There are innumerable clinical considerations that we in the field of gastroenterology encounter on a daily basis. Amid our busy schedules, we do our best to identify the evidence to guide our decisions, but there undoubtedly remain knowledge gaps that can leave even the most research-focused of us feeling uncertain how to proceed.
Luckily, 2022 was a banner year for gastrointestinal (GI)–related literature that shined a light on several key topics. Expert voices were on ample display in the form of randomized controlled trials, review papers, and much-needed guidelines from the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA). Although there was an abundance of options, I believe that these 10 articles offer the greatest practice-changing implications, now and in the years to come.
'Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis'
The WATERFALL study was an early weight-based comparison of aggressive vs nonaggressive goal-directed fluid resuscitation in the initial phase of acute pancreatitis. Patients were randomly assigned to receive intravenous (IV) fluids (lactated Ringer solution) of either aggressive (IV bolus of 20 mL/kg of body weight over 2 hours, followed by 3 mL/kg per hour) or moderate resuscitation (1.5 mL/kg per hour). In this latter group, those who were hypovolemic also received a bolus of 10 mL/kg, whereas no bolus was given in those who were euvolemic.
There was no difference in progressive severity of pancreatitis; however, there was a major difference in the primary safety outcome of fluid overload. The incidence of fluid overload was 20.5% in the aggressive resuscitation arm and 6.3% in the moderate resuscitation arm, resulting in an adjusted relative risk of 2.85 in favor of the latter arm. This prompted the data and safety monitoring board to stop the study.
In an October commentary, I delved further into the details of this landmark trial following its publication in The New England Journal of Medicine, and why it will probably establish new profiles for fluid management in acute pancreatitis.
'ACG Clinical Guideline: Gastroparesis'
Gastroparesis is increasingly encountered in clinical practice. This makes the arrival of these guidelines from ACG such a welcome addition to the year's GI publications.
The authors provide evidence-based recommendations on the risk factors, diagnosis, and management of this condition. They also notably point out that these are the preferred, but not the only, approaches to this condition.
For those interested in learning more, I recommend you also review this April commentary in which I offer a how-to-guide for managing gastroparesis.
'ACG Monograph on GI Diseases and Endoscopy in Pregnancy and Postpartum Period: An Introduction'
This ACG monograph includes nine focused articles by experts from fields including gastroenterology, hepatology, obstetrics/gynecology, maternal-fetal medicine, and nutrition. Their collaborative work addresses GI disease states in the setting of pregnancy and postpartum periods, leading to best practice recommendations for each of these topics.
A tremendous asset, I suggest keeping this monograph close by for easy access when caring for these patients.
'Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline'
An update of previous ACG guidelines, these revised evidence-based recommendations provide new information on definition, diagnosis, screening/surveillance strategies, and medical and endoscopic treatments for Barrett esophagus.
I discussed the practice-changing implications of these guidelines in a May commentary, including such notable updates as nonendoscopic methods, liberalized surveillance schedules for short-segment Barrett esophagus, and defining volume criteria for centers providing endotherapy.
'American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period'
The ACG and the Canadian Association of Gastroenterology collaborated to create an international, multisociety, and multidisciplinary working group on this crucial topic. The fruits of those efforts are these evidence-based, graded recommendations, which focus on the periendoscopic management of anticoagulant and antiplatelet medications for both elective endoscopy and acute GI bleeding.
Specific recommendations are made regarding the use of fresh frozen plasma, vitamin K, prothrombin complex concentrate, and direct oral anticoagulant reversal agents. Furthermore, they touch on clinical decision-making around temporary interruption and/or bridging anticoagulation and antiplatelet agents for elective endoscopy, weighted by the underlying conditions and risks for alterations.
Not offered as a recommendation in this guideline, but a point I've made in a prior commentary, is that the gastroenterologist should not make the primary recommendation for interrupting use of these agents. Instead, this should be done by or in concert with the primary prescribers.
'Acute-on-Chronic Liver Failure Clinical Guidelines'
This guideline is spectacular resource for anyone who is involved in the care of acute and/or chronic liver disease.
It is a veritable tome of evidence and recommendations covering associated related failures of the brain, lungs, kidneys, and coagulation, in which the authors share their preferred approach to the management of patients. Additional discussions focus on infection, nutrition, use of parenteral albumin, transplant considerations, and in which patients such efforts may prove futile.
This is a must-read that you should bookmark immediately.
'AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity'
The epidemic of obesity has implications for all healthcare providers. However, as patients and clinicians seek out endoscopic and pharmacologic approaches to treating this condition, the need for gastroenterologists to play a greater role has become increasingly apparent.
This AGA guideline provides nine evidence-based grade recommendations on the available pharmacotherapies after weighing the certainty of effects against potential benefits and harms. They conclude that long-term pharmacologic therapy is indeed warranted in certain adult patients with overweight and obesity.
'An Expert Opinion/Approach: Clinical Presentations, Diagnostic Considerations, and Therapeutic Options for Gastrointestinal Manifestations of Common Variable Immune Deficiency'
To date, researchers have identified over 400 distinct inborn errors of immunity disorders associated with more than 450 genetic defects, with an estimated population prevalence of 1 in 1200. Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immunodeficiency in adults, estimated to occur in 1 in 25,000. Notably, the GI system is involved in up to one third of these patients, with signs or symptoms mimicking disorders such as celiac disease, pernicious anemia, or inflammatory bowel diseases. Further complicating matters is the fact that there is frequently long and extended delays in making the correct diagnosis.
This review provides an excellent update on the warning signs of immunodeficiency, definitions for CVID, and appropriate GI screening and therapeutic strategies for these complex (and perhaps not so extremely rare) patients.
'AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review'
Subepithelial lesions are encountered in approximately 1 in every 300 endoscopies, with two thirds of these lesions located in the stomach. The implications range from non-neoplastic to potentially or definitely neoplastic lesions.
This expert review provides best practice advice for managing any subepithelial lesions discovered during routine endoscopy. These recommendations address biopsy technique, imaging, and surveillance and resection strategies.
'AGA Clinical Practice Update: Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Lean Individuals: Expert Review'
Although nonalcoholic fatty liver disease (NAFLD) is observed predominantly in patients with obesity or diabetes, approximately 7%-20% have lean body habitus. Emerging data has highlighted the association between NAFLD in these patients and increased cardiovascular, liver, and all-cause mortality.
There has been limited guidance addressing appropriate clinical evaluation of this subset of patients, specifically when it comes to inherited/genetic and inflammatory disorders, lipodystrophy, and drug-induced NAFLD. It was therefore yet more welcome news when the AGA published this expert review, which provides 15 evidence-based recommendations on diagnosis, staging, and management of NAFLD in lean individuals.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.
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Cite this: David A. Johnson. 2022's Top 10 Gastroenterology Publications - Medscape - Dec 20, 2022.
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