Articles in 2010

The best long-term treatment results for patients with idiopathic achalasia have been achieved with pneumatic dilation or surgical myotomy. A new study adds evidence that good or excellent symptomatic results can be achieved in the long term when pneumatic dilation is used as the primary treatment strategy. In cases of early treatment failure (<2 years), surgery was found to be the best rescue therapy.

Propofol sedation by nonanesthesiologists is still a highly controversial issue despite the fact that numerous studies have approved this sedation regimen for gastrointestinal endoscopy. A new position statement from a collaboration of four different American gastroenterology and hepatology societies outlines the latest recommendations for nonanesthesiologist administration of propofol.

Bleeding from gastric varices is relatively common and can be life threatening. The optimal treatment strategy for gastric variceal hemorrhage is controversial. Both interventional radiology and endoscopic therapies require a high level of clinical expertise. Which type of therapy is best? A recent study compared endoscopic cyanoacrylate glue injection with the insertion of a transjuglar intrahepatic portosystemic shunt.

The appropriate management of patients with Barrett esophagus in whom early carcinoma or high-grade intraepithelial neoplasia has been detected continues to be a subject of controversy. For many years radical esophageal resection has been regarded as the treatment of choice, but the high morbidity and mortality rates associated with this procedure have led to less radical treatment strategies being advocated by many groups.

A multicenter, randomized, controlled trial of 610 patients with chronic hepatitis C infected with HCV genotype 1 or 4 compared 48 weeks of standard of care therapy (PEG-IFN and ribavirin) with 12 weeks of induction therapy with high-dose PEG-IFN followed by 36 weeks of standard of care treatment. High-dose PEG-IFN induction therapy did not enhance early or sustained virologic response rates compared with standard of care therapy.

A 50-year-old man from Las Vegas with a history of complicated Crohn's disease and who had received adalimumab therapy presented with left lower quadrant abdominal pain, periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain and weight loss. He was diagnosed with having disseminated coccidioidomycosis. Despite antifungal treatment, surgical debridement and irrigation, and discontinuation of immunosuppressive therapy, the patient eventually died. This case highlights the risk of developing endemic mycoses while receiving biologic therapy.

Occult gastrointestinal bleeding is common and can be caused by virtually any lesion in the gastrointestinal tract. It includes fecal occult blood and/or iron-deficiency anemia. Obscure gastrointestinal bleeding is recurrent and is often caused by bleeding from the small intestine. In this Review, Don Rockey discusses the causes, diagnostic evaluation and treatment of patients with these types of bleeding, as well as the impact that capsule endoscopy and deep enteroscopy have had on patient management.

Celiac disease is an enteropathy associated with gluten sensitivity that affects people of all ages and is a major healthcare problem worldwide. Tack and colleagues discuss the epidemiology and risk factors of celiac disease, draw attention to the broad spectrum of its presenting features and highlight its potential complications. Diagnosis and treatment strategies for uncomplicated and complicated celiac disease are also presented.

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding. Faced with the clinical mandate of performing therapeutic endoscopy, the gastroenterologist encounters a myriad of available techniques, including various forms of injection, ablation, and mechanical therapy. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis, and describes important, practical, details to improve the safety and efficacy of these procedures.

The diagnosis and characterization of nonalcoholic fatty liver disease (NAFLD) ultimately depend on histopathologic evaluation. Elizabeth Brunt discusses the histologic features that are diagnostic for NAFLD and discriminate between steatosis and steatohepatitis. The histologic differences between adult and pediatric NAFLD are also considered, along with the value and potential drawbacks of liver biopsy. Current pathophysiologic concepts relevant to histologic findings are put into context.