12 Highlights You Should Know From DDW 2020

David A. Johnson, MD


June 01, 2020

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Digestive Disease Week (DDW) 2020 did not pan out as intended, with the in-person meeting canceled in favor of a virtual congress. But after reviewing the abstracts and presentations that have been posted, I can say that even though the meeting was virtual, the science is anything but.

Here are some of the highlights.

Real-World Efficacy of Fecal Microbiota Transplantation

In a study of the fecal microbiota transplantation (FMT) national registry,[1] investigators compiled data from 253 patients at 22 sites in North America who received the treatment due to Clostridium difficile infection. They reported a cure rate of approximately 90% at 30 days and 95% at 6 months. These are real-life numbers that we can quote to our patients.

In Colonoscopy, Best to Take a Second Look

In a multicenter study,[2] investigators compared second forward-viewing endoscopic exam of the right colon versus a conventional single forward withdrawal from the right colon in patients undergoing colonoscopies in Asia-Pacific countries. A little over 1000 patients were randomized to short exam with withdrawal with one pullback, or pulling back until the hepatic flexure was reached and then looking again. Compared with the conventional technique, second withdrawal examination increased the adenoma detection rate by 5.5% and the polyp detection rate by 9.2%. Notably, both techniques were high-level adenoma detectors, with the overall detection rate a statistically similar (P = .201) 49% in the second withdrawal group and 45% in the conventional group. Employing a second withdrawal examination added 1.5 minutes to the procedure. These findings affirm the standard recommendation that you should do a second look in such patients.

Fiber-Gut Microbiome Interactions

We've seen increasing data of late on the role of diet in inflammatory diseases of the gastrointestinal tract, in particular inflammatory bowel disease. In a recent commentary, I profiled cohort study findings linking inflammatory diets with diverticulitis over a long period of time.

DDW 2020 featured new data from the Health Professionals Follow-Up Study.[3] Investigators collected stool samples from 307 healthy males to assess their microbiome. Participants' fiber intake was captured by 7-day dietary recall. Results showed that the dietary fiber increased the microbial diversity and beneficial bacteria related to the colon. There were greater microbial differences based on the type of fibers ingested, with better results noted with particular fruits and cereals when compared with vegetables.

I expect that we'll be seeing more and more about diet as it relates to inflammatory diseases. There may even be more emphasis on the types of fiber, as was noted with cereals and fruits in this case.

Amoxicillin-Clavulanate Reduces Hospital Admissions in Diverticulitis

What would be the standard answer if the emergency room called you and said, "We've got a patient with diverticulitis"? You'd most likely give them ciprofloxacin and metronidazole, right?

Investigators analyzed an administrative claims database for Medicare to identify a cohort of nearly 20,000 patients with diverticulitis who filled prescriptions either for amoxicillin-clavulanate (n = 2636) or metronidazole and a fluoroquinolone (n = 17,100).[4] They found that the risk of admission to the hospital was reduced approximately 30% at 90 days and 17% at 1 year in the patients who received amoxicillin-clavulanate, compared with those receiving metronidazole and a fluoroquinolone.

These results may offer something for you to change at your practice in the short term. There's certainly no harm, provided that the patients are not penicillin allergic. We'd like to stay away from ciprofloxacin for lots of reasons, and the same is true for metronidazole.

New Results in Eosinophilic Esophagitis

In a very interesting study,[5] researchers identified a novel syndrome associated with eosinophilic esophagitis (EoE) called "food-induced immediate response of the esophagus" (FIRE), which they defined as a sensation that was painful or unpleasant occurring immediately after contact of the esophagus with certain foods and appearing different and unrelated to dysphagia.

The researchers surveyed national and international experts in EoE about the prevalence of FIRE, and also estimated its frequency in a large group of EoE patients enrolled into a Swiss cohort study. They reported that 90% of the EoE experts recognized FIRE in their patients, and 40% of patients in the Swiss cohort had experienced it. The symptoms of FIRE were reported to begin within 5 minutes of exposure to provoking agents and to have a duration of approximately 120 minutes. FIRE was more typical in males, as is EoE, and in those with concomitant allergic diseases. Fresh fruits, wine, and vegetables were the most commonly reported triggers of FIRE.

The newly identified FIRE syndrome is something you may want to ask your patients with EoE if they've experienced, and perhaps counsel them to stay away from certain triggers if so.

Results were also made available from the largest trial of EoE to date.[6] In a phase 3 multicenter trial, patients with EoE and dysphagia were randomized to receive either oral budesonide suspension at 2 mg twice a day or placebo for 12 weeks. Compared with placebo, budesonide was associated with significant improvements in the validated EoE Endoscopic Reference Score as well as symptom scores. Budesonide should become commercially available soon. In the meantime, most of us are compounding our budesonide slurry solution.

Developing Diabetes May Predict Worsening Pancreatic Cystic Neoplasms

We often struggle with following up on our patients with low-risk pancreatic cystic neoplasms, despite there being lots of guidelines and data out there.

I was therefore happy to come across a very interesting study on this topic at DDW 2020. Investigators took a prospectively maintained database of patients with pancreatic cysts and identified 442 with suspected mucinous cysts without worrisome features or high-risk stigmata.[7] After following these patients over a median of 54 months, they found that those who progress to worrisome features or high-risk stigmata had a significant 15.5 times increase in their risk of developing new-onset diabetes. Also interesting was the finding that if you had prior colon or renal cancer, the hazard ratio was increased by 47.9 and 38.9, respectively.

Based on these results, the development of diabetes is something I think we can put on our list as a metabolic marker when we follow these cystic neoplasm patients longitudinally.

G-POEM Shows Promise in Gastroparesis

In a follow-up study of earlier preliminary data, investigators from North American and South American centers assessed the treatment of refractory gastroparesis with gastric peroral endoscopic myotomy (G-POEM).[8] They reported that G-POEM procedures were technically successful in all cases and this was maintained in 59.7% of the 67 patients followed up to 1 year. Interestingly, pre- and 3-month postprocedure gastric emptying studies were performed in 53 patients, with 64.2% and 47.2% experiencing improvement and normalization, respectively.

I don't believe these results are quite yet ready for prime time, outside of a trial. There were some increases in pylorus distensibility index following G-POEM, which seemed to discriminate who would be most responsive. However, they may be ready for clinical application someday soon.

Narrow-Band Imaging for Nonerosive Reflux Disease

Narrow-band imaging (NBI) is an advanced technology that helps to identify intrapapillary capillary loops and has routinely been used in eosinophilic esophagitis, lymphocytic esophagitis, and squamous cell carcinoma. However, we don't use it in common practice.

An international randomized study[9] assessed the use of NBI in patients with nonerosive reflux disease (NERD; as validated by questionnaires and pH study) compared with control subjects. Lo and behold, intrapapillary capillary loops were evident in 70% of the patients with NERD compared with 30% with white light endoscopy. These also resolved when the patients were treated with proton-pump inhibitor therapy.

NBI is something to keep on your short-term list of options. You can easily perform this when evaluating for NERD.

Coming Soon: A New Blood Test for Colon Cancer?

In a single-center study[10] performed at the Veterans Affairs Palo Alto Health Care System, investigators looked at 354 patients with no prior diagnosis of colorectal cancer (86% were asymptomatic and 14% had symptoms or positive fecal immunochemical test). Prior to undergoing colonoscopy, they drew patients' blood to test it for three biomarkers: circulating gastrointestinal epithelial cells, somatic mutations, and methylation of cell-free DNA. The test actually achieved a 100% sensitivity, a 90% specificity, and a remarkably high 76% rate of detecting colorectal cancer and advanced adenomas.

We've seen a lot of early preliminary studies that suggest great success, and there's certainly more to come with this. It's very promising and hopefully will be available in the not-too-distant future.

A Pair of Intriguing Studies in Barrett Esophagus

The final two studies of note dealt with Barrett esophagus, both of which come to us from Dr Kenneth Wang and colleagues at the Mayo Clinic in Rochester, Minnesota.

In the first analysis, they looked at the role of the microbiome and progression to neoplasia.[11] By using metagenomics, they showed that there was a difference in non-dysplastic Barrett esophagus and dysplastic Barrett esophagus based on the microbiome signature.

We'll have to wait and see how this technology develops, although there is certainly a lot of microbiome data coming out in the esophagus, not only for Barrett esophagus but also for reflux disease. Who would have thought that gastroesophageal reflux might be an infectious disease? Studies have noted that it is driven by things such as cytokines, chemokines, and even the tumor inflammatory pathways (eg, TLR4), frequently stimulated by gram-negative bacteria, particularly in the esophagus. The hope is that these taxonomic shifts may be something we can modify one day.

The second study assessed the possibility of identifying Barrett esophagus using the advanced technology of an electronic nose.[12] Some of you may remember the canine sniffing center in St. Sugar Japan, where they trained dogs to look for volatile organic compounds as predictors of cancer. The seminal work was done with ovarian, lung, prostate, and colon cancer, in which they reported phenomenal success. There's since been a lot of interest in the developing artificial intelligence and neural networks for recognizing these volatile organic compounds.

In their prospective cohort study, Dr Wang's group looked at nearly 300 patients, 37.8% of whom served as controls and the remainder of whom had Barrett esophagus (mean length, 1.7 cm). The positive predictive value of the electronic nose device they employed was a quite striking 71%, with a 77% negative predictive value. So when it comes to noninvasive ways to screen not only for Barrett esophagus but also for other things, there may be an electronic nose in your future.

There was a lot of interesting science on display at DDW 2020, and the excitement surrounding it is anything but "virtual." We will wait and see how these findings develop when they are published as manuscripts. But hopefully some of these are actionable for you now. They certainly are in my practice.

I'm Dr David Johnson. Thanks again for listening.

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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