Viewpoint in 2005

Controversy exists as to whether ursodeoxycholic acid improves survival in patients with primary biliary cirrhosis. This is mainly because the disease is uncommon and slowly progressive, which has meant that many clinical trials lack hard endpoints such as mortality. This Viewpoint article discusses the importance of the appropriate design of clinical trials in this field.

In this era of critical organ shortage, how should physicians and patients decide whether to accept or decline the offer of a specific deceased-donor liver? The author of this Viewpoint article considers recent data evaluating the impact of donor characteristics and severity of recipient disease on the decision-making process.

Acute fatty liver of pregnancy is a devastating disorder that can significantly affect the morbidity and mortality of both mother and fetus. This Viewpoint discusses the prevalence and implications of this disorder and examines the role of genetic screening in helping to identify patients at risk for this disease.

Global differences in drug regulation might influence the availability of drugs for the treatment of irritable bowel syndrome in Europe. The author of this Viewpoint explores the role of drug regulation in the context of the difficulties faced in achieving therapeutic success in this challenging area.

Idiopathic abdominal pain and chest pain of presumed digestive tract origin accounts for a considerable number of hospital admissions each year. The underlying causes of this pain remain unknown. In this Viewpoint the authors propose a novel mechanism for this undefined pain suggesting that ischemic events could be responsible.

Endoscopy in pregnant patients presents unique concerns regarding its safety and benefit to the fetus. This Viewpoint presents an overview of the merits and potential dangers associated with endoscopy in pregnancy and discusses the impact of the latest guidelines for endoscopy in this setting.

The ultimate function of the appendix still remains a mystery; however, increasing evidence suggests it has a role in many intestinal diseases. This viewpoint examines the controversy surrounding the role of the appendix in the etiology of inflammatory bowel disease.

The ubiquity of gluten in foodstuffs, patient compliance, and variable patient susceptibility to gluten are all limiting factors of the gluten-free diet—the treatment of choice for celiac disease. New therapeutic strategies are emerging as a result of improved understanding of the molecular events underlying celiac disease; this Viewpoint considers whether a gluten-free diet is still adequate.

Screening for colorectal cancer is effective in preventing a major cause of morbidity and mortality. Before implementing organized screening programs, however, policymakers must consider its value relative to other health-related and nonhealth-related needs. One way of doing so is cost-effectiveness analysis. This Viewpoint highlights some key issues surrounding such analysis and suggests areas for further research.

Bleeding associated with portal hypertension, is a major cause of morbidity and mortality in patients with cirrhosis. Surgery was originally the only treatment; however, over the past few decades, several new prophylactic and treatment options have evolved which call into question the role of the surgeon in the future management and treatment of bleeding portal hypertension.

Standard therapeutic strategies used to treat gastointestinal disorders are reliant on drugs and carry with them associated adverse side effects. Apheresis, a novel extracorporeal therapy, is reported to be a rapidly acting, effective treatment option without associated serious adverse side effects. This viewpoint discusses the application of this unique process for the treatment of gastrointestinal disorders.

Advances in molecular genetics have aided our understanding of disease pathogenesis and have helped in making therapeutic decisions. Knowledge is still evolving, however, and care must be taken in extrapolating research-based data to genetic testing in clinical practice.

For many years functional heartburn has been linked to gastroesophageal reflux disease, despite a number of characteristics that set this disorder apart. As such little has been researched regarding the physiology and treatment of patients with functional heartburn as a distinct entity. This Viewpoint discusses the evidence for distinguishing this group of patients.

Although it is well-known that Barrett's esophagus is a major risk factor for the development of esophageal adenocarcinoma, our understanding of the pathogenesis, causes of progression and optimal clinical management is limited. This viewpoint considers the problems of managing Barrett's esophagus, which include defining the condition and determining the value of surveillance and interventional strategies.

Helminth parasites mostly have been eliminated in industrialized parts of the world, where the incidence of inflammatory bowel disease (IBD) is the highest. The authors propose that helminths protect the bowel by downregulating inflammatory responses. Evidence for the immune regulatory effect of helminths in animal models of colitis and in human IBD is discussed.

Surgical techniques for gastroesophageal reflux disease (GERD) have improved in recent years. This viewpoint considers the evidence in favor of surgical therapy as an alternative to medical therapy for GERD. The safety and clinical efficacy of surgery has been demonstrated, particularly in patients with Barrett's esophagus and those with GERD-related respiratory symptoms.

Endoscopic antireflux procedures are an alternative treatment for patients who do not desire medical therapy for gastroesophageal reflux disease. This Viewpoint assesses the success rates of endoscopic therapies and highlights the importance of selecting appropriate patients for this therapy.