Reviews & Analysis

Controversy exists as to whether ursodeoxycholic acid improves survival in patients with primary biliary cirrhosis. This is mainly because the disease is uncommon and slowly progressive, which has meant that many clinical trials lack hard endpoints such as mortality. This Viewpoint article discusses the importance of the appropriate design of clinical trials in this field.

Pyoderma gangrenosum is a rare condition of unknown etiology that was described as an extraintestinal manifestation of inflammatory bowel disease in 1930. At present, there are few well-designed published studies that help determine the optimal therapeutic strategy to use for the management of pyoderma gangrenosum. This article reviews the published treatment strategies in current use and aims to guide effective management.

This Review discusses the use of C-reactive protein as an inflammatory marker in gastrointestinal diseases. Inflammation does not produce a good C-reactive protein response in all diseases, however, and until there are more data, the use of C-reactive protein and other biomarkers should be seen only as an aid to clinical observation and physical examination and not as a replacement.

Gastroesophageal reflux disease is associated with laryngopharyngeal reflux, but the cause and effect relationship between these two clinical entities is far from established. This Review considers studies of the pathogenesis of laryngopharyngeal reflux, the value of diagnostic testing either on or off therapy, and treatment options and duration, that have increased our our understanding of this field.

Although there are many similarities among pediatric and adult Crohn's disease patients, some unique features of the pediatric population influence the therapeutic approach adopted; pediatric Crohn's disease can have a significant impact on the patient's quality of life, growth, bone health, and development. This Review focuses on the latest advances in the treatment of complicated pediatric Crohn's disease, including the use of biologic therapies such as infliximab.

In this era of critical organ shortage, how should physicians and patients decide whether to accept or decline the offer of a specific deceased-donor liver? The author of this Viewpoint article considers recent data evaluating the impact of donor characteristics and severity of recipient disease on the decision-making process.

Acute fatty liver of pregnancy is a devastating disorder that can significantly affect the morbidity and mortality of both mother and fetus. This Viewpoint discusses the prevalence and implications of this disorder and examines the role of genetic screening in helping to identify patients at risk for this disease.

The demonstration that endoscopic band ligation has a greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for esophageal varices in patients with cirrhosis. This Review focuses on the role of endoscopic band ligation in the primary and secondary prevention of variceal bleeding as well as in the treatment of acute bleeding episodes.

Smoking can have a detrimental and beneficial effect on gastrointestinal disease—it has such a 'polarizing effect' in patients with Crohn's disease and ulcerative colitis. Studies in tobacco smokers have made it difficult to identify which agents are responsible for these effects, but work on the action of nicotine alone might help to explain some of the positive and negative links between smoking and gastrointestinal disease.

Fecal incontinence is a common symptom that is generally caused by conditions associated with anorectal sensorimotor dysfunction or diarrhea. Clinical assessment and diagnostic testing should be tailored to the patient's age and symptom severity. Management options, including modulation of disordered bowel habits, biofeedback and surgery, must be tailored to the clinical manifestations, and include treatment of underlying diseases.

Global differences in drug regulation might influence the availability of drugs for the treatment of irritable bowel syndrome in Europe. The author of this Viewpoint explores the role of drug regulation in the context of the difficulties faced in achieving therapeutic success in this challenging area.

The availability of new, less-invasive diagnostic tools means that pathological diagnoses are increasingly required to be made from smaller biopsy specimens. The author of this Review addresses the diagnostic terminology used in the reporting of nongynecologic aspiration cytology results, makes recommendations of how clinicians should interpret these results and discusses additional tests that are required for certain diagnostic categories.

This Review considers the optimal approach to assessing the common medical problem of noncardiac chest pain, for which the appropriate application of investigations is controversial. In addition to musculoskeletal and psychiatric investigations, gastroesophageal investigations include esophagogastroduodenoscopy, radiological assessment, ambulatory esophageal pH monitoring, esophageal manometry, provocative tests, and a proton pump inhibitor test.

The authors of this Review discuss the common causes and pathophysiology of gastroparesis—delayed gastric emptying in the absence of mechanical obstruction. The diagnostic approach to gastroparesis is also considered, along with evidence to support medical and surgical therapies, including currently available prokinetic drugs, novel medical therapies, and the promising technique of gastric electrical stimulation.

The authors consider the use of prognostic and diagnostic markers as an addition to initial clinical assessment for the identification of patients who are likely to develop severe acute pancreatitis. They also discuss antibiotic prophylaxis, fluid resuscitation and rehydration, enteral versus parenteral nutrition, pain management and the timing of surgical or interventional necrosectomy.

Idiopathic abdominal pain and chest pain of presumed digestive tract origin accounts for a considerable number of hospital admissions each year. The underlying causes of this pain remain unknown. In this Viewpoint the authors propose a novel mechanism for this undefined pain suggesting that ischemic events could be responsible.

Endoscopy in pregnant patients presents unique concerns regarding its safety and benefit to the fetus. This Viewpoint presents an overview of the merits and potential dangers associated with endoscopy in pregnancy and discusses the impact of the latest guidelines for endoscopy in this setting.

This article reviews an area of translational research that is currently receiving a great deal of attention—the role of the intestinal epithelial barrier in the pathogenesis of gastrointestinal disease. In particular, the authors consider the contribution of the intestinal epithelial barrier, with its intercellular tight junctions, to the development of autoimmunity.