NVUGIB,” the investigators wrote.

The investigators cautioned that emergent endoscopy may actually be associated with poorer outcomes because of “inadequate resuscitation,” and suggested that “[p]atients who are hemodynamically stable, do not have ongoing hematemesis, and have melena only can generally be deferred to the following morning.”

Concerning hemostatic technique, Dr. Mullady and colleagues recommended familiarity with conventional thermal therapy and placement of hemoclips. If these approaches are unsuccessful, or deemed unlikely to succeed, they recommended an over-the-scope clip.

For ulcers “with a rigid and fibrotic base,” or those that are hard to reach, the investigators recommended monopolar hemostatic forceps with low-voltage coagulation.

According to the update, hemostatic powder should be reserved for scenarios in which bleeding is diffuse and difficult to locate.

“In most instances, hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement,” the investigators wrote.

They noted that hemostatic powder generally dissolves in less than 24 hours, so additional treatment approaches should be considered, particular when there is a high risk of rebleeding.

When deciding between transcatheter arterial embolization (TAE) and surgery after endoscopic failure, the update calls for a comprehensive clinical assessment that incorporates patient factors, such as coagulopathy, hemodynamic instability, and multiorgan failure; bleeding etiology; potential adverse effects; and rebleeding risk.

“An important point is that prophylactic TAE of high-risk ulcers after successful endoscopic therapy is not recommended,” the investigators wrote.

Beyond these recommendations, the update includes a comprehensive discussion of relevant literature and strategies for effective clinical decision making. The discussion concludes with global remarks about the evolving role of endoscopy in managing NVUGIB, including a note about cost-effectiveness despite up-front expenses associated with some methods.

“With this expanded endoscopic armamentarium, endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB,” the investigators wrote. “Despite the increased costs of newer devices or multimodal therapy, effective hemostasis to preventing rebleeding and the need for hospital readmission is likely to be a dominant cost-saving strategy.”

Dr. Mullady disclosed relationships with Boston Scientific, ConMed, and Cook Medical.

This story was updated on 9/9/2020.

SOURCE: Mullady DK et al. Gastro. 2020 Jun 20. doi: 10.1053/j.gastro.2020.05.095.

The American Gastroenterological Association (AGA) has published a clinical practice update for endoscopic management of nonvariceal upper GI bleeding (NVUGIB).

The update includes 10 best practice recommendations based on clinical experience and a comprehensive literature review, reported lead author Daniel K. Mullady, MD, of Washington University in St. Louis.

“Numerous endoscopic devices have been developed over the past 30 years with demonstrated effectiveness in treating NVUGIB,” Dr. Mullady and colleagues wrote in Gastroenterology. “The purpose of this clinical practice update is to review the key concepts, new devices, and therapeutic strategies in endoscopically combating this age-old clinical dilemma.”

According to the investigators, endoscopy is central to management of NVUGIB, but only after patients are appropriately triaged and stabilized.

“[E]ndoscopy should be performed to determine the source of bleeding, to assess rebleeding risk, and to treat lesions at high risk for rebleeding,” they wrote. “Exactly when the endoscopy should be performed is a clinical judgment made by the gastroenterologist in consultation with the primary service.”

The investigators recommended that endoscopy be performed within 12 hours for emergent cases and within 24 hours for urgent cases, whereas elective cases could wait longer.

They noted that NVUGIB can range from mild and self-limiting, allowing for outpatient management, to severe and life-threatening, necessitating intensive care. Because of this broad range, the investigators recommended familiarity with triage scoring systems, including the Glasgow-Blatchford Score, the Rockall Score, and AIMS-65.

“A common decision is deciding whether or not to wait until the next morning to perform endoscopy on a patient presenting after hours with suspected NVUGIB,” the investigators wrote.

The investigators cautioned that emergent endoscopy may actually be associated with poorer outcomes because of “inadequate resuscitation,” and suggested that “[p]atients who are hemodynamically stable, do not have ongoing hematemesis, and have melena only can generally be deferred to the following morning.”

Concerning hemostatic technique, Dr. Mullady and colleagues recommended familiarity with conventional thermal therapy and placement of hemoclips. If these approaches are unsuccessful, or deemed unlikely to succeed, they recommended an over-the-scope clip.

For ulcers “with a rigid and fibrotic base,” or those that are hard to reach, the investigators recommended monopolar hemostatic forceps with low-voltage coagulation.

According to the update, hemostatic powder should be reserved for scenarios in which bleeding is diffuse and difficult to locate.

“In most instances, hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement,” the investigators wrote.

They noted that hemostatic powder generally dissolves in less than 24 hours, so additional treatment approaches should be considered, particular when there is a high risk of rebleeding.

When deciding between transcatheter arterial embolization (TAE) and surgery after endoscopic failure, the update calls for a comprehensive clinical assessment that incorporates patient factors, such as coagulopathy, hemodynamic instability, and multiorgan failure; bleeding etiology; potential adverse effects; and rebleeding risk.

“An important point is that prophylactic TAE of high-risk ulcers after successful endoscopic therapy is not recommended,” the investigators wrote.

Beyond these recommendations, the update includes a comprehensive discussion of relevant literature and strategies for effective clinical decision making. The discussion concludes with global remarks about the evolving role of endoscopy in managing NVUGIB, including a note about cost-effectiveness despite up-front expenses associated with some methods.

“With this expanded endoscopic armamentarium, endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB,” the investigators wrote. “Despite the increased costs of newer devices or multimodal therapy, effective hemostasis to preventing rebleeding and the need for hospital readmission is likely to be a dominant cost-saving strategy.”

Dr. Mullady disclosed relationships with Boston Scientific, ConMed, and Cook Medical.

This story was updated on 9/9/2020.

SOURCE: Mullady DK et al. Gastro. 2020 Jun 20. doi: 10.1053/j.gastro.2020.05.095.

The American Gastroenterological Association (AGA) has published a clinical practice update for endoscopic management of nonvariceal upper GI bleeding (NVUGIB).

The update includes 10 best practice recommendations based on clinical experience and a comprehensive literature review, reported lead author Daniel K. Mullady, MD, of Washington University in St. Louis.

“Numerous endoscopic devices have been developed over the past 30 years with demonstrated effectiveness in treating NVUGIB,” Dr. Mullady and colleagues wrote in Gastroenterology. “The purpose of this clinical practice update is to review the key concepts, new devices, and therapeutic strategies in endoscopically combating this age-old clinical dilemma.”

According to the investigators, endoscopy is central to management of NVUGIB, but only after patients are appropriately triaged and stabilized.

“[E]ndoscopy should be performed to determine the source of bleeding, to assess rebleeding risk, and to treat lesions at high risk for rebleeding,” they wrote. “Exactly when the endoscopy should be performed is a clinical judgment made by the gastroenterologist in consultation with the primary service.”

The investigators recommended that endoscopy be performed within 12 hours for emergent cases and within 24 hours for urgent cases, whereas elective cases could wait longer.

They noted that NVUGIB can range from mild and self-limiting, allowing for outpatient management, to severe and life-threatening, necessitating intensive care. Because of this broad range, the investigators recommended familiarity with triage scoring systems, including the Glasgow-Blatchford Score, the Rockall Score, and AIMS-65.

“A common decision is deciding whether or not to wait until the next morning to perform endoscopy on a patient presenting after hours with suspected NVUGIB,” the investigators wrote.

The investigators cautioned that emergent endoscopy may actually be associated with poorer outcomes because of “inadequate resuscitation,” and suggested that “[p]atients who are hemodynamically stable, do not have ongoing hematemesis, and have melena only can generally be deferred to the following morning.”

Concerning hemostatic technique, Dr. Mullady and colleagues recommended familiarity with conventional thermal therapy and placement of hemoclips. If these approaches are unsuccessful, or deemed unlikely to succeed, they recommended an over-the-scope clip.

For ulcers “with a rigid and fibrotic base,” or those that are hard to reach, the investigators recommended monopolar hemostatic forceps with low-voltage coagulation.

According to the update, hemostatic powder should be reserved for scenarios in which bleeding is diffuse and difficult to locate.

“In most instances, hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement,” the investigators wrote.

They noted that hemostatic powder generally dissolves in less than 24 hours, so additional treatment approaches should be considered, particular when there is a high risk of rebleeding.

When deciding between transcatheter arterial embolization (TAE) and surgery after endoscopic failure, the update calls for a comprehensive clinical assessment that incorporates patient factors, such as coagulopathy, hemodynamic instability, and multiorgan failure; bleeding etiology; potential adverse effects; and rebleeding risk.

“An important point is that prophylactic TAE of high-risk ulcers after successful endoscopic therapy is not recommended,” the investigators wrote.

Beyond these recommendations, the update includes a comprehensive discussion of relevant literature and strategies for effective clinical decision making. The discussion concludes with global remarks about the evolving role of endoscopy in managing NVUGIB, including a note about cost-effectiveness despite up-front expenses associated with some methods.

“With this expanded endoscopic armamentarium, endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB,” the investigators wrote. “Despite the increased costs of newer devices or multimodal therapy, effective hemostasis to preventing rebleeding and the need for hospital readmission is likely to be a dominant cost-saving strategy.”

Dr. Mullady disclosed relationships with Boston Scientific, ConMed, and Cook Medical.

This story was updated on 9/9/2020.

SOURCE: Mullady DK et al. Gastro. 2020 Jun 20. doi: 10.1053/j.gastro.2020.05.095.

Increasingly recognized as an independent risk factor for new-onset atrial fibrillation (AFib), new research suggests for the first time that nonalcoholic fatty liver disease (NAFLD) also confers a higher risk for arrhythmia recurrence after AFib ablation.

Over 29 months of postablation follow-up, 56% of patients with NAFLD suffered bouts of arrhythmia, compared with 31% of patients without NAFLD, matched on the basis of age, sex, body mass index (BMI), ejection fraction within 5%, and AFib type (P < .0001).

The presence of NAFLD was an independent predictor of arrhythmia recurrence in multivariable analyses adjusted for several confounders, including hemoglobin A1c, BMI, and AFib type (hazard ratio, 3.0; 95% confidence interval, 1.94-4.68).

The association is concerning given that one in four adults in the United States has NAFLD, and up to 6.1 million Americans are estimated to have Afib. Previous studies, such as ARREST-AF and LEGACY, however, have demonstrated the benefits of aggressive preablation cardiometabolic risk factor modification on long-term AFib ablation success.

Indeed, none of the NAFLD patients in the present study who lost at least 10% of their body weight had recurrent arrhythmia, compared with 31% who lost less than 10%, and 91% who gained weight prior to ablation (P < .0001).

All 22 patients whose A1c increased during the 12 months prior to ablation had recurrent arrhythmia, compared with 36% of patients whose A1c improved (P < .0001).

“I don’t think the findings of the study were particularly surprising, given what we know. It’s just further reinforcement of the essential role of risk-factor modification,” lead author Eoin Donnellan, MD, Cleveland Clinic, said in an interview.

The results were published Augus 12 in JACC Clinical Electrophysiology.

For the study, the researchers examined data from 267 consecutive patients with a mean BMI of 32.7 kg/m² who underwent radiofrequency ablation (98%) or cryoablation (2%) at the Cleveland Clinic between January 2013 and December 2017.

All patients were followed for at least 12 months after ablation and had scheduled clinic visits at 3, 6, and 12 months after pulmonary vein isolation, and annually thereafter.

NAFLD was diagnosed in 89 patients prior to ablation on the basis of CT imaging and abdominal ultrasound or MRI. On the basis of NAFLD-Fibrosis Score (NAFLD-FS), 13 patients had a low probability of liver fibrosis (F0-F2), 54 had an indeterminate probability, and 22 a high probability of fibrosis (F3-F4).

Compared with patients with no or early fibrosis (F0-F2), patients with advanced liver fibrosis (F3-F4) had almost a threefold increase in AFib recurrence (82% vs. 31%; P = .003).

“Cardiologists should make an effort to risk-stratify NAFLD patients either by NAFLD-FS or [an] alternative option, such as transient elastography or MR elastography, given these observations, rather than viewing it as either present or absence [sic] and involve expert multidisciplinary team care early in the clinical course of NAFLD patients with evidence of advanced fibrosis,” Dr. Donnellan and colleagues wrote.

Coauthor Thomas G. Cotter, MD, department of gastroenterology and hepatology, University of Chicago, said in an interview that cardiologists could use just the NAFLD-FS as part of an algorithm for an AFib.

“Because if it shows low risk, then it’s very, very likely the patient will be fine,” he said. “To use more advanced noninvasive testing, there are subtleties in the interpretation that would require referral to a liver doctor or a gastroenterologist and the cost of referring might bulk up the costs. But the NAFLD-FS is freely available and is a validated tool.”

Although it hasn’t specifically been validated in patients with AFib, the NAFLD-FS has been shown to correlate with the development of coronary artery disease  (CAD) and was recommended for clinical use in U.S. multisociety guidelines for NAFLD.

The score is calculated using six readily available clinical variables (age, BMI, hyperglycemia or diabetes, AST/ALT, platelets, and albumin). It does not include family history or alcohol consumption, which should be carefully detailed given the large overlap between NAFLD and alcohol-related liver disease, Dr. Cotter observed.

Of note, the study excluded patients with alcohol consumption of more than 30 g/day in men and more than 20 g/day in women, chronic viral hepatitis, Wilson’s disease, and hereditary hemochromatosis.

Finally, CT imaging revealed that epicardial fat volume (EFV) was greater in patients with NAFLD than in those without NAFLD (248 vs. 223 mL; P = .01).

Although increased amounts of epicardial fat have been associated with CAD, there was no significant difference in EFV between patients who did and did not develop recurrent arrhythmia (238 vs. 229 mL; P = .5). Nor was EFV associated with arrhythmia recurrence on Cox proportional hazards analysis (HR, 1.001; P = .17).

“We hypothesized that the increased risk of arrhythmia recurrence may be mediated in part by an increased epicardial fat volume,” Dr. Donnellan said. “The existing literature exploring the link between epicardial fat volume and A[Fib] burden and recurrence is conflicting. But in both this study and our bariatric surgery study, epicardial fat volume was not a significant predictor of arrhythmia recurrence on multivariable analysis.”

It’s likely that the increased recurrence risk is caused by several mechanisms, including NAFLD’s deleterious impact on cardiac structure and function, the bidirectional relationship between NAFLD and sleep apnea, and transcription of proinflammatory cytokines and low-grade systemic inflammation, he suggested.

“Patients with NAFLD represent a particularly high-risk population for arrhythmia recurrence. NAFLD is a reversible disease, and a multidisciplinary approach incorporating dietary and lifestyle interventions should by instituted prior to ablation,” Dr. Donnellan and colleagues concluded.

They noted that serial abdominal imaging to assess for preablation changes in NAFLD was limited in patients and that only 56% of control subjects underwent dedicated abdominal imaging to rule out hepatic steatosis. Also, the heterogeneity of imaging modalities used to diagnose NAFLD may have influenced the results and the study’s single-center, retrospective design limits their generalizability.

The authors reported having no relevant financial relationships.

Help your patients better understand their risk of NASH and NAFLD by sharing AGA patient education content at http://ow.ly/ZKi930r50am.  

A version of this article originally appeared on Medscape.com.

Increasingly recognized as an independent risk factor for new-onset atrial fibrillation (AFib), new research suggests for the first time that nonalcoholic fatty liver disease (NAFLD) also confers a higher risk for arrhythmia recurrence after AFib ablation.

Over 29 months of postablation follow-up, 56% of patients with NAFLD suffered bouts of arrhythmia, compared with 31% of patients without NAFLD, matched on the basis of age, sex, body mass index (BMI), ejection fraction within 5%, and AFib type (P < .0001).

The presence of NAFLD was an independent predictor of arrhythmia recurrence in multivariable analyses adjusted for several confounders, including hemoglobin A1c, BMI, and AFib type (hazard ratio, 3.0; 95% confidence interval, 1.94-4.68).

The association is concerning given that one in four adults in the United States has NAFLD, and up to 6.1 million Americans are estimated to have Afib. Previous studies, such as ARREST-AF and LEGACY, however, have demonstrated the benefits of aggressive preablation cardiometabolic risk factor modification on long-term AFib ablation success.

Indeed, none of the NAFLD patients in the present study who lost at least 10% of their body weight had recurrent arrhythmia, compared with 31% who lost less than 10%, and 91% who gained weight prior to ablation (P < .0001).

All 22 patients whose A1c increased during the 12 months prior to ablation had recurrent arrhythmia, compared with 36% of patients whose A1c improved (P < .0001).

“I don’t think the findings of the study were particularly surprising, given what we know. It’s just further reinforcement of the essential role of risk-factor modification,” lead author Eoin Donnellan, MD, Cleveland Clinic, said in an interview.

The results were published Augus 12 in JACC Clinical Electrophysiology.

For the study, the researchers examined data from 267 consecutive patients with a mean BMI of 32.7 kg/m² who underwent radiofrequency ablation (98%) or cryoablation (2%) at the Cleveland Clinic between January 2013 and December 2017.

All patients were followed for at least 12 months after ablation and had scheduled clinic visits at 3, 6, and 12 months after pulmonary vein isolation, and annually thereafter.

NAFLD was diagnosed in 89 patients prior to ablation on the basis of CT imaging and abdominal ultrasound or MRI. On the basis of NAFLD-Fibrosis Score (NAFLD-FS), 13 patients had a low probability of liver fibrosis (F0-F2), 54 had an indeterminate probability, and 22 a high probability of fibrosis (F3-F4).

Compared with patients with no or early fibrosis (F0-F2), patients with advanced liver fibrosis (F3-F4) had almost a threefold increase in AFib recurrence (82% vs. 31%; P = .003).

“Cardiologists should make an effort to risk-stratify NAFLD patients either by NAFLD-FS or [an] alternative option, such as transient elastography or MR elastography, given these observations, rather than viewing it as either present or absence [sic] and involve expert multidisciplinary team care early in the clinical course of NAFLD patients with evidence of advanced fibrosis,” Dr. Donnellan and colleagues wrote.

Coauthor Thomas G. Cotter, MD, department of gastroenterology and hepatology, University of Chicago, said in an interview that cardiologists could use just the NAFLD-FS as part of an algorithm for an AFib.

“Because if it shows low risk, then it’s very, very likely the patient will be fine,” he said. “To use more advanced noninvasive testing, there are subtleties in the interpretation that would require referral to a liver doctor or a gastroenterologist and the cost of referring might bulk up the costs. But the NAFLD-FS is freely available and is a validated tool.”

Although it hasn’t specifically been validated in patients with AFib, the NAFLD-FS has been shown to correlate with the development of coronary artery disease  (CAD) and was recommended for clinical use in U.S. multisociety guidelines for NAFLD.

The score is calculated using six readily available clinical variables (age, BMI, hyperglycemia or diabetes, AST/ALT, platelets, and albumin). It does not include family history or alcohol consumption, which should be carefully detailed given the large overlap between NAFLD and alcohol-related liver disease, Dr. Cotter observed.

Of note, the study excluded patients with alcohol consumption of more than 30 g/day in men and more than 20 g/day in women, chronic viral hepatitis, Wilson’s disease, and hereditary hemochromatosis.

Finally, CT imaging revealed that epicardial fat volume (EFV) was greater in patients with NAFLD than in those without NAFLD (248 vs. 223 mL; P = .01).

Although increased amounts of epicardial fat have been associated with CAD, there was no significant difference in EFV between patients who did and did not develop recurrent arrhythmia (238 vs. 229 mL; P = .5). Nor was EFV associated with arrhythmia recurrence on Cox proportional hazards analysis (HR, 1.001; P = .17).

“We hypothesized that the increased risk of arrhythmia recurrence may be mediated in part by an increased epicardial fat volume,” Dr. Donnellan said. “The existing literature exploring the link between epicardial fat volume and A[Fib] burden and recurrence is conflicting. But in both this study and our bariatric surgery study, epicardial fat volume was not a significant predictor of arrhythmia recurrence on multivariable analysis.”

It’s likely that the increased recurrence risk is caused by several mechanisms, including NAFLD’s deleterious impact on cardiac structure and function, the bidirectional relationship between NAFLD and sleep apnea, and transcription of proinflammatory cytokines and low-grade systemic inflammation, he suggested.

“Patients with NAFLD represent a particularly high-risk population for arrhythmia recurrence. NAFLD is a reversible disease, and a multidisciplinary approach incorporating dietary and lifestyle interventions should by instituted prior to ablation,” Dr. Donnellan and colleagues concluded.

They noted that serial abdominal imaging to assess for preablation changes in NAFLD was limited in patients and that only 56% of control subjects underwent dedicated abdominal imaging to rule out hepatic steatosis. Also, the heterogeneity of imaging modalities used to diagnose NAFLD may have influenced the results and the study’s single-center, retrospective design limits their generalizability.

The authors reported having no relevant financial relationships.

Help your patients better understand their risk of NASH and NAFLD by sharing AGA patient education content at http://ow.ly/ZKi930r50am.  

A version of this article originally appeared on Medscape.com.

Increasingly recognized as an independent risk factor for new-onset atrial fibrillation (AFib), new research suggests for the first time that nonalcoholic fatty liver disease (NAFLD) also confers a higher risk for arrhythmia recurrence after AFib ablation.

Over 29 months of postablation follow-up, 56% of patients with NAFLD suffered bouts of arrhythmia, compared with 31% of patients without NAFLD, matched on the basis of age, sex, body mass index (BMI), ejection fraction within 5%, and AFib type (P < .0001).

The presence of NAFLD was an independent predictor of arrhythmia recurrence in multivariable analyses adjusted for several confounders, including hemoglobin A1c, BMI, and AFib type (hazard ratio, 3.0; 95% confidence interval, 1.94-4.68).

The association is concerning given that one in four adults in the United States has NAFLD, and up to 6.1 million Americans are estimated to have Afib. Previous studies, such as ARREST-AF and LEGACY, however, have demonstrated the benefits of aggressive preablation cardiometabolic risk factor modification on long-term AFib ablation success.

Indeed, none of the NAFLD patients in the present study who lost at least 10% of their body weight had recurrent arrhythmia, compared with 31% who lost less than 10%, and 91% who gained weight prior to ablation (P < .0001).

All 22 patients whose A1c increased during the 12 months prior to ablation had recurrent arrhythmia, compared with 36% of patients whose A1c improved (P < .0001).

“I don’t think the findings of the study were particularly surprising, given what we know. It’s just further reinforcement of the essential role of risk-factor modification,” lead author Eoin Donnellan, MD, Cleveland Clinic, said in an interview.

The results were published Augus 12 in JACC Clinical Electrophysiology.

For the study, the researchers examined data from 267 consecutive patients with a mean BMI of 32.7 kg/m² who underwent radiofrequency ablation (98%) or cryoablation (2%) at the Cleveland Clinic between January 2013 and December 2017.

All patients were followed for at least 12 months after ablation and had scheduled clinic visits at 3, 6, and 12 months after pulmonary vein isolation, and annually thereafter.

NAFLD was diagnosed in 89 patients prior to ablation on the basis of CT imaging and abdominal ultrasound or MRI. On the basis of NAFLD-Fibrosis Score (NAFLD-FS), 13 patients had a low probability of liver fibrosis (F0-F2), 54 had an indeterminate probability, and 22 a high probability of fibrosis (F3-F4).

Compared with patients with no or early fibrosis (F0-F2), patients with advanced liver fibrosis (F3-F4) had almost a threefold increase in AFib recurrence (82% vs. 31%; P = .003).

“Cardiologists should make an effort to risk-stratify NAFLD patients either by NAFLD-FS or [an] alternative option, such as transient elastography or MR elastography, given these observations, rather than viewing it as either present or absence [sic] and involve expert multidisciplinary team care early in the clinical course of NAFLD patients with evidence of advanced fibrosis,” Dr. Donnellan and colleagues wrote.

Coauthor Thomas G. Cotter, MD, department of gastroenterology and hepatology, University of Chicago, said in an interview that cardiologists could use just the NAFLD-FS as part of an algorithm for an AFib.

“Because if it shows low risk, then it’s very, very likely the patient will be fine,” he said. “To use more advanced noninvasive testing, there are subtleties in the interpretation that would require referral to a liver doctor or a gastroenterologist and the cost of referring might bulk up the costs. But the NAFLD-FS is freely available and is a validated tool.”

Although it hasn’t specifically been validated in patients with AFib, the NAFLD-FS has been shown to correlate with the development of coronary artery disease  (CAD) and was recommended for clinical use in U.S. multisociety guidelines for NAFLD.

The score is calculated using six readily available clinical variables (age, BMI, hyperglycemia or diabetes, AST/ALT, platelets, and albumin). It does not include family history or alcohol consumption, which should be carefully detailed given the large overlap between NAFLD and alcohol-related liver disease, Dr. Cotter observed.

Of note, the study excluded patients with alcohol consumption of more than 30 g/day in men and more than 20 g/day in women, chronic viral hepatitis, Wilson’s disease, and hereditary hemochromatosis.

Finally, CT imaging revealed that epicardial fat volume (EFV) was greater in patients with NAFLD than in those without NAFLD (248 vs. 223 mL; P = .01).

Although increased amounts of epicardial fat have been associated with CAD, there was no significant difference in EFV between patients who did and did not develop recurrent arrhythmia (238 vs. 229 mL; P = .5). Nor was EFV associated with arrhythmia recurrence on Cox proportional hazards analysis (HR, 1.001; P = .17).

“We hypothesized that the increased risk of arrhythmia recurrence may be mediated in part by an increased epicardial fat volume,” Dr. Donnellan said. “The existing literature exploring the link between epicardial fat volume and A[Fib] burden and recurrence is conflicting. But in both this study and our bariatric surgery study, epicardial fat volume was not a significant predictor of arrhythmia recurrence on multivariable analysis.”

It’s likely that the increased recurrence risk is caused by several mechanisms, including NAFLD’s deleterious impact on cardiac structure and function, the bidirectional relationship between NAFLD and sleep apnea, and transcription of proinflammatory cytokines and low-grade systemic inflammation, he suggested.

“Patients with NAFLD represent a particularly high-risk population for arrhythmia recurrence. NAFLD is a reversible disease, and a multidisciplinary approach incorporating dietary and lifestyle interventions should by instituted prior to ablation,” Dr. Donnellan and colleagues concluded.

They noted that serial abdominal imaging to assess for preablation changes in NAFLD was limited in patients and that only 56% of control subjects underwent dedicated abdominal imaging to rule out hepatic steatosis. Also, the heterogeneity of imaging modalities used to diagnose NAFLD may have influenced the results and the study’s single-center, retrospective design limits their generalizability.

The authors reported having no relevant financial relationships.

Help your patients better understand their risk of NASH and NAFLD by sharing AGA patient education content at http://ow.ly/ZKi930r50am.  

A version of this article originally appeared on Medscape.com.

The American Gastroenterological Association (AGA) has released a clinical practice guideline for gastrointestinal evaluation of iron-deficiency anemia.

The seven recommendations aim to improve quality of care and reduce practice variability, according to lead author Cynthia W. Ko, MD, of the University of Washington , Seattle, and four copanelists.

First, the panel recommended that iron deficiency be defined by a serum ferritin level less than 45 ng/mL, instead of 15 ng/mL. Data from 55 studies showed that the higher cutoff value had a sensitivity of 85% and a specificity of 92%, compared with respective values of 59% and 99% for the lower threshold.

“Optimizing the threshold ferritin level with high sensitivity will detect the great majority of patients who are truly iron deficient, minimize delays in diagnostic workup, and minimize the number of patients in whom serious underlying etiologies such as gastrointestinal malignancy might be missed,” the panelists wrote. The guideline was published in Gastroenterology.

For asymptomatic postmenopausal women and men with iron-deficiency anemia, the panel recommended bidirectional endoscopy instead of no endoscopy. A similar recommendation was given for premenopausal women, calling for bidirectional endoscopy instead of iron-replacement therapy alone.

Dr. Ko and colleagues noted that these recommendations differ from those issued by the British Society of Gastroenterology (BSG).

For postmenopausal women and men, the BSG suggests that symptoms and local availability of endoscopy should inform diagnostic workup, with either colonoscopy or CT colonography used for assessment. The BSG recommends against bidirectional endoscopy in premenopausal women, unless they are older than 50 years, have a family history of colorectal cancer, or show symptoms of gastrointestinal disease.

“In contrast, the AGA recommends bidirectional endoscopy as the mainstay for gastrointestinal evaluation, particularly in men and in postmenopausal women where no other unequivocal source of iron deficiency has been identified,” the panelists wrote.

When bidirectional endoscopy does not reveal an etiology, the panelists recommended noninvasive testing for Helicobacter pylori.

“An association between H. pylori infection and iron deficiency has been demonstrated in observational studies,” noted Dr. Ko and colleagues.

They also cited three randomized controlled trials in which treating patients with iron-deficiency anemia for H. pylori infection in combination with iron replacement therapy led to a 23.2-ng/mL mean improvement in serum ferritin, compared with patients who received iron-replacement therapy alone.

According to the guideline, if asymptomatic patients with negative bidirectional endoscopy are also negative for H. pylori, then they should receive trial iron supplementation, instead of undergoing video capsule endoscopy.

“[T]he evidence required to evaluate the benefits of video capsule endoscopy in iron-deficiency anemia is not currently available,” the panelists noted.

Dr. Ko and colleagues also recommended against routine gastric biopsies to diagnose autoimmune atrophic gastritis, as earlier diagnosis does not appear to affect outcomes or management of iron-deficiency anemia.

Finally, the panelists recommended that asymptomatic patients with iron-deficiency anemia and suspected celiac disease undergo serologic testing first, with small bowel biopsy only performed if testing is positive.

The only two strong recommendations in the guideline are for the ferritin cutoff value and the use of bidirectional endoscopy in men and postmenopausal women. The other five recommendations are conditional, three of which are based on very low quality evidence. As such, the guideline includes a discussion of research needs.

Dr. Ko and colleagues called for more studies investigating the prevalence of gastrointestinal lesions and risks of bidirectional endoscopy in premenopausal women, role of fecal occult blood testing, timing of serologic testing for H. pylori and celiac disease in relation to endoscopy, patient subgroups, comparative efficacy of small bowel visualization techniques, and other topics.

The investigators disclosed no conflicts of interest. The guideline was funded by the AGA Institute.

SOURCE: Ko CW et al. Gastroenterology 2020 Aug 15. doi: 10.1053/j.gastro.2020.06.046.

The American Gastroenterological Association (AGA) has released a clinical practice guideline for gastrointestinal evaluation of iron-deficiency anemia.

The seven recommendations aim to improve quality of care and reduce practice variability, according to lead author Cynthia W. Ko, MD, of the University of Washington , Seattle, and four copanelists.

First, the panel recommended that iron deficiency be defined by a serum ferritin level less than 45 ng/mL, instead of 15 ng/mL. Data from 55 studies showed that the higher cutoff value had a sensitivity of 85% and a specificity of 92%, compared with respective values of 59% and 99% for the lower threshold.

“Optimizing the threshold ferritin level with high sensitivity will detect the great majority of patients who are truly iron deficient, minimize delays in diagnostic workup, and minimize the number of patients in whom serious underlying etiologies such as gastrointestinal malignancy might be missed,” the panelists wrote. The guideline was published in Gastroenterology.

For asymptomatic postmenopausal women and men with iron-deficiency anemia, the panel recommended bidirectional endoscopy instead of no endoscopy. A similar recommendation was given for premenopausal women, calling for bidirectional endoscopy instead of iron-replacement therapy alone.

Dr. Ko and colleagues noted that these recommendations differ from those issued by the British Society of Gastroenterology (BSG).

For postmenopausal women and men, the BSG suggests that symptoms and local availability of endoscopy should inform diagnostic workup, with either colonoscopy or CT colonography used for assessment. The BSG recommends against bidirectional endoscopy in premenopausal women, unless they are older than 50 years, have a family history of colorectal cancer, or show symptoms of gastrointestinal disease.

“In contrast, the AGA recommends bidirectional endoscopy as the mainstay for gastrointestinal evaluation, particularly in men and in postmenopausal women where no other unequivocal source of iron deficiency has been identified,” the panelists wrote.

When bidirectional endoscopy does not reveal an etiology, the panelists recommended noninvasive testing for Helicobacter pylori.

“An association between H. pylori infection and iron deficiency has been demonstrated in observational studies,” noted Dr. Ko and colleagues.

They also cited three randomized controlled trials in which treating patients with iron-deficiency anemia for H. pylori infection in combination with iron replacement therapy led to a 23.2-ng/mL mean improvement in serum ferritin, compared with patients who received iron-replacement therapy alone.

According to the guideline, if asymptomatic patients with negative bidirectional endoscopy are also negative for H. pylori, then they should receive trial iron supplementation, instead of undergoing video capsule endoscopy.

“[T]he evidence required to evaluate the benefits of video capsule endoscopy in iron-deficiency anemia is not currently available,” the panelists noted.

Dr. Ko and colleagues also recommended against routine gastric biopsies to diagnose autoimmune atrophic gastritis, as earlier diagnosis does not appear to affect outcomes or management of iron-deficiency anemia.

Finally, the panelists recommended that asymptomatic patients with iron-deficiency anemia and suspected celiac disease undergo serologic testing first, with small bowel biopsy only performed if testing is positive.

The only two strong recommendations in the guideline are for the ferritin cutoff value and the use of bidirectional endoscopy in men and postmenopausal women. The other five recommendations are conditional, three of which are based on very low quality evidence. As such, the guideline includes a discussion of research needs.

Dr. Ko and colleagues called for more studies investigating the prevalence of gastrointestinal lesions and risks of bidirectional endoscopy in premenopausal women, role of fecal occult blood testing, timing of serologic testing for H. pylori and celiac disease in relation to endoscopy, patient subgroups, comparative efficacy of small bowel visualization techniques, and other topics.

The investigators disclosed no conflicts of interest. The guideline was funded by the AGA Institute.

SOURCE: Ko CW et al. Gastroenterology 2020 Aug 15. doi: 10.1053/j.gastro.2020.06.046.

The American Gastroenterological Association (AGA) has released a clinical practice guideline for gastrointestinal evaluation of iron-deficiency anemia.

The seven recommendations aim to improve quality of care and reduce practice variability, according to lead author Cynthia W. Ko, MD, of the University of Washington , Seattle, and four copanelists.

First, the panel recommended that iron deficiency be defined by a serum ferritin level less than 45 ng/mL, instead of 15 ng/mL. Data from 55 studies showed that the higher cutoff value had a sensitivity of 85% and a specificity of 92%, compared with respective values of 59% and 99% for the lower threshold.

“Optimizing the threshold ferritin level with high sensitivity will detect the great majority of patients who are truly iron deficient, minimize delays in diagnostic workup, and minimize the number of patients in whom serious underlying etiologies such as gastrointestinal malignancy might be missed,” the panelists wrote. The guideline was published in Gastroenterology.

For asymptomatic postmenopausal women and men with iron-deficiency anemia, the panel recommended bidirectional endoscopy instead of no endoscopy. A similar recommendation was given for premenopausal women, calling for bidirectional endoscopy instead of iron-replacement therapy alone.

Dr. Ko and colleagues noted that these recommendations differ from those issued by the British Society of Gastroenterology (BSG).

For postmenopausal women and men, the BSG suggests that symptoms and local availability of endoscopy should inform diagnostic workup, with either colonoscopy or CT colonography used for assessment. The BSG recommends against bidirectional endoscopy in premenopausal women, unless they are older than 50 years, have a family history of colorectal cancer, or show symptoms of gastrointestinal disease.

“In contrast, the AGA recommends bidirectional endoscopy as the mainstay for gastrointestinal evaluation, particularly in men and in postmenopausal women where no other unequivocal source of iron deficiency has been identified,” the panelists wrote.

When bidirectional endoscopy does not reveal an etiology, the panelists recommended noninvasive testing for Helicobacter pylori.

“An association between H. pylori infection and iron deficiency has been demonstrated in observational studies,” noted Dr. Ko and colleagues.

They also cited three randomized controlled trials in which treating patients with iron-deficiency anemia for H. pylori infection in combination with iron replacement therapy led to a 23.2-ng/mL mean improvement in serum ferritin, compared with patients who received iron-replacement therapy alone.

According to the guideline, if asymptomatic patients with negative bidirectional endoscopy are also negative for H. pylori, then they should receive trial iron supplementation, instead of undergoing video capsule endoscopy.

“[T]he evidence required to evaluate the benefits of video capsule endoscopy in iron-deficiency anemia is not currently available,” the panelists noted.

Dr. Ko and colleagues also recommended against routine gastric biopsies to diagnose autoimmune atrophic gastritis, as earlier diagnosis does not appear to affect outcomes or management of iron-deficiency anemia.

Finally, the panelists recommended that asymptomatic patients with iron-deficiency anemia and suspected celiac disease undergo serologic testing first, with small bowel biopsy only performed if testing is positive.

The only two strong recommendations in the guideline are for the ferritin cutoff value and the use of bidirectional endoscopy in men and postmenopausal women. The other five recommendations are conditional, three of which are based on very low quality evidence. As such, the guideline includes a discussion of research needs.

Dr. Ko and colleagues called for more studies investigating the prevalence of gastrointestinal lesions and risks of bidirectional endoscopy in premenopausal women, role of fecal occult blood testing, timing of serologic testing for H. pylori and celiac disease in relation to endoscopy, patient subgroups, comparative efficacy of small bowel visualization techniques, and other topics.

The investigators disclosed no conflicts of interest. The guideline was funded by the AGA Institute.

SOURCE: Ko CW et al. Gastroenterology 2020 Aug 15. doi: 10.1053/j.gastro.2020.06.046.

Changes in a variety of T cells in the liver and visceral adipose tissue play a key role in the pathogenesis of nonalcoholic steatohepatitis, according to the results of a murine study.

Mikhaïl A. Van Herck, of the University of Antwerp (Belgium), and associates fed 8-week old mice a high-fat, high-fructose diet for 20 weeks, and then switched the mice to standard mouse chow for 12 weeks. The high-fat, high-fructose diet induced the metabolic syndrome and nonalcoholic steatohepatitis (NASH), accompanied by shifts in T cells. Interleukin-17–producing (Th17 cells increased in the liver, visceral adipose tissue, and blood, while regulatory T cells decreased in visceral adipose tissue, and cytotoxic T (Tc) cells rose in visceral adipose tissue while dropping in the blood and spleen.

These are “important immune disruptions,” the researchers wrote in Cellular and Molecular Gastroenterology and Hepatology. “In particular, visceral adipose tissue Tc cells are critically involved in NASH pathogenesis, linking adipose tissue inflammation to liver disease.”

After the mice were switched from the high-fat, high-fructose diet to standard mouse chow, their body weight, body fat, and plasma cholesterol significantly decreased and their glucose tolerance and insulin sensitivity improved to resemble the metrics of mice fed standard mouse chow throughout the study. Mice who underwent diet reversal also had significantly decreased liver weight and levels of plasma ALT, compared with mice that remained on the high-fat, high-fructose diet. Diet reversal also improved liver histology (nonalcoholic fatty liver disease activity scores), compared with the high-fat, high-fructose diet, the researchers wrote. “Importantly, the NASH was not significantly different between diet-reversal mice and mice fed the control diet for 32 weeks.”

Genetic tests supported these findings. On multiplex RNA analysis, hepatic expression of Acta2, Col1a1, and Col1a3 reverted to normal with diet reversal, indicating a normalization of hepatic collagen. Hepatic expression of the metabolic genes Ppara, Pparg, and Fgf21 also returned to normal, while visceral adipose tissue showed a decrease in Lep and Fgf21 expression and resolution of adipocyte hypertrophy.

However, diet reversal did not reverse inflammatory changes in T-cell subsets. Administering anti-CD8a antibodies after diet reversal decreased Tc cells in all tissue types that were tested, signifying “a biochemical and histologic attenuation of the high-fat, high-fructose diet-induced NASH,” the investigators wrote. Treating the mice with antibodies targeting IL-17A did not attenuate NASH but did reduce hepatic inflammation.

The fact that “the most pronounced effect” on NASH resulted from correcting immune disruption in visceral adipose tissue underscored “the immense importance of adipose tissue inflammation in [NASH] pathogenesis,” the researchers wrote. The finding that diet reversal alone did not reverse inflammation in hepatic or visceral adipose tissue “challeng[es] our current understanding of the reversibility of NASH and other obesity-related conditions.” They called for studies of underlying mechanisms as part of “the search for a medical treatment for NASH.”

Funders included the University Research Fund, University of Antwerp, and Research Foundation Flanders. The researchers reported having no conflicts of interest except that one coinvestigator is the chief science officer at Biocellvia, which performed some histologic analyses.

SOURCE: Van Herck MA et al. Cell Molec Gastroenterol Hepatol. 2020 Apr 20. doi: 10.1016/j.jcmgh.2020.04.010.

Changes in a variety of T cells in the liver and visceral adipose tissue play a key role in the pathogenesis of nonalcoholic steatohepatitis, according to the results of a murine study.

Mikhaïl A. Van Herck, of the University of Antwerp (Belgium), and associates fed 8-week old mice a high-fat, high-fructose diet for 20 weeks, and then switched the mice to standard mouse chow for 12 weeks. The high-fat, high-fructose diet induced the metabolic syndrome and nonalcoholic steatohepatitis (NASH), accompanied by shifts in T cells. Interleukin-17–producing (Th17 cells increased in the liver, visceral adipose tissue, and blood, while regulatory T cells decreased in visceral adipose tissue, and cytotoxic T (Tc) cells rose in visceral adipose tissue while dropping in the blood and spleen.

These are “important immune disruptions,” the researchers wrote in Cellular and Molecular Gastroenterology and Hepatology. “In particular, visceral adipose tissue Tc cells are critically involved in NASH pathogenesis, linking adipose tissue inflammation to liver disease.”

After the mice were switched from the high-fat, high-fructose diet to standard mouse chow, their body weight, body fat, and plasma cholesterol significantly decreased and their glucose tolerance and insulin sensitivity improved to resemble the metrics of mice fed standard mouse chow throughout the study. Mice who underwent diet reversal also had significantly decreased liver weight and levels of plasma ALT, compared with mice that remained on the high-fat, high-fructose diet. Diet reversal also improved liver histology (nonalcoholic fatty liver disease activity scores), compared with the high-fat, high-fructose diet, the researchers wrote. “Importantly, the NASH was not significantly different between diet-reversal mice and mice fed the control diet for 32 weeks.”

Genetic tests supported these findings. On multiplex RNA analysis, hepatic expression of Acta2, Col1a1, and Col1a3 reverted to normal with diet reversal, indicating a normalization of hepatic collagen. Hepatic expression of the metabolic genes Ppara, Pparg, and Fgf21 also returned to normal, while visceral adipose tissue showed a decrease in Lep and Fgf21 expression and resolution of adipocyte hypertrophy.

However, diet reversal did not reverse inflammatory changes in T-cell subsets. Administering anti-CD8a antibodies after diet reversal decreased Tc cells in all tissue types that were tested, signifying “a biochemical and histologic attenuation of the high-fat, high-fructose diet-induced NASH,” the investigators wrote. Treating the mice with antibodies targeting IL-17A did not attenuate NASH but did reduce hepatic inflammation.

The fact that “the most pronounced effect” on NASH resulted from correcting immune disruption in visceral adipose tissue underscored “the immense importance of adipose tissue inflammation in [NASH] pathogenesis,” the researchers wrote. The finding that diet reversal alone did not reverse inflammation in hepatic or visceral adipose tissue “challeng[es] our current understanding of the reversibility of NASH and other obesity-related conditions.” They called for studies of underlying mechanisms as part of “the search for a medical treatment for NASH.”

Funders included the University Research Fund, University of Antwerp, and Research Foundation Flanders. The researchers reported having no conflicts of interest except that one coinvestigator is the chief science officer at Biocellvia, which performed some histologic analyses.

SOURCE: Van Herck MA et al. Cell Molec Gastroenterol Hepatol. 2020 Apr 20. doi: 10.1016/j.jcmgh.2020.04.010.

Changes in a variety of T cells in the liver and visceral adipose tissue play a key role in the pathogenesis of nonalcoholic steatohepatitis, according to the results of a murine study.

Mikhaïl A. Van Herck, of the University of Antwerp (Belgium), and associates fed 8-week old mice a high-fat, high-fructose diet for 20 weeks, and then switched the mice to standard mouse chow for 12 weeks. The high-fat, high-fructose diet induced the metabolic syndrome and nonalcoholic steatohepatitis (NASH), accompanied by shifts in T cells. Interleukin-17–producing (Th17 cells increased in the liver, visceral adipose tissue, and blood, while regulatory T cells decreased in visceral adipose tissue, and cytotoxic T (Tc) cells rose in visceral adipose tissue while dropping in the blood and spleen.

These are “important immune disruptions,” the researchers wrote in Cellular and Molecular Gastroenterology and Hepatology. “In particular, visceral adipose tissue Tc cells are critically involved in NASH pathogenesis, linking adipose tissue inflammation to liver disease.”

After the mice were switched from the high-fat, high-fructose diet to standard mouse chow, their body weight, body fat, and plasma cholesterol significantly decreased and their glucose tolerance and insulin sensitivity improved to resemble the metrics of mice fed standard mouse chow throughout the study. Mice who underwent diet reversal also had significantly decreased liver weight and levels of plasma ALT, compared with mice that remained on the high-fat, high-fructose diet. Diet reversal also improved liver histology (nonalcoholic fatty liver disease activity scores), compared with the high-fat, high-fructose diet, the researchers wrote. “Importantly, the NASH was not significantly different between diet-reversal mice and mice fed the control diet for 32 weeks.”

Genetic tests supported these findings. On multiplex RNA analysis, hepatic expression of Acta2, Col1a1, and Col1a3 reverted to normal with diet reversal, indicating a normalization of hepatic collagen. Hepatic expression of the metabolic genes Ppara, Pparg, and Fgf21 also returned to normal, while visceral adipose tissue showed a decrease in Lep and Fgf21 expression and resolution of adipocyte hypertrophy.

However, diet reversal did not reverse inflammatory changes in T-cell subsets. Administering anti-CD8a antibodies after diet reversal decreased Tc cells in all tissue types that were tested, signifying “a biochemical and histologic attenuation of the high-fat, high-fructose diet-induced NASH,” the investigators wrote. Treating the mice with antibodies targeting IL-17A did not attenuate NASH but did reduce hepatic inflammation.

The fact that “the most pronounced effect” on NASH resulted from correcting immune disruption in visceral adipose tissue underscored “the immense importance of adipose tissue inflammation in [NASH] pathogenesis,” the researchers wrote. The finding that diet reversal alone did not reverse inflammation in hepatic or visceral adipose tissue “challeng[es] our current understanding of the reversibility of NASH and other obesity-related conditions.” They called for studies of underlying mechanisms as part of “the search for a medical treatment for NASH.”

Funders included the University Research Fund, University of Antwerp, and Research Foundation Flanders. The researchers reported having no conflicts of interest except that one coinvestigator is the chief science officer at Biocellvia, which performed some histologic analyses.

SOURCE: Van Herck MA et al. Cell Molec Gastroenterol Hepatol. 2020 Apr 20. doi: 10.1016/j.jcmgh.2020.04.010.