News & Views in 2009

The treatment of primary sclerosing cholangitis is a major challenge. Complications such as dominant bile duct stenoses and biliary infections are associated with poor outcomes. Data from a new prospective study with a follow-up of 20 years now show that dominant stenosis and fungal, but not bacterial infections reduce survival free of liver transplantation.

The management of chronic anal fissure has received renewed interest and has been re-evaluated over the past 20 years. The use of botulinum toxin seems to be a promising and safe approach, particularly in patients at high risk for incontinence. A recent meta-analysis investigated the efficacy of botulinum toxin injection compared with lateral internal sphincterotomy for the management of this condition.

The Bordeaux group has made major progress in the genotyping and phenotyping of hepatocellular adenomas. Their efforts have allowed the classification of hepatocellular adenomas into subtypes, which enhances our understanding of this benign liver lesion. The clinical relevance of their findings is open to debate.

A Markov model using data from a randomized, controlled trial has demonstrated that laparoscopic fundoplication is a cost-effective intervention for the management of chronic GERD. However, there are some limitations of the model, discussed below, which suggest that the results should be viewed cautiously until longer follow-up is reported.

Endoscopic band ligation (EBL) and nonselective β-blockade are two effective strategies in the primary prevention of variceal bleeding. Meta-analyses have shown an advantage of EBL over propranolol with regard to bleeding rates but not mortality. By contrast, a recent randomized, controlled trial shows less bleeding associated with the use of carvedilol compared with EBL.

Autoimmune hepatitis is an inflammatory liver disease of unknown etiology that predominantly affects females, and requires immunosuppressive treatment. A new study investigates the role of mycophenolate mofetil as a rescue treatment for children with the disease.

IFN-α therapy for hepatitis C is associated with a high prevalence of thyroid dysfunction, which is often irreversible. Two studies have recently investigated the role of HCV, PEG-IFN-α and ribavirin in the development of autoimmune thyroid disorders in patients with hepatitis C on antiviral treatment.

When all state-of-the-art reflux monitoring technologies are available, which should be used for patients who have persistent reflux symptoms despite acid suppressive therapy? A single-center study has investigated this clinical dilemma and provides guidance on the best diagnostic strategy.

Advances in gastroenterology, including the introduction of PPIs, effective therapies for Helicobacter pylori infection, and endoscopic intervention, have promised to improve the incidence and outcomes of gastrointestinal bleeding and perforation. However, have these improvements been borne out in clinical practice?

Whether a midline or transverse incision is used in abdominal surgery depends mainly on the disease, anatomy and potential effects on wound healing, pain and postoperative complications. Decisions can, however, be based on a surgeon's experience and preference, as the procedures' respective benefits remain to be clearly delineated.

A new study has found undetectable serum levels of HBV DNA at week 24 of treatment to be the strongest predictor of optimal outcomes for patients with chronic HBV infection. Although this finding is not surprising, it has important implications for those patients on antiviral therapy who do not achieve a favorable response.

The current re-treatment options available to patients with chronic hepatitis C who fail to respond to treatment with pegylated interferon plus ribavirin are limited. Findings from a large, multicenter study suggest that re-treatment with consensus interferon plus ribavirin should now be considered for compliant, motivated nonresponders.

A recent survey of patients, primary physicians and gastroenterologists found that an overwhelming majority prefer endoscopic polypectomy for small polyps detected by screening CT colonography. These hypothetical results, however, strongly contradict results in actual clinical practice.

Among the challenges of studying the contribution of individual dietary factors to cancer risk is the interwoven nature of diet—dietary factors are often correlated and eating patterns are complex. A large, prospective epidemiological study of diet patterns used cluster analyses to demonstrate the benefit of a fruit and vegetable diet to colorectal cancer risk.

The optimal therapy for patients with metastatic and treatment-refractory colorectal cancer is controversial. Questions with regard to both the sequence and combinations of different drugs need to be answered by well-designed and adequately powered studies before the most appropriate option for second-line treatment for these patients can be defined.

Relatively little information exists on the prognosis for elderly patients with chronic hepatitis C (CHC). Moreover, the majority of randomized, clinical trials of hepatitis C treatment exclude elderly patients. Findings from a 2009 clinical study address risk of hepatocellular carcinoma, life expectancy and the influence of antiviral therapy in elderly patients with CHC.

Nonalcoholic fatty liver disease has long been neglected by health-care professionals unless affected patients develop cirrhosis; however, new research shows this disease impairs health-related quality of life. The association of nonalcoholic fatty liver disease with chronic metabolic diseases and cardiovascular complications restricts our ability to define a specific role for liver damage in the poor perceived health status of these patients.

Considerable advances in tools for the diagnosis and management of Crohn's disease have been made. Despite technological progress, a new study reports that more than one-third of patients with Crohn's disease are still diagnosed with fistulizing disease intraoperatively and that the surgical management of these patients is not well characterized.

More than 50% of patients infected with HCV genotype 1 fail respond to standard treatment with peginterferon plus ribavirin. Potent treatment strategies are urgently needed to improve outcomes for such patients. Novel interferons and specifically targeted antiviral therapy for HCV (STAT-C) represent promising strategies.

Few randomized, controlled trials have investigated the efficacy of pharmacological treatment for lymphocytic colitis. Data from a new randomized, placebo-controlled trial have demonstrated the efficacy of budesonide in inducing remission of this disease; this study is an important contribution to this field.