Viewpoint in 2007

Any worthwhile guideline must be evidence-based, or should it? Evidence for the construction of guidelines often comes from clinical trials that are performed in the West according to the priorities and goals of that population and those of the pharmaceutical industry whose resources are relied upon to perform such trials. This Viewpoint article discusses the development of guidelines using an evidence-based approach and whether this approach is applicable worldwide.

Clinical Guidelines are primarily developed in the affluent West. This Viewpoint article discusses whether these guidelines are really useful and relevant to resource-poor, developing countries, and whether attempts to adhere to such guidelines obscure more fundamental issues such as the provision of basic health care. The authors argue that if guidelines are adapted to local resources and needs, and employ a 'cascade' approach they can work.

Evidence-based guidelines from wealthy countries define optimum goals for resource-constrained countries. This Viewpoint article discusses how health-care policy in developing countries can only be influenced through local involvement in the construction and implementation of guidelines. The authors also discuss the potential yet controversial role of the biomedical industry in facilitating the development and dissemination of global guidelines.

Clinical understanding of IBS has been advanced considerably by studying a small subgroup of patients who develop IBS acutely after an episode of infectious gastroenteritis. This Viewpoint article discusses post-infective IBS and how psychosocial and gut-specific factors (including activation of the gut mucosal immune system) interact to produce IBS symptoms.

Most patients with hepatocellular carcinoma have underlying liver disease and the optimal treatment is, therefore, liver transplantation. When liver transplantation is not possible clinicians must decide whether to resect or ablate the cancer. The author of this Viewpoint article discusses the advantages and disadvantages of these two approaches and their use in clinical practice.

Acute appendicitis remains one of the abdominal diseases most commonly requiring emergency treatment. Successful nonsurgical management of appendicitis has raised the possibility of treating this condition with antibiotics alone. The author of this Viewpoint article examines the available evidence for this therapeutic approach and discusses its role in clinical practice.

Convincing new evidence suggests that mild hypothermia prevents intracranial hypertension and its complications in patients with acute liver failure. This Viewpoint examines available data for the use of mild hypothermia as a novel therapy in this setting, and calls for controlled clinical trials and systematic studies of its potential adverse effects.

Chronic pancreatitis is a difficult disease to diagnose, particularly in its early stages. EUS has been increasingly used as a method for diagnosing chronic pancreatitis because of its ability to generate high-resolution images of the pancreas. This Viewpoint examines the practical role of EUS as screening tool for chronic pancreatitis, and compares it with other diagnostic modalities.

Partial liver resection alone is not able to cure a substantial number of patients who have liver tumors. Thermoablation expands the therapeutic modalities available to these patients by using heat (radiofrequency ablation) or cold (cryoablation) to achieve tumor necrosis. This Viewpoint discusses the evidence for using these two ablative modalities in clinical practice and suggests that radiofrequency ablation is the superior approach.

The rising incidence of esophageal adenocarcinoma has stimulated interest in screening for Barrett's esophagus, but there is no proof that screening decreases esophageal cancer mortality. This Viewpoint argues that, on the basis of the available evidence, screening is beneficial, and that it is better to err on the side of caution and perform unnecessary screening rather than miss curable cancers.

Disrupted sleep is reported by many patients with IBS, yet the role of sleep in IBS is not defined. This Viewpoint article discusses the subjective and objective evidence for disrupted sleep in patients with IBS, examines the relationship between gastrointestinal symptoms and sleep disturbance, and highlights areas for future research.

Many clinicians approach the diagnosis of IBS as one of exclusion, even though diagnostic testing usually has a low yield and the Rome guidelines encourage diagnosis on the basis of symptoms alone. This Viewpoint discusses patterns of IBS diagnosis in practice, provides theories on why guidelines are not adhered to, and offers some practical guidance on IBS diagnosis.

The cause of irritable bowel syndrome (IBS) remains a mystery and treatment continues to pose a real challenge. This Viewpoint examines the role of dietary, pharmaceutical and psychological therapies in IBS and the value of taking an integrated treatment approach to the management of patients with this condition.

Advances in our understanding of hepatic fibrosis have provoked great excitement over the prospect of effective antifibrotic therapy. This Viewpoint looks at how far the field has advanced, what the remaining obstacles are, and whether antifibrotic therapy might soon become a clinical reality for patients with chronic liver disease.

This Viewpoint highlights the apparent shift in ulcer epidemiology, with regard to the observed increase in the prevalence of non-Helicobacter pylori, non-NSAID, idiopathic ulcers. The authors recommend that the underlying cause of idiopathic ulcers be investigated further, with rigorous use of diagnostic techniques, and that efforts be made to improve the management and prevention of this condition.

The worldwide incidence of morbid obesity is rapidly increasing. When considering how to treat morbid obesity there are two surgical treatments—laparoscopic adjustable gastric banding and gastric bypass—that go head to head. This Viewpoint examines the safety and efficacy of laparoscopic adjustable gastric banding and gastric bypass for achieving weight loss, and their ability to resolve comorbidities such as type 2 diabetes mellitus.

Diagnosis of obscure gastrointestinal bleeding is challenging for gastroenterologists. Capsule endoscopy has revolutionized examination of the small bowel in this setting, but has several limitations. Double balloon enteroscopy is a new technique that also allows for extensive evaluation of the small bowel. This Viewpoint examines the usefulness of these techniques in clinical practice.

Leptin is involved in many biological processes that implicate it in the development of colorectal cancer. This Viewpoint discusses the biological plausibility of a relationship between leptin and colorectal cancer, and the evidence available to support such a relationship.

The treatment of chronic hepatitis C is rapidly evolving. Current treatment modalities are being refined, and entirely new, specifically targeted, antiviral therapies (known as STAT-C) that inhibit the various steps of viral replication are being developed. This Viewpoint discusses the status of agents in development and their implications for the future treatment of hepatitis C.

Although alcohol consumption and tobacco use are the major risk factors for esophageal cancer in developed countries, nutrition and diet are also important. This Viewpoint discusses evidence for a link between diet and esophageal cancer and the influence it might have with regard to the prevention of esophageal cancer.