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.
I'm back from attending Digestive Disease Week (DDW) 2023 in Chicago, where there was a bevy of information — so much so that I'm going to split this into two separate discussions of all the significant findings I believe to possibly have practice-changing implications, now or on the near horizon.
The Option for Occlusion Devices in Atrial Fibrillation and Cirrhosis
Let's begin part 1 of this overview of DDW 2023 with a study of outcomes in patients with cirrhosis and a left atrial appendage occlusion (LAAO) device, also known as the WATCHMAN procedure. We use this in our patients with atrial fibrillation, but when these patients also have cirrhosis, it can cause concern among the interventional cardiologist and the surgeons backing them up, who must assess the risk profile to determine whether or not patients should even undergo this procedure.
Investigators reviewed 207,443 index hospitalizations for patients with cirrhosis and atrial fibrillation, of whom 767 had the LAAO device. In total, 15,397 patients died during the principal hospitalization, but none of the patients in the subgroup who had the LAAO device. After patients with cirrhosis were subgrouped based on Child-Pugh Classification scores, there was no difference in outcomes.
Additionally, patients with the LAAO device had a lower risk for gastrointestinal (GI) bleeding, hospitalization, rehospitalization, and shorter length of stay compared with those who didn't undergo LAAO intervention.
These results indicate that the presence of compensated cirrhosis and atrial fibrillation should not deter clinicians from using LAAO interventions.
Lesions at Higher Risk for Colorectal Cancer After Polypectomy
The next study was about cancer risk after polypectomy in patients who were fecal immunochemical test (FIT) positive on colon cancer screening evaluation.
Dutch investigators conducted their analysis over 6 years, during which time they looked for metachronous cancers diagnosed after 6 months of their baseline colonoscopy.
They looked at 253,833 colonoscopies, followed up for a median of 3 years, and identified 504 cases of metachronous colorectal cancer. Hazard ratios for colorectal cancer were higher in patients who had index findings of advanced serrated polyp lesions with or without the presence of advanced adenomas, and in patients with advanced sessile serrated polyps without advanced adenomas.
This means that patients presenting with those cancer derivatives need to be watched very closely.
Take a second look when you find these lesions, look hard, and make sure there's nothing left behind. This may result in a more restrictive post-polypectomy surveillance guideline in terms of the follow-up intervals we use. We'll wait and see how these findings transfer into the national database.
Two Studies on Gastroparesis
The first of two studies in gastroparesis looked at the efficacy of cannabidiol, in the form of a randomized placebo-controlled trial led by Dr Michael Camilleri and colleagues from the Mayo Clinic College of Medicine in Rochester, Minnesota. Medical cannabis is used to relieve nausea and pain. The nonselective cannabinoid receptor agonist dronabinol is something many of us have probably used in patients. I know I've used it in patients with gastric symptoms resulting from cancer. It delays gastric emptying and enhances gastric accommodation.
The question the investigators sought to answer here was whether cannabidiol, which is a selective cannabinoid receptor agonist with limited side effects in the central nervous system, would also modulate effects related to sensation. They looked at an oral formulation of a purified cannabidiol (100 mg/mL) approved by the US Food and Drug Administration (FDA). Over a 4-week horizon, they assessed its use at up to 10 mg/kg/d, using FDA dose-escalation guidance, with symptoms assessed via the Gastroparesis Cardinal Symptom Index.
At baseline, they identified 29 patients as idiopathic disease, six as having type 1 diabetes, and six as having type 2 diabetes. Those receiving cannabidiol had improvement in all their tolerance symptoms and the ability to tolerate a normal-sized meal.
In summary, I think this is a pretty easy treatment to apply in patients with gastroparesis. It's commercially available and certainly something that we could try in the short term.
The second study, which comes from the National Institutes of Health's Gastroparesis Clinical Resource Research Consortium, dealt with the use of buspirone in early satiety of patients with symptoms of gastroparesis. Buspirone is a 5-HT1 receptor agonist reported to improve fundic accommodation.
In a 4-week, multicenter, randomized trial, investigators looked at 96 patients with symptoms of gastroparesis, of whom 50% had delayed gastric emptying and 39% were diabetic. Although they found no improvement between buspirone and placebo in improving overall symptoms, there were quite striking results in certain subsets revealed by the secondary post hoc analysis. Specifically, it was suggested that buspirone at 10 mg three times a day was significantly better in patients with more severe bloating.
I therefore think buspirone should be considered. It has a very low downside in patients with moderate to severe fullness and symptoms of severe bloating.
Mixed Results on the AI Revolution in Colonoscopy
There were multiple studies on the use of AI and other computer-assisted developments for improving colonoscopy. This has been talked about quite often as revolutionizing endoscopy in so many ways, yet several studies broke with this idea by presenting the idea that maybe it isn't quite needed in all regards. I'd like to highlight two of these negative studies, as well as one positive study.
The first negative study was by Dr Uri Ladabaum and colleagues at Stanford, who looked at over 1000 colonoscopies from 24 endoscopists. They reported that an AI system had no significant effect on adenoma detection rate.
The second negative study came from investigators in Spain, who conducted a multicenter, parallel-controlled randomized trial. They assessed a group of FIT-positive patients, in whom they looked for advanced colon lesions. They reported no difference in overall outcomes between patients who underwent colonoscopy with and without computer-aided detection. There was some benefit as it relates to certain serrated lesions that were either small (≤ 5 mm) or large (≥ 10 mm). But overall, the adenoma detection rate was just 62% in patients evaluated using high-level computer-aided detection; given that these patients are FIT-positive, that detection rate should be higher.
Therefore, when it comes to the question of whether we need these methods in advanced adenoma detectors, the answer is probably not.
However, there was one study that suggested there is some benefit for endoscopists in training. Investigators from Hong Kong performed a single-blind, parallel-group randomized study. They looked at 766 patients and found that the use of real-time AI improved the adenoma detection rate for endoscopists in training. Right- and left-sided flat lesions and advanced lesions showed a difference in advanced adenoma detection favoring AI, but sessile serrated lesions did not.
So, in summary, this technology may have a significant value in improving upon what are already relatively low rates of adenoma detection in those who are just beginning their training.
Self-Administered Therapy for IBS
There were very interesting findings provided by Dr William Chey and colleagues, in the form of a randomized parallel-group study of self-administered digital gut-directed hypnotherapy vs muscle relaxation in irritable bowel syndrome (IBS).
The entire field of cognitive intervention in functional diseases was once underutilized but is now considered overly promising as we look at new therapies. Gut-directed hypnotherapy has demonstrated efficacy for the treatment of IBS, but access has been limited. There was also some suggestion that muscle relaxation treatments may improve symptoms in these patients.
This gut-directed hypnotherapy is digital, self-administered, and commercially available. It is by prescription only. There are costs involved. It's around $75 without insurance.
This is the first randomized controlled trial to assess this, and investigators reported that there was strong evidence that this was advantageous.
It's something that patients could do at home, although obviously it diminishes some of the healthcare-provided interventions. But again, this is very promising and simple to use, with minimal costs. In the short term, I think it's very easy to administer.
Prevention of Rebleeding in High-Risk Peptic Ulcers
Finally, there was an interesting study on a potassium-competitive acid blocker, vonoprazan.
There are seven drugs in this treatment class in various stages of development around the world, although vonoprazan is considered particularly promising and likely to be the first-in-class treatment in the United States. It has been approved but not released by the FDA for a double-drug and a triple-drug regimen for Helicobacter pylori and is presently under review for erosive esophagitis, where the data are strikingly favorable. There has been a hiccup in the process due to nitrosamine detection, which is analogous to what we saw with ranitidine, which the FDA is evaluating with the sponsor company.
This particular study assessed the use of oral vonoprazan therapy vs intravenous (IV) proton pump inhibitor (PPI) therapy for prevention of high-risk peptic ulcer bleeding after successful endoscopic treatment.
As you likely know, the standard treatment for patients who present with GI bleeding is to put them on an IV PPI — pantoprazole 80-mg bolus, followed by an 8-mg/h infusion for 72 hours continuously — and then twice-daily PPI for the next 28 days, irrespective of what they have, and then longer if needed.
The idea of giving them an oral therapy of vonoprazan at 20 mg twice daily for 3 days, then 20 mg once daily for the next month, rather than using the intensive care unit (ICU) and potentially the IV administration, is certainly a very promising one.
There was no difference in the treatments in terms of the primary outcome of rebleeding within 30 days. The investigators chose a study design that did not necessarily look for an improvement in discharge, but I think as more and more people become comfortable with this oral treatment, we can certainly accelerate the discharge of patients coming in with GI bleeding, without major differences in the rate of transfusion.
So, stay tuned, as this is certainly a treatment option likely to be available in the short term, if and when it's ultimately approved in the United States.
This concludes part 1 of my overview of DDW 2023. However, there is a lot of cutting-edge, exciting additional data to share with you in part 2. Make sure you tune in to that as well!
I'm Dr David Johnson. Thanks 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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Cite this: David A. Johnson. 9 Highlights From Digestive Disease Week 2023: Part 1 - Medscape - May 25, 2023.