What's new in gastroenterology and hepatology

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.

COLORECTAL CANCER

Colonoscopy or fecal immunochemical testing for colorectal cancer screening (April 2025)

Screening for colorectal cancer (CRC) reduces CRC deaths, but comparative data between available screening tests are limited. In a population-based, randomized trial of over 57,000 adults at average risk for CRC, the risk of CRC mortality was similar among those screened by fecal immunochemical test (FIT) versus colonoscopy (0.24 versus 0.22 percent at 10 years) [1]. Participation in any form of CRC screening was higher in the group randomized to FIT (40 versus 32 percent). For adults at average risk of CRC, colonoscopy every 10 years or FIT every one to three years are our preferred screening strategies. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Test selection'.)

ENDOSCOPY

Trends in the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis (April 2025)

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with relatively high rates of adverse events including post-ERCP pancreatitis. Whether the incidence of post-ERCP pancreatitis has changed over time is uncertain. In a systematic review including over two million patients who underwent ERCP from 2000 to 2024, rates of post-ERCP pancreatitis in all patients and in first-time patients were 4.6 and 6.5 percent, respectively [2]. These rates remained stable during the study period despite technical improvements and preventive strategies. The lack of decrease over time may be related to non-modifiable factors, such as the proximity of the pancreatic orifice to the biliary orifice. Future studies may inform additional strategies for lowering the risk of post-ERCP pancreatitis. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis", section on 'Definition and epidemiology'.)

Quality indicators for upper gastrointestinal endoscopy (March 2025)

The American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy have endorsed quality indicators for upper gastrointestinal endoscopy [3,4]. The goals of applying quality indicators are to perform high-quality upper endoscopy and improve patient outcomes. The quality measures include confirming an appropriate procedure indication, careful inspection of the gastrointestinal mucosa, and documenting inspection of specific anatomic locations with endoscopic images. Postprocedure care includes communicating findings, including follow-up recommendations with patients and referring clinicians. Our approach is consistent with this guidance. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Quality indicators'.)

Updated guidance on performing colonoscopy (December 2024)

Colonoscopy is a common and safe procedure for colorectal cancer screening and for evaluating gastrointestinal symptoms. The American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Quality Task Force has published a practice update on performing high-quality colonoscopy [5]. The quality indicators include confirming an appropriate procedure indication, achieving adequate visualization following bowel preparation, and using a high-definition white-light endoscopy system. The guidance also endorses targets for cecal intubation rates, adenoma detection rates, and mean withdrawal times. Our approach is consistent with this guidance. (See "Overview of colonoscopy in adults", section on 'Quality indicators'.)

Endoscopic ultrasound-guided technique for difficult biliary access (November 2024)

For patients with difficult biliary access, endoscopic ultrasound (EUS)-guided technique for establishing biliary access has been used as an alternative to endoscopic retrograde cholangiopancreatography (ERCP), but outcome data have been limited. In a randomized trial comparing EUS-guided rendezvous technique with ERCP-guided precut sphincterotomy in 100 patients with difficult biliary access, both groups had similar rates of technical success, overall adverse events, and post-procedure pancreatitis [6]. These data are promising, but larger randomized trials are needed to establish the possible benefits of EUS-guided technique for achieving biliary access. In addition, its use may be limited by the availability of endoscopic expertise. (See "Therapeutic endoscopic ultrasound", section on 'Accessing the biliary duct'.)

ESOPHAGEAL AND GASTRIC DISEASE

Updated guidelines on eosinophilic esophagitis (January 2025)

The American College of Gastroenterology has published updated guidelines on diagnosis and management of eosinophilic esophagitis (EoE) [7]. The guidelines establish the diagnosis of EoE based esophageal symptoms, ≥15 eosinophils per high-power field on biopsy, and excluding other causes of eosinophilia. Endoscopic evaluation includes obtaining multiple biopsies from two esophageal levels (ie, proximal/mid and distal esophagus). For initial treatment, the guidelines endorse a limited empiric food elimination diet or pharmacologic (proton pump inhibitor or topical glucocorticoid) therapy. Our approach is generally consistent with these guidelines. (See "Treatment of eosinophilic esophagitis (EoE)", section on 'Introduction'.)

Gastrointestinal manifestations of scleroderma (January 2025)

Although systemic sclerosis (SSc) is commonly associated with cutaneous and cardiopulmonary manifestations, gastrointestinal (GI) manifestations of SSc are equally important. Among 907 patients from the Australian Scleroderma Cohort Study, 789 patients (87 percent) reported GI symptoms, including moderate to severe levels of reflux, abdominal bloating, diarrhea, and constipation [8]. Compared with patients with mild GI symptoms, patients with more severe symptoms had worse quality of life, physical function, energy, and mental health. Severe GI manifestations were also linked to higher unemployment rates but not increased mortality. These findings underscore the need for proactive management of GI symptoms in patients with SSc. (See "Gastrointestinal manifestations of systemic sclerosis (scleroderma)", section on 'Epidemiology'.)

Treatment of Helicobacter pylori infection in adults (November 2024)

Over half of individuals in the United States with Helicobacter pylori infection continue to receive clarithromycin-based treatment regimens, despite rising rates of H. pylori resistance to clarithromycin and declining rates of treatment success with these regimens [9]. Recent guidelines from the American College of Gastroenterology reinforce the importance of using non-clarithromycin-based regimens for the initial and salvage treatment of H. pylori infection [10]. Preferred regimens for the empiric management of H. pylori infection in treatment-naïve adults include optimized bismuth quadruple therapy, rifabutin triple therapy, and vonoprazan-amoxicillin dual therapy. The guidelines also emphasize testing to confirm H. pylori eradication after treatment and discuss the role of antimicrobial susceptibility testing in H. pylori management. Based on available evidence, we suggest optimized bismuth quadruple therapy as the preferred regimen for H. pylori infection in treatment-naïve adults. (See "Treatment of Helicobacter pylori infection in adults".)

HEPATOLOGY

Pharmacologic strategy for preventing complications of cirrhosis (April 2025)

Although complications of cirrhosis (eg, spontaneous bacterial peritonitis) can be serious, general strategies to prevent such complications are limited. In a randomized trial comparing simvastatin plus rifaximin therapy with placebo in 237 patients with decompensated cirrhosis, pharmacotherapy did not significantly lower rates of cirrhosis-related complications (43 versus 46 percent), liver transplantation or death (19 versus 24 percent), or acute-on-chronic liver failure (18 versus 14 percent) [11]. While statins reduce cardiovascular risk and rifaximin prevents recurrent hepatic encephalopathy, data from this trial do not support the use of a statin plus rifaximin as a general preventive strategy. (See "Cirrhosis in adults: Overview of complications, general management, and prognosis", section on 'Slowing or reversing disease progression'.)

Safety of obeticholic acid for treating primary biliary cholangitis (February 2025)

The US Food and Drug Administration has updated safety information on obeticholic acid for treating primary biliary cholangitis (PBC). Since 2021, use of obeticholic acid has been limited to patients who do not have decompensated cirrhosis [12]. The recent safety update recommends monitoring patients receiving obeticholic acid with liver biochemistries because cases of liver injury have been reported in patients without cirrhosis. When we use obeticholic acid as second-line therapy for PBC in patients without cirrhosis, we monitor for symptoms of liver decompensation (eg, jaundice) and measure liver biochemistries every three months. (See "Overview of the management of primary biliary cholangitis", section on 'Subsequent therapy'.)

HepB-CpG for hepatitis B vaccine nonresponders with HIV (January 2025)

Persons with HIV are less likely to develop a protective serologic response to conventional hepatitis B vaccines (eg, Engerix-B or Recombivax HB) compared with those without HIV; nonresponders to the initial series should be reimmunized. In a randomized trial of patients on antiretroviral therapy who did not respond to HBV vaccination, revaccination with two or three doses of HepB-CpG (Heplisav) led to greater seroprotection than three doses of the conventional hepatitis B vaccine (93 and 99 versus 81 percent, respectively) [13]. Seroprotective responses were also achieved more rapidly with HepB-CpG. Thus, for nonresponders to an initial hepatitis B vaccine series, we recommend repeat vaccination with HepB-CpG rather than conventional hepatitis B vaccines. However, if HepB-CpG is not available, the vaccine series should be repeated using a double dose of a conventional hepatitis B vaccine. (See "Prevention of hepatitis B virus infection in adults with HIV", section on 'Initial approach for most patients'.)

PANCREATIC AND BILIARY DISEASE

Endoscopic versus surgical treatment of painful chronic pancreatitis with a dilated duct (March 2025)

Painful, chronic pancreatitis characterized by a dilated duct can be treated endoscopically or surgically. In a randomized trial of 88 such patients, early surgery (Puestow, Frey, or Beger procedure) resulted in superior pain relief and patient satisfaction compared with endoscopic treatment at both 18 months and 8 years [14]. Patients who progressed from endoscopy to surgery had worse outcomes than those undergoing early surgery. Given these findings, surgeons and gastroenterologists should work collaboratively in such cases, rather than exhausting nonoperative therapies before considering surgery. (See "Surgery for chronic pancreatitis", section on 'Endoscopy versus surgery'.)

SMALL BOWEL AND COLONIC DISEASE

Large vessel vasculitis in patients with inflammatory bowel disease (April 2025)

The overlap between inflammatory bowel disease (IBD) and large vessel vasculitis (LVV) has been poorly characterized. In this multicenter case-control study of 196 patients, Crohn disease was more common among patients with Takayasu arteritis (TAK-IBD, 67 percent), while ulcerative colitis predominated in those with giant cell arteritis (GCA-IBD, 58 percent) [15]. LVV most commonly developed after the patient had already been diagnosed with IBD (TAK-IBD: 56 percent; GCA-IBD: 75 percent). LVV should be considered in patients with IBD who develop evidence of systemic inflammation or vascular compromise (eg, aortic regurgitation, asymmetric pulses, or stroke). (See "Overview of gastrointestinal manifestations of vasculitis", section on 'Co-occurrence with inflammatory bowel disease'.)

Vedolizumab for preventing postoperative recurrent Crohn disease (March 2025)

Anti-tumor necrosis factor (TNF) therapy is effective for preventing recurrent Crohn disease (CD) following ileocolic resection, but data on other strategies are limited. In a trial comparing vedolizumab with placebo in 84 patients with ileocolic resection for CD and at least one risk factor for recurrence (eg, fistulizing disease), vedolizumab resulted in lower rates of both severe endoscopic recurrence (23 versus 62 percent) and any endoscopic recurrence (58 versus 97 percent) after 26 weeks [16]. Rates of serious adverse events were numerically similar in both groups. These data support our approach of using vedolizumab for preventing CD recurrence in patients who do not tolerate or respond to anti-TNF therapy. (See "Management of Crohn disease after surgical resection", section on 'Other biologics'.)

Mirikizumab for moderate to severe Crohn disease (January 2025)

Mirikizumab (a monoclonal antibody that targets the p19 subunit of interleukin-23) is now approved in the United States for treating moderate to severe Crohn disease [17]. Approval was based on a randomized trial comparing mirikizumab with placebo in over 1000 patients with Crohn disease refractory to prior biologic or immunosuppressive therapy. Mirikizumab resulted in higher rates of achieving a composite endpoint defined as symptomatic improvement at week 12 in addition to clinical remission at week 52 (45 versus 20 percent) [18]. Rates of serious adverse events were lower in the mirikizumab group (10 versus 17 percent). We anticipate using mirikizumab as first- or second-line therapy in adults with moderate to severe Crohn disease. (See "Medical management of moderate to severe Crohn disease in adults", section on 'Anti-interleukin (IL) antibody therapy'.)

Cutaneous and noncutaneous manifestations of IgA vasculitis (January 2025)

The relationship between the cutaneous and noncutaneous manifestations of immunoglobulin A (IgA) vasculitis is not well understood. In a retrospective study of 489 patients with IgA vasculitis, 7 percent of patients had a persistent rash (ie, lasting for longer than one month) and 29 percent had a rash that affected the trunk, arms, or face [19]. Patients with a persistent rash were more likely to develop glomerulonephritis, while patients with lesions above the level of the buttocks were more likely to develop gastrointestinal or genital tract involvement. These results imply that the cutaneous manifestations of IgA vasculitis may be helpful to predict outcomes in patients with this diagnosis. (See "IgA vasculitis (Henoch-Schönlein purpura): Management", section on 'Prognosis'.)

Axial spondyloarthritis in patients with psoriasis, uveitis, or inflammatory bowel disease (January 2025)

Axial spondylarthritis (axSpA) often goes unrecognized in patients with chronic back pain who also have psoriasis, acute anterior uveitis, or inflammatory bowel disease. In two prospective cohort studies of over 350 such patients with undiagnosed chronic back pain, axSpA was present in approximately 25 percent of patients with psoriasis or inflammatory bowel disease and 60 percent of patients with acute anterior uveitis [20]. However, musculoskeletal symptoms, response to nonsteroidal anti-inflammatory drugs, and family history (which are commonly used to identify axSpA) did not help discriminate axSpA from other causes of chronic back pain. This study implies that axSpA is common in patients with psoriasis, acute anterior uveitis, or inflammatory bowel disease, but may be challenging for a nonexpert to distinguish from other causes of chronic back pain. (See "Diagnosis and differential diagnosis of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'History'.)

Guselkumab for moderate to severe ulcerative colitis (December 2024)

Therapeutic options for moderate to severe ulcerative colitis (UC) are expanding. In an induction trial comparing guselkumab (an anti-interleukin-23 antibody) with placebo in 701 patients with UC, guselkumab (200 mg at weeks 0, 4, and 8) resulted in higher rates of clinical remission after 12 weeks (23 versus 8 percent) [21]. In the maintenance trial including 568 patients, guselkumab (200 mg every four weeks or 100 mg every eight weeks) resulted in higher rates of clinical remission after 44 weeks (50 and 45 percent, respectively, versus 19 percent). The US Food and Drug Administration has approved guselkumab for adults with moderate to severe UC, and we may use it as first- or second-line therapy [22]. (See "Management of moderate to severe ulcerative colitis in adults", section on 'Anti-interleukin (IL) antibody-based therapy'.)