The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ENDOSCOPY
Endoscopic sleeve gastroplasty versus lifestyle modification for weight loss (August 2022)
An endoscopic suturing device designed to perform endoscopic sleeve gastroplasty (ESG) for weight loss has recently been approved by the US Food and Drug Administration. In a multicenter trial (MERIT) comparing ESG plus lifestyle modifications versus lifestyle modifications alone in 209 individuals with class 1 or 2 obesity (BMI 30 to 50 kg/m2), the ESG group lost more weight at 52 weeks (mean excess weight loss [EWL]: 49 versus 3 percent) and had a higher proportion of patients with improvement in ≥1 metabolic comorbidities (80 versus 45 percent) [1]. At 104 weeks, 68 percent of the ESG group maintained ≥25 percent EWL. Although ESG is a promising technique, long-term durability remains unclear. (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Expected excess weight loss from ESG'.)
ESOPHAGEAL AND GASTRIC DISEASE
Updated guidance on gastroparesis (August 2022)
Updated guidance on gastroparesis from the American College of Gastroenterology emphasizes glycemic control in patients with diabetes mellitus and dietary management with a small particle diet [2]. Suggested pharmacologic treatment options include prokinetic agents and antiemetics for symptom control. The guideline also advises against the routine use of central neuromodulators but notes limited evidence of improvement in abdominal pain associated with gastroparesis. In addition, it advises against the use of intrapyloric botulinum injection and herbal therapies for treatment of gastroparesis. Our approach is consistent with the guideline. (See "Treatment of gastroparesis", section on 'Dietary modification'.)
HEPATOLOGY
Markers of liver fibrosis and risk of surgical mortality (December 2022)
The benefit of checking preoperative liver biochemistries in healthy individuals is uncertain because most patients with abnormal biochemistries do not have advanced liver disease. However, emerging data suggested that an elevated FIB-4 score, which consists of age, aminotransferases, and platelet count, may be associated with increased surgical mortality. In a large cohort study of individuals without known liver disease, a preoperative FIB-4 score ≥2.67 (defined as the threshold for advanced fibrosis) was associated with increased risk of intraoperative mortality, mortality during hospitalization, and 30-day mortality [3]. While biochemical markers of liver disease may have a future role for assessing surgical risk, additional studies are needed to confirm these findings. (See "Assessing surgical risk in patients with liver disease", section on 'Screening for liver disease before surgery'.)
COVID-19 vaccination in patients with chronic liver disease (August 2022)
In a study comparing the immunogenicity of COVID-19 vaccines in patients with chronic liver disease versus healthy individuals, chronic liver disease was associated with lower rates of development of positive SARS-CoV-2 neutralizing antibodies (77 versus 90 percent) [4]. Antibody positivity rates were similar among patients with noncirrhotic chronic liver disease, compensated cirrhosis, or decompensated cirrhosis. These data suggest that additional vaccine doses may be needed in patients with chronic liver disease, but further studies are required before making a recommendation for a different vaccine schedule in these patients versus the general adult population. (See "COVID-19: Issues related to liver disease in adults", section on 'COVID-19 vaccination'.)
PANCREATIC AND BILIARY DISEASE
Fluid resuscitation in acute pancreatitis (October 2022)
Fluid therapy is central to the management of acute pancreatitis, but recommendations on the volume of intravenous fluid required have varied. In a randomized trial, 249 patients with acute pancreatitis were assigned to aggressive fluid resuscitation (lactated Ringer solution bolus of 20 mL/kg followed by 3 mL/kg/hour) versus moderate resuscitation (1.5 mL/kg/hour with a 10 mL/kg bolus in patients with hypovolemia) with subsequent goal-directed management [5]. There was no difference in rates of moderately severe or severe pancreatitis or duration of hospitalization, but the trial was terminated early due to higher rates of fluid overload in the aggressive resuscitation group (20 versus 6 percent). This study supports our approach to use moderate fluid resuscitation with goal-directed therapy in patients with acute pancreatitis. (See "Management of acute pancreatitis", section on 'Fluid replacement'.)
Pancreatic cancer surveillance in high-risk individuals (August 2022)
While surveillance for pancreatic cancer in high-risk individuals (HRIs) is recommended by expert groups, the long-term benefits have not been clearly established. In an analysis of 1,731 HRIs enrolled in the multicenter Cancer of Pancreas Screening (CAPS) study, 26 invasive cancers were diagnosed over a >20 year period; cases detected during surveillance were more likely to be early stage and associated with longer survival [6]. In a separate cohort study of 347 carriers of a pathogenic variant in CDKN2A who participated in a longitudinal surveillance protocol and were followed for approximately six years, 30 of the 36 pancreatic cancers detected were resectable at diagnosis; 12 were stage I [7]. Five-year survival was 32 percent in the entire cohort but among the six individuals with stage I tumors who underwent resection, five (83 percent) remained alive at three years. These studies demonstrate that early detection of potentially curable pancreatic cancer in HRIs is possible with frequent image-based surveillance, and that the numbers needed to test to detect a single case of pancreatic cancer are reasonable (194 HRIs in the CAPS analysis and 70 in CDKN2A carriers). (See "Familial risk factors for pancreatic cancer and screening of high-risk patients", section on 'Diagnostic yield, benefits, and harms'.)
SMALL BOWEL AND COLONIC DISEASE
Use of anti-tumor necrosis factor therapy for inflammatory bowel disease in pregnancy (November 2022)
Data on the use of anti-tumor necrosis factor (TNF) agents for treatment of inflammatory bowel disease (IBD) during pregnancy are accumulating. In a population-based study including >5000 pregnancies exposed to these agents from conception, use beyond 24 weeks of gestation was associated with a 7 percent reduction in the relative risk of an IBD flare between 32 weeks of gestation and 6 months postpartum compared with stopping therapy, after adjusting for factors such as IBD type and glucocorticoid use [8]. In addition, anti-TNF therapy was not associated with increased risk of adverse pregnancy outcomes. These data support our approach of continuing anti-TNF therapy throughout pregnancy in patients with IBD. (See "Fertility, pregnancy, and nursing in inflammatory bowel disease", section on 'Anti-tumor necrosis factor agents'.)
Therapeutic drug monitoring for patients with inflammatory bowel disease (October 2022)
For patients with inflammatory bowel disease (IBD) in remission, the benefits of therapeutic drug monitoring (ie, measuring serum concentrations of anti-tumor necrosis factor [TNF] agents and antidrug antibodies) are uncertain. In a meta-analysis of nine trials including 1405 patients with IBD in remission with anti-TNF therapy, there were no significant differences in rates of sustained remission, antidrug antibodies, or serious adverse events between patients who had therapeutic drug monitoring versus those managed conventionally [9]. We reserve drug monitoring for patients with IBD in clinical remission who are at higher risk of complications from a disease flare, rather than performing it routinely in all patients. (See "Treatment of Crohn disease in adults: Dosing and monitoring of tumor necrosis factor-alpha inhibitors", section on 'Patients in remission'.)
Updated guidelines for irritable bowel syndrome with constipation (September 2022)
Updated guidelines from the American Gastroenterological Association on the pharmacologic management of irritable bowel syndrome with constipation (IBS-C) recommend use of linaclotide for management of constipation [10]. Other pharmacologic options include plecanatide, lubiprostone, and tenapanor. The guidelines suggest that polyethylene glycol can be used to treat constipation in IBS-C, but studies are needed to evaluate its efficacy in patients with IBS-C in whom abdominal pain is the predominant symptom. Our recommendations are consistent with these guidelines. (See "Treatment of irritable bowel syndrome in adults", section on 'Constipation'.)
Guidelines on pharmacologic management of irritable bowel syndrome with diarrhea (August 2022)
Updated American Gastroenterological Association (AGA) clinical guidance on the pharmacologic management of irritable bowel syndrome with diarrhea (IBS-D) suggests the use of rifaximin as an option for initial treatment of patients with IBS-D and retreatment with rifaximin in those with recurrent symptoms after an initial response [11]. The guideline also cautions against the use of eluxadoline for management of IBS-D in patients without a gallbladder or those who drink >3 alcoholic beverages daily. Although tricyclic antidepressants can be used to treat IBS symptoms, the guideline recommends against use of selective serotonin reuptake inhibitors. Our approach is consistent with this AGA guideline. (See "Treatment of irritable bowel syndrome in adults", section on 'Antidepressants'.)
Ustekinumab versus adalimumab for moderate to severe Crohn disease (July 2022)
Treatment options for Crohn disease (CD) include drugs that target tumor necrosis factor-alpha or interleukins. However, whether one approach is more effective for inducing and maintaining remission is uncertain. In a trial comparing ustekinumab with adalimumab in 386 biologic-naïve patients with moderate to severe CD, rates of clinical remission at 52 weeks were not significantly different (65 versus 61 percent) [12]. In addition, rates of serious infections were similar in both groups (2 versus 3 percent). These data support the use of ustekinumab or adalimumab for treating moderate to severe CD, while further studies may help guide selection of biologic therapies. (See "Overview of medical management of high-risk, adult patients with moderate to severe Crohn disease", section on 'Ustekinumab'.)
Risankizumab for moderate to severe Crohn disease (July 2022)
Therapeutic options for moderate to severe Crohn disease (CD) are expanding. In two induction trials comparing 600 and 1200 mg risankizumab (an anti-interleukin 23 antibody) with placebo in adults with moderate to severe CD, risankizumab resulted in higher rates of clinical remission at 12 weeks (40 to 45 percent in the treatment groups versus 20 to 25 percent in the placebo groups) [13]. In a maintenance trial comparing risankizumab 180 or 360 mg with placebo, risankizumab resulted in higher rates of sustained remission after 52 weeks (52 and 55 percent in the treatment groups versus 41 percent in the placebo group) [14]. No safety signals were detected. Based on these data, the US Food and Drug Administration approved risankizumab for adults with moderate to severe CD. We anticipate using risankizumab as an alternative to other first-line biologic therapies. (See "Overview of medical management of high-risk, adult patients with moderate to severe Crohn disease", section on 'Other biologic agents'.)
COVID-19 vaccination in patients with inflammatory bowel disease (July 2022)
Data on the immunogenicity of COVID-19 vaccines in patients with inflammatory bowel disease (IBD) are accumulating. In a meta-analysis of 31 studies including nearly 9500 patients with IBD who completed a COVID-19 vaccination series, the pooled seroconversion rate was 96 percent [15]. Seroconversion rates were not significantly different by drug therapy (ie, biologics, small molecules, immunomodulators, and/or glucocorticoids). In most studies that reported durability of serologic response, antibody titers began declining four weeks after vaccination. These data provide some reassurance for patients on immunosuppressive medications and lend support for additional vaccine doses in patients with IBD. (See "COVID-19: Issues related to gastrointestinal disease in adults", section on 'COVID-19 vaccination'.)
OTHER GASTROENTEROLOGY AND NUTRITION
Reducing risk of monkeypox virus transmission through fecal microbiota transplant (August 2022)
In August 2022, the US Food and Drug Administration (FDA) issued guidance to reduce the risk of transmission of monkeypox virus through fecal microbiota transplants (FMT) [16]. The recommended measures include screening donors with questions directed at identifying those at high risk for monkeypox and those with recent or active monkeypox virus infection, developing exclusion criteria to exclude donors with a positive questionnaire screen, and providing informed consent to all FMT recipients regarding the possible risk of monkeypox virus transmission via FMT. Donor screening should be performed retrospectively on FMT prepared from donor stool collected on or after March 15, 2022. The FDA issued the guidance in response to the detection of monkeypox virus DNA in rectal swabs and/or stool samples from infected individuals, suggesting the potential for monkeypox virus transmission via FMT. (See "Fecal microbiota transplantation for treatment of Clostridioides difficile infection", section on 'Stool donor selection'.)
