Reviews & Analysis

Childhood obesity is at epidemic proportions globally and its management is controversial. This Viewpoint considers the role of surgery for pediatric extreme obesity and the prevalence of this type of bariatric surgery. Guidelines for the use of bariatric surgery, clinical outcomes, and future research avenues are also discussed.

Functional vomiting, cyclic vomiting syndrome and chronic idiopathic nausea are fairly rare but highly disabling disorders. Although there is a dearth of randomized, controlled treatment trials for these disorders, interest in their etiology and treatment is increasing. In this Review, the authors consider the nomenclature, pathophysiology, clinical presentation and management of these functional gastroduodenal disorders, with a particular focus on cyclic vomiting syndrome.

The consumption of fish that are high in omega-3 fatty acids has been shown to have cardioprotective benefits; however, these benefits are tempered by the risk of mercury poisoning. This Viewpoint article discusses the benefits and potentially harmful effects of a fish diet, and considers the amount and type of fish that should be consumed to obtain the most benefit with the least risk of toxicity.

This article considers the case of a 22-year-old female with congenital disorder of glycosylation type Ib and a history of congenital hepatic fibrosis, portal hypertension and esophageal varices, who presented with edema, diarrhea, hypoalbuminemia and pancytopenia. Protein-losing enteropathy was diagnosed. As previous mannose therapy was associated with diarrhea and abdominal pain, albumin was infused followed by intravenous and subcutaneous therapy with unfractionated heparin.

Patients with diabetes often have gastrointestinal symptoms, but the extent and severity of this problem and the specificity of the symptoms experienced are not nearly as well defined as generally assumed. The authors of this Review examine the frequency and type of gastrointestinal symptoms experienced by patients with diabetes, review the underlying pathophysiology of these gastrointestinal complications and consider the therapeutic options available.

The author of this Review considers the modalities available for the treatment of dysphagia in patients with malignant or benign esophageal strictures. State-of-the-art techniques, such as stent placement for malignant strictures and dilation therapy for benign strictures, are discussed, as are new developments, such as brachytherapy for malignant strictures. New indications, such as stent placement and incisional therapy for refractory benign strictures, are also considered.

This Case Study describes a 40-year-old female laboratory technician who accidentally came into contact with water containing snails infected withSchistosoma mansoni. Cercarial dermatitis occurred in the areas exposed to the contaminated water, but a unique treatment approach involving a single oral dose of oxamniquine (50 mg/kg) on the day of exposure resulted in cure during the early stages of disease. No further symptoms were observed throughout follow-up.

This Case Study describes a 72-year-old male who had an unresectable adenocarcinoma of the pancreas and enrolled in a clinical trial of endoscopic ultrasound-guided neoadjuvant therapy to downstage the tumor. The tumor was surgically removed with a complete pathologic response and showed no signs of recurrence at the 12-month follow-up, although the patient went on to develop bilateral pulmonary nodules and a liver mass, consistent with metastatic disease.

There is a growing tendency to use noninvasive measures instead of histopathological analysis of liver tissue for the evaluation of disease progression in patients with chronic liver disease. The authors of this Review provide an overview of the proposed noninvasive diagnostic methodologies, focusing on those that are easily available to clinicians—biochemical markers and transient elastography.

Gastrointestinal bleeding affects a substantial number of elderly persons and is a common indication for hospitalization. The authors of this Review discuss trends in the epidemiology and outcome of gastrointestinal bleeding in elderly patients. Specific causes of upper and lower gastrointestinal bleeding are also discussed, along with recommendations for an approach to endoscopic diagnosis and therapy.

This Case Study describes a 47-year-old woman who was treated with indomethacin for osteoarthritis-related hip pain. Soon after beginning treatment she developed nausea, vomiting, abdominal pain, dark urine and jaundice. Despite discontinuing all medications, her symptoms worsened. Treatment with prednisone 40 mg/day was initially successful, but after tapering (over 18 months) and then discontinuing prednisone her liver chemistry test results worsened and a liver biopsy showed evidence of chronic hepatitis.

The idiopathic inflammatory bowel diseases remain a vexing diagnostic challenge for clinicians. There have, however, been advances in the imaging modalities available for the diagnosis of IBD and the assessment of disease activity. In this Review, the authors discuss the new imaging techniques available—abdominal ultrasound, MRI, CT, capsule endoscopy and double-balloon endoscopy—and how they compare with each other and with more traditional diagnostic modalities.

This Case Study describes a 45-year-old white female who was admitted to hospital with a 1-week history of right upper quadrant abdominal pain, progressive tiredness and jaundice. Test results raised concerns that the she had a concomitant acute onset of HCV and autoimmune hepatitis, necessitating liver biopsy. The patient was diagnosed with acute symptomatic infection with HCV genotype 1a with no evidence of autoimmune hepatitis.

This Case Study discusses a 39-year-old man who initially presented with a 2-month history of abdominal pain, jaundice, non-bloody diarrhea, weakness and weight loss. Vanishing bile duct syndrome and IBD, type unclassified, were diagnosed. Budesonide therapy improved the patient's symptoms, but they worsened several months later. Repeat evaluation revealed extensive lymphadenopathy and an elevated white blood cell count, and Hodgkin's lymphoma was diagnosed.

The diagnostic process for patients who have noninfectious and non-IBD forms of colitis is often burdensome because of our limited knowledge of these conditions. This Review discusses the pathophysiology, epidemiology, histopathology, and clinical characteristics of microscopic colitis, Behçet's syndrome, diversion colitis, diverticular colitis, eosinophilic colitis, ischemic colitis and radiation colitis, and provides treatment recommendations based on the current evidence.

From being considered mainly as a nosocomial disease associated with the use of broad spectrum antibiotics, the epidemiology ofClostridium difficile-associated disease (CDAD) seems to be changing. In this Review, the author focuses on outbreaks of CDAD that have been associated with higher mortality rates and reduced effectiveness of treatment with metronidazole. The emergence of a fluoroquinolone-resistant strain of C. difficile(BI/NAP1/027), new at-risk populations and the increased incidence of CDAD are also discussed.

Since Crohn's disease and ulcerative colitis were first described, it has become apparent that infectious agents could be involved in the causation and/or exacerbation of IBD. Infections can also occur as a complication of IBD and its treatment, and even have potential as a treatment for IBD. In this Review, the authors consider the evidence for these associations.

This Case Study describes a 17-year-old boy who presented with sudden onset of visual impairment, identified as bilateral anterior uveitis by an ophthalmologist. The patient was diagnosed with multifocal Crohn's disease, involving the terminal ileum, cecum, stomach and duodenum. The authors discuss the importance of rapid evaluation of extraintestinal manifestations of Crohn's disease.

Medical therapy for GERD has improved remarkably since the introduction of PPIs; however, despite twice-daily dosing of PPIs, reflux symptoms can persist, new symptoms can occur or be unmasked, and esophagitis can fail to heal. Management of such 'refractory' GERD can be a challenge. The author of this Review considers the diagnostic approach to refractory GERD and the diagnoses that are possible.

Minimal hepatic encephalopathy (MHE)—the mild cognitive impairment commonly seen in patients who have cirrhosis—has a significant impact on quality of life. Current understanding is that MHE forms part of the spectrum of hepatic encephalopathy, although this remains to be proven. This Review focuses on the pathogenesis and neuropsychological findings of MHE, the effect of MHE on quality of life and survival, and treatment options.