Top 11 Practice Changers in Gastroenterology: 2016

David A. Johnson, MD


December 28, 2016

Editor's Note:
As in years past, 2016 produced some notable publications in gastroenterology, including both research findings and evidence-based guidelines that will affect clinical practice. In this highlight review, Dr David Johnson has selected 11 articles that he believes to be among the year's most important.

Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial

Kelly CR, Khoruts A, Staley C, et al
Ann Intern Med. 2016;165:609-616

Fecal microbiota transplantation (FMT) has become a standard of care for treating patients with relapsing Clostridium difficile infection. This is the first randomized, controlled, double-blind trial of FMT for recurrent C difficile infection that demonstrated a high cure rate for FMT (91%) compared with autologous patient transplantation (63%). The reinfusion success for autologous infusion is very surprising, but still markedly inferior to that of FMT—which, owing to commercially available access and easy infusion by colonoscopy, sets a new standard for relapsing infection. Alternative strategies, such as oral or nasogastric tube administration, are inferior options at present.


Acute Pancreatitis

Forsmark CE, Swaroop Vege S, Wilcox CM
N Engl J Med. 2016;375:1972-1981

Cases of acute pancreatitis have increased over the past decade. They account for more than 275,000 annual hospital admissions in the United States and $2.5 billion in estimated medical costs. This review focuses on the most recent practice changes and addresses ongoing issues and questions related to the management of acute pancreatitis.

The most useful predictors of severe disease are an elevated hematocrit (> 44%), elevated levels of blood urea nitrogen (> 20 mg/dL) and creatinine (> 1.8 mg/dL), and systemic inflammatory response syndrome (presence of two or more of the following signs: temperature < 36°C or > 38°C, pulse > 90 beats/min, respiratory rate > 20 breaths/min or arterial carbon dioxide value < 32 mm Hg, and white blood cell count < 4000 or > 12,000 cells/mm3) at the time of admission to 24-48 hours thereafter. These patients should be directed to high-intensity nursing units. Vigorous fluid therapy is most critical during the first 12-24 hours after symptoms begin, but not very useful after 24 hours. Whether artificial enteral feeding is needed can be predicted by day 5. Nasogastric, nasoduodenal, and nasojejunal approaches have similar results. Early nasoenteric feeding within 24 hours of admission is not superior to assessing the feasibility of oral feeding at 72 hours.

Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett's Esophagus With Radiofrequency Ablation

Guthikonda A, Cotton CC, Madanick RD, et al
Am J Gastroenterol. 2016 Oct 11. [Epub ahead of print]

This article emphasizes that dysplastic Barrett esophagus is a lifelong condition that requires regular endoscopic surveillance for recurrence. During 540 person-years, 52 patients (24%) had a recurrence (incidence rate, 9.6% per year; mean time to recurrence, 1.88 years). Of particular note is the higher rate of dysplastic recurrence in the gastric cardia. This is notable because current guidelines do not recommend routine histologic surveillance of this area, and these lesions would have been missed without it. I strongly recommend a change in routine practice to include four-quadrant biopsies of the cardia for all patients after complete eradication of intestinal metaplasia.



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