Current Gastroenterology Reports

The use of endoscopic ultrasound (EUS) in pancreatic disease is rapidly evolving as the field moves from a primarily diagnostic role to one of therapeutic intervention. Therapeutic EUS includes techniques such as the celiac block and transmural pseudocyst drainage. Newer techniques include EUS-guided fine-needle injection therapy in which a variety of agents are being investigated for the treatment of pancreatic cancer. Novel EUS-guided techniques are being devised to drain and alleviate pancreaticobiliary and gastroduodenal obstruction.

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

Inflammatory bowel diseases (IBD) are chronic and disabling conditions. Accumulating evidence indicates that we need to look beyond clinical symptoms as current therapeutic strategies have not modified the course of IBD. Therapeutic goals for IBD have evolved from a mere control of symptoms to mucosal healing (MH). Achieving deep remission (clinical remission, biomarker remission and MH) might be the only way to alter disease course in IBD patients. In Crohn’s disease (CD), deep remission has been recently defined as Crohn’s Disease Activity Index <150 and complete MH. In ulcerative colitis (UC), there is no proposed definition of deep remission. It could be defined as clinical and endoscopic remission in UC. These definitions remain to be validated in large prospective studies. In the near future, the concept of deep remission might include transmural healing in CD and histologic healing in UC. Advances in drug development have provided highly effective treatments for IBD, making deep remission a realistic goal. Whether IBD patients may benefit by experiencing a ‘deep’ remission beyond the control of clinical symptoms, which might ultimately impact on important outcomes such as the need for surgery and the development of disability, needs to be evaluated in future disease modification trials.

Impedance planimetry measures tissue wall distensibility as a function of pressure and cross-sectional area. Recent interest in this technique’s relevance to the gastrointestinal tract has been accelerated by the availability of the functional lumen imaging probe, a catheter-based system that dynamically quantitates these biomechanical properties. Herein, we review the device’s particular utility in the setting of esophageal pathology, including processes affecting the esophageal body as well as the upper and lower esophageal sphincters. An expanding suite of disease-specific indications for impedance planimetry includes achalasia, gastroesophageal reflux disease, and eosinophilic esophagitis. The technique has also demonstrated a role in the intraoperative guidance of therapy and in the definition of hitherto unrecognized patterns of esophageal dysmotility. Device-specific technology remains in active evolution, which, in conjunction with progressively larger datasets, sets the stage for broader clinical applicability in the near future.

Primary biliary cirrhosis (PBC) is one of the most common chronic cholestatic liver diseases affecting the adult population. The clinical presentation of PBC can be diverse, ranging from the presymptomatic individual to the patient with advanced liver disease. Initial evaluation to establish diagnosis and appropriate follow-up are very important in the life-long management of these patients. The primary medical treatment in PBC should focus on reducing the rate of disease progression. To this extent, treatment with ursodeoxycholic acid has been extensively evaluated and has been shown to improve liver biochemistries and survival in patients with PBC. Secondary medical management in PBC should address the treatment of complications of chronic cholestasis, hepatic cirrhosis, and liver failure. Liver transplantation remains the only established therapeutic approach in treatment of patients with end-stage PBC and the associated complications.

Esophageal diseases represent a wide variety of conditions affecting esophageal anatomy, physiology, and motility. Therapy focuses on pharmacotherapy and endoscopic or surgical management. Dietary therapy can be considered in management algorithms for specific esophageal diseases. This review focuses on outlining the literature related to dietary therapy in gastroesophageal reflux disease, eosinophilic esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma. Currently, data are strongest for dietary manipulation in eosinophilic esophagitis, specifically the six-food elimination diet. Dietary effects on gastroesophageal reflux disease are less clear, though newer research indicates that increased fiber with reduction in simple sugar intake may improve symptoms. In terms of Barrett’s esophagus and esophageal adenocarcinoma, antioxidant intake may affect carcinogenesis, though to an unknown degree. Outcomes data regarding dietary manipulation for the management of esophageal diseases is heterogeneous. Given the rising interest in non-pharmacological treatment options for these patients, continued research is warranted.