COMMENTARY

Top 10 Gastroenterology Articles Provide Essential Guidance

David A. Johnson, MD

Disclosures

December 23, 2020

If ever there was a year when clinicians needed some guidance, it was 2020, as the ongoing pandemic and continued advances in our field dramatically altered how we perform some of our most fundamental procedures. Thankfully, this year's publications did not disappoint, with crucial recommendations offered on multiple topics, including diagnosing and surveilling malignancies, using probiotics, and ensuring patient and healthcare worker safety during COVID-19. These 10 articles (presented in no particular order) represent what I believe to be the key reviews for those involved in the delivery of gastrointestinal (GI) care.

Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer

These expert panel recommendations provide crucial guidance regarding the assessment of colon polyps for endoscopic features of cancer. The authors highlight the importance of the endoscopic polyp surface pattern in defining deep mucosal classification. They also detail some of the most commonly used classification systems in the United States, such as the Kudo and Narrow Band Imaging International Colorectal Endoscopic systems, helpfully accompanied by high-quality images of differing polyp presentations.

They also provide guidance on the best methods for resection, advising that polyps with deep submucosal invasion should not have endoscopic removal but rather be referred directly to surgery, describing endoscopic techniques for resection of superficial submucosal invasive cancer, and weighing the risks and benefits for surgery when a polyp removed endoscopically has histologic evidence of submucosal invasion.

AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

COVID-19 has forced endoscopic centers to carefully consider the best methods for screening their patients while maintaining sufficient volume and optimal care. Many hospitals and some private practices require specific COVID-19 testing, whereas others rely on screening-related questioning.

In this timely bit of expert advice, the panel drafted recommendations on screening for SARS-COV-2 infection before endoscopic procedures are performed. The recommendations employ different strategies for asymptomatic individuals based on the local prevalence rates of SARS-CoV-2 infection.

When low (< 0.5%), they advise no testing and use of N95 masks if available and surgical mask use otherwise. When intermediate (0.5%-2.0%), they advise considering testing. But when testing logistics are challenging and test specificity is variable, it is reasonable to choose not to implement a pretesting strategy and proceed with use of high-grade personal protective equipment (PPE; N95/N99 or powered air purifier respirators) for all procedures. When high, they recommend reserving endoscopy for time-sensitive procedures/emergencies, with use of high-grade PPE for all cases.

They also note that there is no role for serum-based tests, which demonstrate that the patient has had infection but cannot accurately tell you whether it is currently active.

This is a valuable resource reference, albeit one that is also subject to changes based on prevalence and evolving data.

Gastrointestinal Endoscopy During the COVID-19 Pandemic: An Updated Review of Guidelines and Statements from International and National Societies

Further information on performing endoscopy during the ongoing COVID-19 pandemic is provided in this superb consolidation of guidance from international and national societies.

All societies recommended use of PPE during the examination, including gloves, mask, goggles or face shield, gown, and hairnet, as well as double gloves and N95 or FFP2/3 masks in highly suspected or confirmed cases. However, of concern is that only 43% of these societies recommended that the endoscopy team be trained in donning and doffing PPE.

In addition, 95% recommended temporarily postponing elective/nonurgent procedures; 86%, stratifying patients for COVID-19 risk before the examination, using a questionnaire for symptoms and/or taking patients' body temperature; 38%, reducing the number of people who accompany patients; 33%, requiring healthcare workers to perform self-surveillance for signs and symptoms (again by questionnaire and temperature checks); and 19%, contacting patients 14 days after the examination to check symptoms (which we routinely do at our practice).

The article's supplemental materials also provide useful web links for all societies and recommendations.

AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia

These must-read guidelines provide updated recommendations for a common GI evaluation. They call for performing same-day bidirectional endoscopy (upper endoscopy and colonoscopy), changing the threshold for iron deficiency from a ferritin level of 15 ng/mL to 45 ng/mL, establishing a role for initial celiac testing prior to any duodenal biopsies and dismissing a role for gastric biopsies in routine assessment, and considering a trial of oral iron before further testing with video capsule endoscopy in asymptomatic patients with negative bidirectional endoscopy.

AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis

Although once thought to be a pediatric disease, the prevalence of eosinophilic esophagitis (EoE) among adult patients is rapidly increasing in the practice of gastroenterology. As such, the data on EoE continue to evolve.

These expert recommendations provide the most current evidence-based advice on managing patients with EoE. The authors state that proton pump inhibitors, topical steroids, and elimination diet are all preferable over no treatment, with best practice entailing that the patients are involved in a shared decision-making process when selecting single or combination therapy. They recommend continuing beyond short-term treatment with topical (rather than oral) steroids, depending on the patient's history of strictures, recurrent dysphagia, and the possibly patient-related adverse effects of long-term use.

AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders

The use of probiotics is increasingly widespread, as their over-the-counter availability grows and more healthcare providers recommend their use for promoting health or mitigating disease. These clinical practice guidelines essentially call for a "time out" on the routine use of probiotics, given the continued uncertainty surrounding their relative harms and benefits.

The authors recommend the use of probiotics exclusively in the following indications and settings: for Clostridioides difficile, irritable bowel syndrome, ulcerative colitis, or Crohn's disease, only in the context of a clinical trial; with specific strains of probiotics for those with severe illness or high value for prevention of C difficile; and for preterm infants (< 37 weeks' gestation or low birth weight) using a combination of Lactobacillus species and Bifidobacterium species.

As I noted in a previous commentary, these recommendations are required reading for any clinicians who have been asked about probiotics by their patients.

ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation

Disorders of the arterial and/or venous hepatic and mesenteric blood supply have major GI consequences. The arrival of this evidence-based guideline provides timely assistance to supplant the relative scant literature on how best to manage these disorders.

The authors note that hemostatic pathways in compensated cirrhosis are generally intact, although that tenuous balance is subject to the deleterious effects of kidney dysfunction, sepsis, and hypothermia. With cirrhosis, the loss of procoagulant liver-derived factors is also associated with loss of anticoagulant factors (protein C) and increased von Willebrand factor and endothelial-derived factor VIII, and hence may result in increased thrombotic risk.

They recommend not transfusing fresh-frozen plasma in an attempt to correct international normalized ratio, the use of nonselective beta-blockers over band ligation for prevention of variceal bleed with high-risk varices and portal or mesenteric vein thrombosis requiring anticoagulation, and surveillance for hepatocellular carcinoma with hepatic ultrasound and serum alpha-fetoprotein levels every 6 months in patients with chronic Budd-Chiari syndrome.

ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth

Although small intestinal bacterial overgrowth (SIBO) has been recognized for decades in specific patient groups, there is increasing recognition of its potential implications for pathogenesis of a long list of luminal and hepatic diseases.

Recommendations offered in this clinical guideline include the use of glucose hydrogen or the lactulose hydrogen breath test for the diagnosis of SIBO in patients with irritable bowel syndrome or in symptomatic patients (abdominal pain, gas, bloating, and/or diarrhea) with previous luminal abdominal surgery, as well as using antibiotics in symptomatic patients with SIBO to eradicate overgrowth and help resolve associated symptoms.

Those interested in learning more about SIBO are advised to also check out clinical practice updates published this year in the journal Gastroenterology.

Checkpoint Inhibitor–Induced Colitis

Immune checkpoint inhibitors (ICI) have undoubtedly revolutionized the treatment of many cancers, in particular small cell lung cancer, renal cell carcinoma, and melanoma. The growing use of these treatments has demonstrated a related potential GI consequence sharing similarities with inflammatory bowel disease. Although this is considered a distinct form of acute colitis, there can be a rapid progression leading to potential complications, including bowel perforation and death.

This review of the literature on immune-mediated colitis makes several points of interest to gastroenterologists. Prompt recognition and management of this condition using early endoscopic evaluation is critical. Corticosteroids are the initial management strategy, with early response to this therapy assessed to decide whether and when to escalate to biologics. Most patients will respond with full resolution, but endoscopic assessment for mucosal healing should be considered 8-10 weeks post-treatment. If you plan to reinstitute ICI, you should also consider concomitant vedolizumab therapy.

Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer

New data on post-colonoscopy follow-up and polyp surveillance prompted this updated set of recommendations. The authors recommend not using categories such as "high-risk adenoma" or "low-risk adenoma." Rather, clinicians should specify the individual criteria being captured by the category (eg, one to two adenomas of < 10 mm instead of the term "low-risk adenoma"), given that evidence supporting level of risk for various criteria is constantly evolving.

They also suggest extending follow-up intervals for < 10 mm tubular adenomas — that is, from 1-2 to 7-10 years for one to two adenomas, and from 3-4 to 3-5 years for three to four adenomas. All of these recommendations are predicated on a high-quality exam.

This article is a must-read for those performing colonoscopy, as compliance with guideline recommendations is a mark of high-quality performance.

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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