This is a useful article in evaluation of elevated ferritin levels in adults. This approach is NOT applicable in young children but may have some use in adolescents. In young children, other considerations include HLH and macrophage activation. In newborns, elevation of ferritin (along with liver dysfunction) may be indicative of GALD (gestational alloimmune liver disease).
W. Palmer et al. AJG 2020; 115: 1353-55. How I Approach Patients With Elevated Serum Ferritin
Image from ACG Twitter Link
E Stahl et al. Gastroenterol 2020; DOI:https://doi.org/10.1053/j.gastro.2020.04.063 Link: Collagenous Colitis Is Associated With HLA Signature and Shares Genetic Risks With Other Immune-Mediated Diseases
“In this largest genetic study of CC to date with histologically confirmed diagnosis, we strongly implicated the HLA locus and proposed potential non-HLA mechanisms in disease pathogenesis. We also detected a shared genetic risk between CC, celiac disease, CD, and UC.”
This is a useful review -with helpful diagrams: Full text Ten Things Every Gastroenterologist Should Know About Antireflux Surgery (S Park et al. Clin Gastroenterol Hepatol 2020; 18: 1923-1929)
A couple excerpts:
Selecting Patients for Surgery: Current guidelines fall short in determining appropriate patients who would benefit most from surgery. For instance, the recommendation that a desire to discontinue PPI therapy is a suitable indication for antireflux surgery fails to recognize that 62% of patients end up back on PPIs within 9 years. Furthermore, indicating that those patients who failed medical management would benefit from surgery neglects the fact that the patients who respond best to antireflux surgery are those who have responded well to PPI therapy in the first place
Complications: Late postoperative complaints are more common and often are referred back to the referring gastroenterologist for diagnosis and management. These include late-onset dysphagia (3%–24%), recurrent heartburn (up to 62%), gas-bloat syndrome (up to 85%), and diarrhea (18%–33%). Anatomic failure of the fundoplication (Figure Below) can present a unique challenge to the clinician because the symptoms and patient presentation (postoperative dysphagia, regurgitation, and heartburn) can be clinically indistinct from the issues seen commonly after this surgery even in the best of circumstances. Therefore, the gastroenterologist should assess symptoms carefully in a stepwise approach with upper endoscopy, barium swallow, esophageal manometry, and/or ambulatory pH monitoring when appropriate and plan any interventions based on objective findings from focused testing.
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A Khan et al. Clin Gastroenterol Hepatol 2020; 18: 1913-1922. Nonceliac Gluten and Wheat Sensitivity
This useful review notes that ” there is a great deal of skepticism within the scientific community questioning the existence of NCGS as a distinct clinical disorder.”
Key points:
My take: GFD is often unnecessary and ineffective, even in those who have previously identified gluten as a potential food trigger. Fructans are more likely to induce gastrointestinal symptoms.
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Misty morning -Chattahoochee River, Island Ford
Briefly noted: F Humbel et al. Clin Gastroenterol Hepatol 2020; 18: 2019-2029. Association of Alterations in Intestinal Microbiota With Impaired Psychological Function in Patients With Inflammatory Bowel Diseases in Remission
In a prospective study with 171 adults with IBD in remission, the authors combined
Key findings:
My take: This study adds another dimension to the idea of bidirectionality between psychological well-being and course of inflammatory bowel disease. The microbiome may directly influence both psychological well-being and IBD activity.
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A Ofusu et al. J Clin Gastroenterol 2020. doi:10.1097/MCG.0000000000001379. The Efficacy and Safety of Hemospray for the Management of Gastrointestinal Bleeding
This systematic review and meta-analysis included 19 studies and 814 patients.
Key findings:
Related study: D Chahal et al. Dig Liver Dis 2020. DOI: https://doi.org/10.1016/j.dld.2020.01.009 Full text: High rate of re-bleeding after application of Hemospray for upper and lower gastrointestinal bleeds Findings (n=86): Immediate hemostasis rate was 88.4%, but there was a high rate of re-bleeding (33.7%). Most re-bleeds occurred within 7 days (86.2%)
My take: Hemospray is effective in achieving immediate hemostasis but there are high rates of rebleeding. It may be eliminated by GI tract in as few as 24 hours after use. Thus, for lesions at high risk for bleeding, hemospray is likely more of a last resort endoscopic option.
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Briefly noted: Microscopic colitis is much more frequent in adults than in children; nevertheless, it is often important to exclude. A recent study (B Virine et al. Clin Gastroenterol Hepatol 2020; 18: 2003-2009. Full text: Biopsies From Ascending and Descending Colon Are Sufficient for Diagnosis of Microscopic Colitis) indicates that biopsies can be limited to the ascending and descending colon.
Methods: This was a retrospective study using biopsies from 101 consecutive patients with MC (52 cases of collagenous colitis, 42 cases of lymphocytic colitis, 7 combined cases),
Key finding:
My take: The authors note that previous guidelines have suggested taking 8 biopsy specimens. Their findings support taking much fewer biopsies.
Related blog post/related article:
Several recent studies have examined biomarkers to predict Crohn’s disease. A recent prospective study (W Turpin et al. Gastroenterol 2020; DOI: https://doi.org/10.1053/j.gastro.2020.08.005. Increased Intestinal Permeability is Associated with Later Development of Crohn’s Disease) sought to determine whether increased intestinal permeability, as measured by urinary fractional excretion of lactulose to mannitol ratio (LMR), is associated with future development of CD.
Methods: 1420 asymptomatic first-degree relatives (6–35 years old) of patients with CD (collected from 2008 through 2015) had LMR measured and were then followed for a diagnosis of CD from 2008 to 2017, with a median follow up time of 7.8 years. We analyzed data from 50 participants who developed CD after a median of 2.7 years during the study period, along with 1370 individuals who remained asymptomatic until October 2017
Key findings:
My take: It remains unclear whether abnormal barrier function primarily precedes or follows CD development. The authors state that these findings support a model in which altered intestinal barrier function contributes to pathogenesis.
Almost all polyps that pediatric gastroenterologist manage are pedunculated polyps. Nevertheless, a recent study (H Pohl et al. Gastroenterol 2020; 159: 119-28. Full text: Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial) on cautery for non-pedunculated polyps was intriguing.
Methods: This multicenter, randomized, controlled, single-blinded study enrolled patients with a large colorectal polyp across 18 medical centers between April 2013 and October 2017. N=928. ERBE device.
Key finding:
Discussion:
My take: Both of these settings yielded similar results. For now, with pedunculated polyps, probably best to rely on the coagulation setting (Blue).
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A recent study (BN Limketkai et al. Clin Gastroenterol Hepatol 2020; 18: 1769-76. Levels of Vitamin D Are Low After Crohn’s Disease Is Established But Not Before) takes advantage of stored serum from U.S. military personnel.
Key finding: By examining 240 with Crohn’s disease (CD) along with 240 control patients, the authors show that vitamin D levels prior to CD diagnosis are not associated with the development of CD up to 8 years preceding the diagnosis.
Two other articles on predictive biomarkers for CD and an associated editorial:
My take: Stored tissue/blood eventually may help predict who will develop CD. Given a lack of current treatment options in those at risk, the importance of these predictive markers is unclear.
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