10 PRACTICE GEH CHANGES IN 2013:
Kurdistan GEH Board journal club:
1.Adalimumab Is More Effective in Crohn's
Adalimumab Is More Effective Than Azathioprine and
Mesalamine at Preventing Postoperative Recurrence of
Crohn's Disease: A Randomized Controlled Trial
Savarino E, Bodini G, Dulbecco P, et al
Am J Gastroenterol. 2013;108:1731-42
2. Diagnostic Delay in Crohn's Disease Is Associated With a Complicated Disease Course and
Increased Operation Rate
Schoepfer AM, Dehlavi MA, Fournier N, et al Am J Gastroenterol. 2013;108:1744-1753
Clearly, multiple factors can lead to a delay in diagnosis
of Crohn disease and the appropriate initiation of
therapies. The importance of avoiding a delay in
diagnosis to prevent complications is underscored by the
results of this study.
3. Vedolizumab as Induction and Maintenance Therapy for Ulcerative Colitis
Feagan BG, Rutgeerts P, Sands BE, et al
N Engl J Med. 2013;369:699-710
Vedolizumab is a new, effective option for induction and
maintenance therapy for patients with IBD. It is anticipated
that this will receive US Food and Drug Administration (FDA)
approval and be available in 2014. The gut-specific effects
and the lack of risk for potentially devastating PML will make
this an attractive therapeutic option for appropriate patients.
4.Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Surawicz CM, Brandt LJ, Binion DG, et al Am J Gastroenterol. 2013;108:478-498
This American College of Gastroenterology guideline provides a comprehensive review of current diagnosis and
treatment. Notable strong recommendations include:
Only patients with diarrhea (a stool that takes the shape of the container) should be tested for CDI.
Initial testing should be done with glutamate dehydrogenase or nucleic acid amplification test for CDI, without
repeat testing unless suspicion for infection is high and initial GDH testing is done.
Patients with resolution of diarrhea should not be tested to document cure of CDI.
Initial antibiotic treatment for patients with mild to moderate CDI infection should be metronidazole 500 mg 3 times
daily orally (provided there is no drug allergy contraindication).
Initial treatment for severe CDI or failure to respond to 5-7 days of metronidazole should be vancomycin 125 mg 4
times daily orally. If severe or complicated CDI, intravenous metronidazole 500 mg 3 times daily should be added.
In patients with severe ileus or complicated CDI, the best antibiotic plan is intravenous metronidazole 500 mg 3
times daily plus oral vancomycin 500 mg 4 times daily with vancomycin 500 mg in 500 cc fluid 4 times daily (given
rectally by retention enema).
Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Surawicz CM, Brandt LJ, Binion DG, et al Am J Gastroenterol. 2013;108:478-498
First recurrence of CDI can be treated with the initial regimen if it induced an appropriate clinical response.
Second recurrence of CDI should be treated with pulsed vancomycin.
If third recurrence or unresponsive severe CDI, FMT should be considered.
Current data suggest limited, if any, value of probiotics for CDI treatment or prevention of relapse.
High-level disinfection (sporicidal label claim or 5000 ppm chlorine-containing cleaning agents) of environmental
surfaces in bathrooms; if inpatient, disinfection of contact surfaces is recommended.
Contact precautions should be continued at least until resolution of the patient's diarrhea.
5.Peroral Endoscopic Myotomy for Treatment of Achalasia: From
Bench to Bedside (With Video)
Chiu PW, Wu JC, Teoh AY, et al Gastrointest Endosc. 2013;77:29-38
The cumulative 5-year remission rate of pneumatic dilation for achalasia has
been reported at 50%-70%, LHM has a failure rate of 10%-15%, and
gastroesophageal reflux disease is reported in 30%.
Data on POEM show impressive results without major complications. Clearly,
this procedure should be performed in centers of excellence with advanced
therapeutic experience in this technique. Because the myotomy for POEM is
targeted for 15-17 cm vs 6-8 cm with LHM, this may be more effective in the
Chicago classification type III patient with vigorous achalasia. The failure rate
for these patients to date has been the ineffective control of associated chest
pain, which may be much more adequately treated with this longer myotomy.
Although not yet ready for prime time as a preferred treatment, it is a
promising alternative (if only in selected patients).
6.Outcomes of Treatment for Achalasia Depend on Manometric Subtype
Rohof WO Gastroenterology. 2013;144:718-725
This study provides the best evidence to date that manometric subtype
of achalasia using Chicago classification is important in predicting
treatment success for different interventions. The relative lack of
treatment success with both PD and LHM in patients with type III
achalasia is probably attributable to the extended myotomy. The
extended myotomy achieved with peroral endoscopic myotomy (POEM)
may be more effective in these patients but needs to be studied.
Clearly, longer-term follow-up is needed, but these findings should help
clinicians avoid arbitrary selection of interventions for achalasia.
7.Sofosbuvir and Ledipasvir Fixed-Dose Combination With and Without Ribavirin in
Treatment-Naive and Previously Treated Patients With Genotype 1 Hepatitis C Virus Infection
(LONESTAR): An Open-Label, Randomised, Phase 2 Trial
Lawitz E, Poordad FF, Pang PS, et al Lancet. 2013 Nov 1.
The results of this small phase 2 study are impressive and
set the stage, in the very near future, for having nearly
universally effective, safe, and well-tolerated short-term
therapies for HCV infection. The treatment paradigm will
be shifting rapidly.
8.Muscle Cramps in Liver Disease
Mehta SS, Fallon MB Clin Gastroenterol Hepatol. 2013;11:1385-1391
Mehta and Fallon provide an excellent algorithm for the
approach and diagnostic workup of these patients, as well
as specific treatments for different clinical pathways. It's a
must-read for all who take care of cirrhotic patients.
9.Coagulation in Liver Disease: A Guide for the Clinician
Northup PG, Caldwell SH Clin Gastroenterol Hepatol. 2013;11:1064-1074
This excellent review makes specific recommendations to guide clinical management.
Bleeding varices. Transfuse platelets to a target level of ≥ 56,000/mm3. Aggressive transfusion is to be avoided because
higher volumes increase the intravascular pressures and risk for ongoing or recurrent variceal bleeding. Transfusions should
target a hemoglobin of 7 g/dL. The empiric use of fresh frozen plasma (FFP) should be avoided. A fibrinogen level should
be checked and maintained with a target of > 100 mg/dL (which is lower than the 150 mg/dL target recommended for
disseminated intravascular coagulation). This is best achieved by infusing cryoprecipitate that contains factor VIII,
fibrinogen, fibronectin, and factor XIII.
Before invasive procedures. Prophylactic platelets should be infused to a target of 50,000-60,000/mm3 (or >
100,000/mm3 for extremely high-risk procedures). Prophylactic FFP should be avoided. The use of prophylactic intranasal
desmopressin acetate (DDAVP) for dental extraction improves platelet function.
Peripheral venous thrombosis. For patients with acute or subacute (but not chronic) peripheral venous thrombosis or
cavernous transformation of the portal vein, therapeutic anticoagulation with low-molecular-weight heparin is
Bedridden patients. In all hospitalized or extended bed-restricted patients with cirrhosis, standard medical prophylaxis
against deep venous thrombosis or pulmonary embolus should be considered as it would be for patients who do not have
10.Impact of Endoscopic Surveillance on Mortality From Barrett's Esophagus-Associated
Corley DA Gastroenterology. 2013;145:312-319.e1
Several studies have documented the development of incurable malignancies
in some patients despite adherence to endoscopic surveillance programs.
A previous report estimated that the annual incidence of EAC would have to
be > 1.9% for surveillance of nondysplastic BE at 5-year intervals to be cost-
The most recent annual incidence estimates for high-grade dysplasia or EAC
are 0.1% to 0.2%. The time has come to question the standard practice of
routine endoscopic surveillance -- much less screening -- for patients with
nondysplastic BE. A risk-stratification paradigm improvement is clearly