Review Articles

Metoclopramide is one of the most widely used drugs for gastroenterological motility disorders, but it has many potentially troublesome neurological adverse effects, particularly movement disorders. The authors of this Review discuss the indications for metoclopramide, its side effects and common pitfalls of prescribing metoclopramide, and describe strategies to minimize the medicolegal risks to the prescribing physician.

In this Review, the authors discuss the justification for living donor liver transplantation (LDLT), the introduction of LDLT for the treatment of pediatric patients and its expansion to include the treatment of adult recipients. How pediatric and adult recipients are selected, LDLT performed, and the implications for living donors affected by these decisions are also considered.

Although the incidence of peptic ulcer disease and ulcer complications has decreased over the past few decades, there has been an increase in ulcer bleeding, especially in elderly patients. The authors of this Review consider the current status of understanding, diagnosis and treatment of peptic ulcer disease, and management issues that remain to be solved.

Constipation is often mild and intermittent, but can be debilitating and require medical consultation. When management with first-line conservative therapy is unsuccessful, additional studies are needed to better understand the underlying pathophysiology. This Review considers the modern principles and therapies used to manage chronic constipation of varying severities.

One area of gastroenterology that lags behind other specialties in the quality of the evidence base for clinical practice is the prevention of gastrointestinal cancer. In this Review the authors assess the evidence for various cancer prevention strategies, especially chemoprevention, and highlight the obstacles to further exploitation of this knowledge base.

In the past 20 years the management of peptic ulcer bleeding has been revolutionized by effective endoscopic hemostasis and potent acid-suppressing agents. The author of this Review considers the roles that risk stratification, pharmacologic therapy, endoscopic therapy and surgery now have to play in the management of this common and potentially fatal condition.

Optimal management of anticoagulant and antiplatelet agents during the periendoscopic period requires consideration, but limited prospective data mean that guidelines have largely relied on expert opinion. This Review summarizes the ASGE guidelines, details the relevant literature on which they are based, considers literature that has become available since their publication, and provides a framework for the management of periendoscopic anticoagulation.

This Review discusses cholangiocarcinoma, the incidence of which is increasing globally. There are several established risk factors for cholangiocarcinoma, and others are now being recognized. Diagnosis requires the integration of clinical information, imaging studies, tumor markers and histology. Surgery can be curative, but most patients have unresectable disease, in which case palliation can improve quality of life and might also improve survival.

Pyoderma gangrenosum is a rare condition of unknown etiology that was described as an extraintestinal manifestation of inflammatory bowel disease in 1930. At present, there are few well-designed published studies that help determine the optimal therapeutic strategy to use for the management of pyoderma gangrenosum. This article reviews the published treatment strategies in current use and aims to guide effective management.

This Review discusses the use of C-reactive protein as an inflammatory marker in gastrointestinal diseases. Inflammation does not produce a good C-reactive protein response in all diseases, however, and until there are more data, the use of C-reactive protein and other biomarkers should be seen only as an aid to clinical observation and physical examination and not as a replacement.

Gastroesophageal reflux disease is associated with laryngopharyngeal reflux, but the cause and effect relationship between these two clinical entities is far from established. This Review considers studies of the pathogenesis of laryngopharyngeal reflux, the value of diagnostic testing either on or off therapy, and treatment options and duration, that have increased our our understanding of this field.

Although there are many similarities among pediatric and adult Crohn's disease patients, some unique features of the pediatric population influence the therapeutic approach adopted; pediatric Crohn's disease can have a significant impact on the patient's quality of life, growth, bone health, and development. This Review focuses on the latest advances in the treatment of complicated pediatric Crohn's disease, including the use of biologic therapies such as infliximab.

The demonstration that endoscopic band ligation has a greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for esophageal varices in patients with cirrhosis. This Review focuses on the role of endoscopic band ligation in the primary and secondary prevention of variceal bleeding as well as in the treatment of acute bleeding episodes.

Smoking can have a detrimental and beneficial effect on gastrointestinal disease—it has such a 'polarizing effect' in patients with Crohn's disease and ulcerative colitis. Studies in tobacco smokers have made it difficult to identify which agents are responsible for these effects, but work on the action of nicotine alone might help to explain some of the positive and negative links between smoking and gastrointestinal disease.

Fecal incontinence is a common symptom that is generally caused by conditions associated with anorectal sensorimotor dysfunction or diarrhea. Clinical assessment and diagnostic testing should be tailored to the patient's age and symptom severity. Management options, including modulation of disordered bowel habits, biofeedback and surgery, must be tailored to the clinical manifestations, and include treatment of underlying diseases.

The availability of new, less-invasive diagnostic tools means that pathological diagnoses are increasingly required to be made from smaller biopsy specimens. The author of this Review addresses the diagnostic terminology used in the reporting of nongynecologic aspiration cytology results, makes recommendations of how clinicians should interpret these results and discusses additional tests that are required for certain diagnostic categories.

This Review considers the optimal approach to assessing the common medical problem of noncardiac chest pain, for which the appropriate application of investigations is controversial. In addition to musculoskeletal and psychiatric investigations, gastroesophageal investigations include esophagogastroduodenoscopy, radiological assessment, ambulatory esophageal pH monitoring, esophageal manometry, provocative tests, and a proton pump inhibitor test.

The authors of this Review discuss the common causes and pathophysiology of gastroparesis—delayed gastric emptying in the absence of mechanical obstruction. The diagnostic approach to gastroparesis is also considered, along with evidence to support medical and surgical therapies, including currently available prokinetic drugs, novel medical therapies, and the promising technique of gastric electrical stimulation.

The authors consider the use of prognostic and diagnostic markers as an addition to initial clinical assessment for the identification of patients who are likely to develop severe acute pancreatitis. They also discuss antibiotic prophylaxis, fluid resuscitation and rehydration, enteral versus parenteral nutrition, pain management and the timing of surgical or interventional necrosectomy.

This article reviews an area of translational research that is currently receiving a great deal of attention—the role of the intestinal epithelial barrier in the pathogenesis of gastrointestinal disease. In particular, the authors consider the contribution of the intestinal epithelial barrier, with its intercellular tight junctions, to the development of autoimmunity.