What's New in Gastroenterology and Hepatology - UpToDate PDF

10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate Official reprint from UpToDate® www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved. What's new in gastroenterology and hepatology AUTHORS: Shilpa Grover, MD, MPH, AGAF, Kristen M Robson, MD,...

10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate Official reprint from UpToDate® www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved. What's new in gastroenterology and hepatology AUTHORS: Shilpa Grover, MD, MPH, AGAF, Kristen M Robson, MD, MBA, FACG, Anne C Travis, MD, MSc, FACG, AGAF All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Sep 2023. This topic last updated: Oct 05, 2023. 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 Risk of post-sphincterotomy bleeding with antithrombotic therapy (June 2023) The magnitude of post-sphincterotomy bleeding risk is uncertain in patients on antithrombotic therapy undergoing endoscopic retrograde cholangiopancreatography (ERCP). In a large study of such patients, the adjusted odds for post-sphincterotomy bleeding was 2.2 for antiplatelet agents (excluding aspirin) and 3.6 for anticoagulants [1]. Patients who resumed anticoagulants within 24 hours after ERCP had higher bleeding rates than those not resuming anticoagulants within 24 hours (14 versus 5 percent). While these data inform periprocedural management of antithrombotic agents, other factors to consider include the patient's underlying risk for thrombosis and specific features of the antithrombotic agent. We also consult with the clinician managing antithrombotic therapy to determine if it can be safely interrupted. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding", section on 'Factors that guide decisionmaking'.) New guidelines on management of biliary strictures (April 2023) The American College of Gastroenterology has published new guidelines on managing biliary strictures [2]. For patients with unresectable extrahepatic biliary strictures, they recommend placing self-expandable metal stents (SEMS) and individualizing the decision for use of uncovered versus covered SEMS. For patients with malignant hilar strictures who require hepatobiliary drainage, they emphasize preprocedure cross-sectional imaging with a https://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 1/6 10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate goal of draining >50 percent of the liver. Our approach to stenting malignant biliary strictures is generally consistent with these guidelines. (See "Endoscopic stenting for malignant biliary obstruction", section on 'Introduction'.) ESOPHAGEAL AND GASTRIC DISEASE Rifabutin triple therapy for Helicobacter pylori (October 2023) Management of patients who have failed multiple antibiotic regimens for Helicobacter pylori is an increasingly frequent challenge. In a randomized trial in which 364 subjects with H. pylori who failed at least two prior treatments were assigned to rifabutin triple therapy or bismuth quadruple therapy for 14 days, H. pylori eradication rates were similar in both groups [3]. However, the rifabutin group had a higher compliance rate and a lower rate of adverse effects. This trial supports current guidelines and our recommendation to use rifabutin triple therapy as a salvage treatment for H. pylori. (See "Treatment regimens for Helicobacter pylori in adults", section on 'Salvage regimens'.) HEPATOLOGY Sugar-sweetened beverages and risk of liver cancer (September 2023) There is interest in evaluating the impact of sugar-sweetened beverages (such as regular sodas and fruit drinks) on the risk of developing liver cancer. In an observational study of almost 99,000 postmenopausal females, higher intake of sugar-sweetened beverages (one or more servings per day) was associated with an increased risk of developing liver cancer (hazard ratio 1.85) relative to less frequent consumption (three or less servings per month) [4]. These findings support the importance of limiting or avoiding sugar-sweetened beverages as part of a healthy diet for adults and for cancer prevention. (See "Epidemiology and risk factors for hepatocellular carcinoma", section on 'Dietary factors'.) Gene therapy for Crigler-Najjar syndrome (September 2023) Gene therapy for Crigler-Najjar syndrome is directed at restoring sufficient UGT1A1 activity to maintain serum bilirubin in a safe range. In an open-label study of five young adults with Crigler-Najjar syndrome and severe hyperbilirubinemia managed with daily phototherapy (two with adjunctive phenobarbital), gene therapy was administered at one of two doses [5]. For the three participants in the high-dose cohort, the mean total bilirubin concentrations declined from 20.5 mg/dL (351 micromol/L) with phototherapy to 8.7 mg/dL (149 micromol/L) without phototherapy by 80 weeks. There were transient increases in liver enzymes, managed with immunosuppressive therapy, and no serious adverse events. Further studies are needed to determine the indications, optimal protocol, and long-term https://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 2/6 10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate efficacy and safety of gene therapy. (See "Crigler-Najjar syndrome", section on 'Investigational therapies'.) Updated guidance on management of nonalcohol-associated fatty liver disease (June 2023) The American Association for the Study of Liver Diseases (AASLD) has published updated guidance on the management of nonalcohol-associated fatty liver disease (NAFLD) [6]. The guidance endorses dietary modification and physical activity for patients who are overweight or obese, with consideration for subsequent interventions (eg, bariatric surgery, pharmacologic therapy) for those who do not achieve weight loss goals with lifestyle modification. AASLD emphasizes optimizing glucose control for patients with diabetes, lipidlowering therapy for patients with hyperlipidemia, and abstinence from alcohol for patients with clinically significant hepatic fibrosis. Our approach is generally consistent with this guidance. (See "Management of nonalcoholic fatty liver disease in adults", section on 'Introduction'.) Bariatric surgery for patients with nonalcoholic fatty liver disease and obesity (June 2023) In a trial of 288 patients with biopsy-proven nonalcoholic steatohepatitis (NASH), gastric bypass or sleeve gastrectomy resulted in higher rates of resolution without worsening fibrosis after one year than lifestyle modification (56, 57, and 16 percent, respectively) [7]. By per-protocol analysis, gastric bypass or sleeve gastrectomy also resulted in higher rates of improvement in fibrosis without worsening NASH (46, 47, and 28 percent, respectively). A large database study comparing bariatric surgery with no surgical intervention in patients with nonalcoholic fatty liver disease (NAFLD) found surgery was associated with lower risks of new-onset heart failure, cardiovascular events, cerebrovascular events, coronary artery interventions, and all-cause mortality at up to seven years follow-up [8]. These data support use of bariatric surgery for patients with NAFLD and obesity who do not achieve weight loss through lifestyle modification. (See "Outcomes of bariatric surgery", section on 'Nonalcoholic fatty liver disease'.) FDA warning on selective androgen receptor modulators in some supplements (May 2023) Selective androgen receptor modulators (SARMs) are found in some supplements labeled as natural testosterone replacements or used for muscle-building. SARMs cannot be legally marketed as dietary supplements in the United States. The US Food and Drug Administration recently issued a consumer warning because of increasing reports of SARM-related adverse events, such as liver injury (predominantly cholestatic) and hallucinations [9]. This warning reinforces our approach to advise patients to avoid pre-workout and musclehttps://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 3/6 10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate building supplements and to ask patients with unexplained liver injury about supplement use. (See "High-risk dietary supplements: Patient evaluation and counseling", section on 'Anabolic (muscle-building) supplements (higher risk)' and "Hepatotoxicity due to herbal medications and dietary supplements", section on 'Androgenic anabolic steroids'.) Aspirin and risk of acute rejection after liver transplantation (April 2023) Whether aspirin use mitigates the risk of acute T-cell mediated rejection after liver transplantation is uncertain. In a cohort study comparing daily, low-dose aspirin use with no aspirin in over 2000 liver transplant recipients, aspirin use was associated with higher rates of rejection-free survival after one, three, and five years (89, 87, and 84 percent versus 82, 81, and 80 percent, respectively) [10]. Aspirin was not associated with increased bleeding complications. Although these data are promising, additional evidence is needed to confirm efficacy and safety before aspirin prophylaxis can be routinely recommended in liver transplant recipients. (See "Liver transplantation in adults: Clinical manifestations and diagnosis of acute T-cell mediated (cellular) rejection of the liver allograft", section on 'Protective factors'.) PANCREATIC AND BILIARY DISEASE New guidelines on managing post-liver transplant biliary strictures (July 2023) The American Society for Gastrointestinal Endoscopy has new guidance for managing biliary strictures in liver transplantation recipients [11]. They recommend endoscopic retrograde cholangiopancreatography-guided intervention as initial therapy rather than percutaneous transhepatic biliary drainage; placing a fully covered, self-expandable metal stent for patients with extrahepatic, anastomotic biliary strictures; and administering antibiotic prophylaxis for patients at risk for incomplete biliary drainage. Our approach to managing post-liver transplant biliary strictures is generally consistent with these guidelines. (See "Liver transplantation in adults: Endoscopic management of biliary adverse events", section on 'Goals'.) SMALL BOWEL AND COLONIC DISEASE Mirikizumab for moderate to severe ulcerative colitis (August 2023) Mirikizumab (a monoclonal antibody that targets the p19 subunit of interleukin-23) is under investigation for treating adults with moderate-to-severe ulcerative colitis. In the induction phase of a trial including nearly 1300 such patients, mirikizumab (300 mg intravenously every four weeks) resulted in higher rates of clinical remission compared with placebo after 12 weeks (24 versus 13 percent) [12]. In the maintenance phase trial of the 544 patients who https://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 4/6 10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate responded to induction therapy, mirikizumab (200 mg subcutaneously every four weeks) resulted in higher rates of clinical remission after 40 weeks (50 versus 25 percent). These data show promise, but regulatory approval is needed before incorporating mirikizumab into clinical practice in the United States. (See "Management of moderate to severe ulcerative colitis in adults", section on 'Investigational therapies'.) Guidelines on chronic idiopathic constipation (July 2023) The American College of Gastroenterology and American Gastroenterological Association updated guidelines on the management of chronic idiopathic constipation (CIC) include use of fiber as first-line therapy and the use of stimulant laxatives for short-term use and rescue therapy [13]. Options for CIC refractory to over-the-counter agents include lubiprostone, linaclotide, plecanatide, and prucalopride. Our recommendations are largely consistent with these guidelines. (See "Management of chronic constipation in adults", section on 'Bulkforming laxatives'.) Etrasimod for treating moderate to severe ulcerative colitis (July 2023) Etrasimod, an oral sphingosine 1-phosphate (S1P) receptor modulator, is under investigation for treating adults with moderate to severe ulcerative colitis. In the induction phase of a trial including over 780 such patients who had inadequate or loss of response to prior therapy, etrasimod 2 mg daily resulted in higher rates of clinical remission than placebo after 12 weeks (25 to 27 percent versus 7 to 15 percent) [14]. In the maintenance phase of this trial, etrasimod resulted in higher rates of sustained clinical remission after 52 weeks (32 versus 7 percent). These data show promise but further studies and regulatory approval are needed before incorporating etrasimod into clinical practice. (See "Management of moderate to severe ulcerative colitis in adults", section on 'Investigational therapies'.) Upadacitinib for moderate to severe Crohn disease (June 2023) Therapeutic options for patients with moderate to severe Crohn disease (CD) are expanding. In two induction trials comparing 45 mg upadacitinib (an oral small molecule) with placebo in adults with moderate to severe CD, upadacitinib resulted in higher clinical remission rates at 12 weeks (39 to 49 percent in the treatment groups versus 21 to 29 percent in the placebo groups) [15]. In the maintenance trial comparing upadacitinib 15 or 30 mg with placebo, upadacitinib resulted in higher rates of sustained remission after 52 weeks (37 and 48 percent, respectively, versus 15 percent). Based on these data, the US Food and Drug Administration approved upadacitinib for patients with moderate to severe CD who have not responded to antitumor necrosis factor therapy [16]. We anticipate using upadacitinib as an option for second-line therapy for CD. (See "Medical management of moderate to severe Crohn disease in adults", section on 'Other agents'.) https://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 5/6 10/15/23, 1:42 PM What's new in gastroenterology and hepatology - UpToDate Vedolizumab for treating chronic pouchitis (April 2023) Pouchitis is common in patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis. Some patients develop chronic pouchitis that does not improve with standard therapies (eg, antibiotics, mesalamine), but data on additional treatment options are limited. In a trial comparing the biologic agent vedolizumab with placebo in 102 patients with chronic pouchitis, vedolizumab resulted in higher rates of combined clinical and endoscopic remission after 14 and 34 weeks (14 weeks: 31 versus 10 percent; 34 weeks: 35 versus 18 percent) [17]. These data support our approach of using vedolizumab for chronic pouchitis that does not respond to other therapies. (See "Management of acute and chronic pouchitis", section on 'Other options'.) Use of UpToDate is subject to the Terms of Use. Topic 8351 Version 12249.0  https://www.uptodate.com/contents/whats-new-in-gastroenterology-and-hepatology/print?search=gastroenterology&source=search_result&select… 6/6