News & Views

The modern colonoscopist faces two problems: identifying all relevant lesions and then making an appropriate risk assessment of the detected lesions. The latter is crucial for determining patient outcome. A feasibility study suggests that a new endomicroscopy technology could greatly improve the detection and assessment of neoplastic colorectal lesions.

Confocal laser endomicroscopy (CLE) is an emerging technology with important applications in gastrointestinal imaging. Fluorescein, the contrast agent most commonly employed in CLE, has not yet been approved by the FDA for intravenous use with this technique in the gastrointestinal setting. A cross-sectional study suggests that fluorescein is generally safe and usually has none or only mild adverse effects in patients undergoing CLE.

Chronic sacral nerve stimulation has an important role in the treatment of fecal incontinence. Newly reported findings indicate that this technique is an effective treatment for fecal incontinence resulting from unrepaired morphological defects of the anal sphincters, and suggest that the indications for this treatment can be expanded to include intractable constipation.

Few effective treatments for the common disorder of chronic constipation are currently available. Linaclotide, a guanylate cyclase C receptor agonist, has shown promising efficacy as a treatment for chronic constipation in a phase IIb, double-blinded, placebo-controlled, dose-ranging trial. This new therapy could potentially improve symptoms, such as bloating and discomfort, as well as bowel habits for patients with chronic constipation.

Venous thromboembolism is an important cause of morbidity and mortality in patients with IBD. A large population-based study now suggests that patients with active disease, whether they are hospitalized or ambulatory, are at increased risk of developing thromboembolic complications. The value of thromboprophylaxis in patients with active IBD should now be evaluated.

One of the major challenges in IBD therapy is targeting delivery of the drug to the specific site of inflammation. A recent approach to combat this problem is the use of nanoparticulate drug delivery systems that selectively accumulate a given drug at the site of affected tissue. As the drug load is delivered locally, drug dose and adverse effects are reduced.

Aldosterone antagonists are the first-line diuretic therapy for moderate ascites in patients with cirrhosis. In patients who do not respond to aldosterone antagonists alone, the addition of a loop diuretic is recommended; however, for patients with recurrent ascites, receiving a combination of agents from the start might be preferable to such 'sequential' therapy.

Biliary drainage before surgery for cancer of the head of the pancreas can relieve obstructive jaundice and potentially improve surgical outcomes. However, van der Gaag et al. found that preoperative biliary drainage increases the rate of serious complications in these patients. Should this procedure be routinely performed in patients undergoing surgery for pancreatic cancer?

The optimal treatment for classic Whipple disease has not yet been determined. A recent study reported encouraging results for initial treatment with intravenous ceftriaxone or meropenem followed by long-term treatment with oral trimethoprim–sulfamethoxazole. However, discrepancies in the failure and/or relapse rates associated with trimethoprim–sulfamethoxazole show that this regimen may not be optimal.

Insulin sensitizing agents, such as the thiazolidinediones pioglitazone and rosiglitazone, have been used in clinical trials for the treatment of nonalcoholic steatohepatitis, a common form of liver disease that is associated with insulin resistance. The results of these trials have been variable, suggesting that a deeper understanding of other contributing factors to the development of nonalcoholic steatohepatitis is needed to establish whether improving adipose insulin sensitivity might be important.

Although a great deal is known about the environmental and genetic causes of colorectal cancer, it is still one of the most common cancers in the world. A new German study including >17,500 patients focuses on differences between proximal and distal disease. Is there anything new from this study that could help us further understand the etiology of colorectal cancer and improve the screening and management of this disease?

The need for mass screening of the general population for colorectal cancer is well established. However, there is no consensus on the best screening test. A recent study brings new data to clinicians and health authorities regarding the optimal test for colorectal cancer screening.

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.

Many experts maintain that GERD is caused by dysfunction of the gastroesophageal barrier and that gastric acid secretion is not the primary underlying defect. By contrast, a recent study by Reimer and colleagues raises the possibility that increased gastric acid secretion is an important cause of GERD.

Evidence from a recent study strongly implicates innate immunity in the etiology of Crohn's disease, with particular focus on impaired secretion of cytokines and chemokines by intestinal macrophages in response to bacterial stimuli. These findings highlight the importance of acute inflammatory responses in the first stages of disease pathogenesis.

Narrow-band imaging (NBI) is a new imaging modality that may improve the effectiveness of endoscopic surveillance and screening. Two recent studies have compared NBI with white light endoscopy; one study demonstrated no difference in adenoma detection rate between the two imaging modalities, the other study demonstrated improved differentiation of lesions with NBI compared with white light endoscopy.