From landmark trials leading to new drug approvals to updated clinical practice guidelines, 2024 brought an abundance of pivotal advancements in gastroenterology. Selecting the top 10 must-read articles was no easy task, but I’ve identified those that I believe will most significantly enhance your clinical decision-making across a range of conditions.
Covering topics such as metabolic dysfunction–associated steatotic liver disease (MASLD), inflammatory bowel disease (IBD), and the management of pancreatic cysts, these expertly curated summaries provide essential insights to keep you informed and at the forefront of our dynamic field.
Resmetirom for NASH With Liver Fibrosis
This landmark phase 3 trial highlighted the effectiveness of resmetirom, an oral thyroid hormone receptor beta-selective agonist, which was subsequently approved as the first drug for the treatment of adults with noncirrhotic nonalcoholic steatohepatitis (NASH, now renamed metabolic dysfunction–associated steatohepatitis [MASH]).
Over the course of 52 weeks of treatment, patients receiving resmetirom at 80 mg and 100 mg experienced significant improvements in the study’s two primary endpoints: resolution of NASH (including a reduction in nonalcoholic fatty liver disease activity score by ≥ 2 points) and reduction of fibrotic stage.
Resolution of NASH was achieved in 25.9% of patients in the 80-mg group and in 29.9% of those in 100-mg group, vs 9.7% in the placebo group. Reduction of fibrotic stage was achieved in 24.2% of the 80-mg group and 25.9% of the 100-mg group, vs 14.2% in the placebo group.
Although nausea and diarrhea were more common in both of the active treatment groups, there were no significant adverse events in either the active arm or the control arm.
In the United States, approximately 1.5 million patients are currently estimated to have been diagnosed with NASH, roughly one third of whom have associated moderate to advanced liver fibrosis.
Although resmetirom is not indicated for decompensated liver disease, it holds great promise for many of our patients.
EASL/EASD/EASO Guidelines: Management of MASLD
This joint guideline from the European Association for the Study of the Liver (EASL), the European Association for the Study of Diabetes (EASD), and the European Association for the Study of Obesity (EASO) provides the latest information related to the definition, prevention, screening, diagnosis, and treatment strategies for MASLD, including advice about using resmetirom in those with significant liver fibrosis.
The authors provide broad evidence-based recommendations for all aspects of care, including lifestyle interventions (diet, exercise, and discouraging alcohol consumption), imaging, fibrosis assessment, and pharmacologic treatments for diabetes and obesity, including when to consider surgical bariatric procedures for the latter condition.
This is a great read for clinicians involved in the management of an extremely common disease.
AGA Guideline: Managing Pouchitis and Inflammatory Pouch Disorders
This year, the American Gastroenterological Association (AGA) fulfilled a long-standing need by developing the first society-sponsored guideline on pouchitis and its related inflammatory conditions. It offers an evidence-based approach for standardizing definitions and clinical issues for management and surveillance.
The expert panel of authors put forward nine recommendations on topics ranging from probiotics to antibiotics and immunosuppressants. When they encountered a relative lack of clear evidence, they instead offered their real-world experience to generate recommendations.
For clinicians who do not regularly encounter patients with pouchitis, this document serves as a tremendous one-stop resource.
AGA Guideline: Pharmacologic Management of Ulcerative Colitis
Recent years have seen explosive growth in pharmacologic research around IBD. Although this has resulted in several novel IBD medications, it’s also created a conundrum for both clinicians and patients: Which of these treatments should be favored based on the best available evidence?
The AGA assembled an expert panel to answer this question. Their efforts produced comprehensive but patient-centered evidence-based recommendations for the treatment of moderate to severe ulcerative colitis.
It’s a must-read for clinicians looking to identify the treatments best positioned to produce optimal outcomes among their patients with ulcerative colitis.
ACG Guideline: Focal Liver Lesions
The increasing use of abdominal imaging has led to a corresponding rise in the detection of focal liver lesions, especially as incidental findings in asymptomatic patients.
Focal lesion etiologies range from benign cystic or solid, to vascular or neoplastic disease. Accordingly, clinicians encountering these lesions must carefully weigh the risk/benefits for diagnosis, clinical management, and follow-up.
This incredibly detailed and practical evidence-based guideline from the American College of Gastroenterology (ACG) provides recommendations covering the broad array of focal hepatic lesions. It will undoubtedly serve as an invaluable resource for clinicians for years to come.
Diagnosis and Management of Pancreatic Cysts
As with focal liver lesions, increased abdominal imaging has also led to a spike in the number of pancreatic cystic lesions being detected. Yet the management of these lesions has proven extremely divisive.
Notably, it is estimated that the surveillance of pancreatic cystic lesions comes at a cost of approximately $3.6 million per cancer detected, without any related decrease in cyst-related mortality.
In this review, expert authors provide the latest data on the incidence; diagnosis; risks for malignant transformation; management interventions; and, where appropriate, surveillance of pancreatic cysts. The authors don’t shy away from discussing the many controversies inherent to this issue.
Although the optimal approach to managing these lesions will undoubtedly continue to evolve, this report provides a fantastic snapshot of the current evidence.
Managing Colorectal Neoplasia in Patients With IBD
Patients with IBD are at an increased risk of developing colorectal dysplasia and subsequent cancer, making colonoscopy surveillance a critical element of standard of care. Advances in endoscopic visualization techniques, including chromoendoscopy, have significantly improved the detection and identification of neoplastic lesions, enabling more frequent and accurate diagnoses.
Managing dysplasia in IBD requires a multidisciplinary approach that brings together the varied expertise of gastroenterologists, pathologists, and surgeons. An example of this is the relatively new approach to dysplasia-associated lesions or masses. Not too long ago, the standard treatment called for surgical resection of the colon. However, it is now increasingly apparent that an endoscopic approach is not only less invasive but also preferred when performed by skilled specialists.
The authors cover an array of clinical management issues, ranging from visible and invisible dysplasia, as well as the incremental risks associated with primary sclerosing cholangitis.
These and other insights are discussed in this essential overview for clinicians involved in the care of patients with IBD.
Quality Indicators for Colonoscopy
Colonoscopy is the best test we have for preventing colorectal cancers, via early recognition and resection of precancerous lesions. It also accounts for most endoscopies performed by gastroenterologists in their practice. However, there is substantial room for improvement, as evidence shows that the relative benefits of colonoscopy are highly dependent on the quality of both the exam and the examiner.
The ACG and the American Society of Gastrointestinal Endoscopy collaborated to provide guidance on quality colonoscopy performance beginning in 2006, and then again in 2015. This year, these societies surveyed the latest data and updated their guidelines once again.
This document sets new standards for the preparation, technical performance, and repeat recommended intervals for colonoscopy. It offers several notable changes from earlier guidelines. Minimum threshold targets for adequacy of adenoma detection rate have increased to 35% for all colonoscopies performed. Performance targets are increased by a further 10%-15% if colonoscopies are indicated following abnormal stool testing (ie, fecal immunochemical test or multitarget stool DNA test). The authors also propose a new minimum detection threshold of 6% for sessile serrated lesions. Finally, they expand their recommendations to include discussions of surveillance and IBD.
All clinicians performing colonoscopy should be aware of these new standards, in particular for adenoma detection rate and sessile serrated lesion detection.
ACG Guidelines: Management of Acute Pancreatitis
Acute pancreatitis is one of the most common gastrointestinal diseases prompting hospitalization in the United States. Although most cases resolve quickly, approximately 20% progress with related complications requiring extended hospitalization. This results in over 1 million in-hospital patient days and $2.5 billion in related costs annually.
There have been evolving, and sometimes conflicting, reports regarding the best practice for the use of fluids, imaging, antibiotics, nutrition, endoscopy, and surgical interventions for acute pancreatitis. This evidence-based analysis attempts to resolve some of this confusion by providing new best-practice recommendations for clinicians to optimize outcomes.
The key takeaway message is that we must focus on short-term, early, aggressive hydration with Ringer’s lactate, but also closely monitor parameters to ensure this does not lead to significant consequences of fluid overload.
ESNM/ANMS Expert Review: Prokinetics Safety and Efficacy
Although the prokinetic class of medications is aimed at improving gastrointestinal transit, effective agents for the upper gastrointestinal system have been lacking.
This extensive and excellent review from the European Society of Neurogastroenterology and Motility (ESNM) and the American Neurogastroenterology and Motility Society (ANMS) provides the most up-to-date findings on six classes of prokinetics, with specific attention to the newer agents and their safety and efficacy for upper and lower gastrointestinal dysmotility.
Although the pediatric indications for use were declared beyond the scope of this review, it is a key reference for those who aim to better understand these agents.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.