Covering the Cover

  • Covering the Cover

    • Andrew T. Chan,
    • Christopher S. Williams
    Published online: January 10, 2020
    A multicenter, double-blind, cross-over trial assessed the efficacy of gastric electrical stimulation in the management of patients with refractory vomiting with or without gastroparesis.

Meeting Summary


  • On and Off of Gastric Electrical Stimulation for Refractory Vomiting

    • Jan Tack,
    • Jolien Schol,
    • Karen Van den Houte,
    • Florencia Carbone
    Published online: December 26, 2019
    In March 2000, the US Food and Drug Administration approved the humanitarian device exemption application for gastric electrical stimulation (GES), for the treatment of chronic, intractable nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology. The GES device is a neurostimulator, implanted under the skin and with lead wires implanted in the wall of the proximal stomach. The accompanying summary document stated that “the available clinical data demonstrated some improvement in the reduction in vomiting with respect to the baseline evaluation period, and some improvement in secondary endpoints.”1 A humanitarian device exemption is exempt from the effectiveness requirements of the Federal Food, Drug & Cosmetic Act and, since this approval, the efficacy of GES remained a matter of controversy.
  • New Blood Marker of Endoscopic Disease Activity—A Step Forward in Treating Crohn’s Disease to Target?

    • Manasi Agrawal,
    • Ryan C. Ungaro,
    • Jean-Frederic Colombel
    Published online: December 19, 2019
    In this issue of Gastroenterology, D’Haens et al1 report on the performance of a new blood-based biomarker panel in assessing endoscopic disease activity in Crohn’s disease (CD). This discovery could be a step forward in the treat-to-target paradigm,2 which has shifted the goal of CD therapy from resolution of clinical symptoms only to a composite of clinical and endoscopic remission. Subsequently, the CALM study demonstrated the positive impact of a tight control approach to therapy escalation with treatment decisions incorporating C-reactive protein (CRP) or fecal calprotectin in addition to symptoms.
  • One Step Forward But Room for Improvement in Reducing Risk of Gastric Cancer by Curing Helicobacter pylori Infection

    • Colin W. Howden
    Published online: November 12, 2019
    For 2019, the American Cancer Society predicted that there would be 27,510 new cases of gastric cancer in the United States.1 This estimate exceeded that for both histologic forms of esophageal cancer combined by a ratio of almost 1.6. However, that imbalance does not reflect the activities of US-based gastroenterologists who are typically more focused on screening for esophageal adenocarcinoma (or, rather, antecedent Barrett’s esophagus) than the identification of patients at risk of gastric cancer.
  • New Drugs in the Ulcerative Colitis Pipeline: Prometheus Unbound

    • Silvio Danese
    Published online: December 17, 2019
    Like Prometheus, who gave fire to humans and paid with the price of eternal torment, so the gift of new drugs in ulcerative colitis (UC) brings the consequence of patients with heterogeneous disease being cycled indiscriminately through similarly modestly effective agents. In this issue of Gastroenterology, Sandborn et al1 report positive results from the phase 2 trial of etrasimod, a small molecule selective sphingosine-1-phosphate (S1P) receptor modulator, in patients with UC. Although this success should be welcomed, the benefits of UC novel therapies can be realized only with personalized treatment strategies enabled by expanded research on biomarkers predicting response.
  • Exposing the Achilles Heel of Antibiotic Therapy for Pouchitis Using Microbial Function and Composition

    • Julia Fritsch,
    • Maria T. Abreu
    Published online: December 18, 2019
    Pouchitis after J-pouch surgery for colitis is almost universal.1–4 Antibiotics, usually ciprofloxacin, metronidazole, or both, are the mainstays of therapy.5–7 In general, antibiotics are given in repeated courses or continuously and effectively reduce symptoms and inflammation.7 Previous work by this group has shown that patients with pouchitis had a less diverse microbiota with an increase in certain inflammatory bacteria that were correlated with pouch disease.8 In the current issue of Gastroenterology, Dubinsky et al9 characterize the microbiota of the pouch in response to antibiotic treatment in a methodical way.
  • The Vexing Problem of Incidental Gastric Intestinal Metaplasia: Do the AGA Guidelines Help?

    • Shahnaz Sultan
    Published online: December 13, 2019
    Gastric intestinal metaplasia (GIM), defined as the replacement of gastric mucosa by epithelium-resembling intestinal morphology, is a common finding reported in ≤20% of patients undergoing upper endoscopy and which often poses a clinical challenge.1–3 GIM is associated with an increased risk for intestinal-type gastric adenocarcinoma, therefore raising the question about the need for further endoscopic testing or surveillance. The model of carcinogenesis, first described by Correa et al4 in 1975, outlines the following cascade of steps leading to the development of intestinal-type gastric adenocarcinoma: normal gastric mucosa → nonatrophic gastritis → multifocal atrophic gastritis without intestinal metaplasia → intestinal metaplasia of the complete (small intestine) type → intestinal metaplasia of the incomplete (colonic) type → low-grade dysplasia → high-grade dysplasia → invasive adenocarcinoma.

Gastroenterology in Motion

Clinical Challenges and Images in GI

  • New-Onset Diffuse Parenchymal Lung Disease in a 52-Year-Old Woman With Ulcerative Colitis

    • Eva De Backer,
    • Hannelore Bode,
    • Filip Baert
    Published online: September 24, 2019
    Question: A 52-year old woman with an 11-year history of ulcerative colitis presented with new onset dyspnea on exertion and nonproductive cough. The patient was being treated for ulcerative colitis with intravenous vedolizumab every 8 weeks as single therapy for 2 years and was in durable clinical and endoscopic remission.
  • Dyspnea in Hepatocellular Carcinoma

    • Al Tripathi,
    • Raj Paspulati,
    • Stanley Martin Cohen
    Published online: September 24, 2019
    Question: A 64-year-old man with untreated hepatitis B and C presented with fatigue, dyspnea, and abdominal pain. He had a 1.7-cm hepatic lesion suspicious for hepatocellular carcinoma in 2011. He never followed up for further care until 2018, when he presented with abdominal discomfort. Magnetic resonance imaging of the liver revealed findings consistent with multifocal hepatocellular carcinoma (Figure A). He was not interested in systemic chemotherapy and did not return until he developed fatigue and dyspnea with hypoxia requiring 6 L of oxygen support via nasal cannula in 2019.
  • Multiple Polypoid Lesions in the Sigmoid Colon

    • Joon Woo Park,
    • Dong Hoon Baek,
    • So Jeong Lee
    Published online: September 24, 2019
    Question: A 60-year-old man with C3 tetraplegia was referred to our department for evaluation of abdominal pain and hematochezia. He was diagnosed with adrenal insufficiency 5 years prior and has been taking low-dose prednisolone (7.5 mg) once a day. One year before presentation, he complained of intermittent loose, mucoid stool and abdominal pain. Sigmoidoscopy revealed multiple small yellowish plaques in the sigmoid colon (Figure A). However, symptoms improved without any treatment, and he was discharged from the rehabilitation department.
  • A Patient with Metastatic Lung Cancer and Dysphagia

    • Judith Biechele,
    • Mark Fox
    Published online: November 15, 2019
    Question: A 73-year-old woman with advanced lung cancer presented to our clinic with increasing pain, weakness, and weight loss related to metastatic disease involving the liver and lymphatic system. The patient also complained of increasing difficulty with eating over several weeks. Initially, her symptoms were worse with solids, but progressed to involve ingestion of pureed food and yogurt. Constipation was a problem as well.

Electronic Clinical Challenges and Images in GI

  • Persistent Abdominal Distention After Endoscopic Percutaneous Endoscopic Gastrostomy Tube Replacement

    • Jae Keun Kim,
    • Jin Woong Park,
    • Kee Myung Lee
    Published online: August 05, 2019
    Question: A 38-year-old man presented with abdominal distention and irritability. He was in a semicomatose state after traumatic intracerebral hemorrhage 12 years ago. He had percutaneous endoscopic gastrostomy (PEG) 8 years ago and has had the tube changed 7 times. The patient visited the emergency department with persistent abdominal distention and irritability after an endoscopic assistant changed the tube several hours earlier. Abdominal distention used to be subsided immediately after PEG tube had been replaced in the past.
    Online Only
  • Think Twice Before Extracting a Harmless Foreign Body From the Upper Esophagus

    • Eyal Avivi,
    • Vered Richter,
    • Haim Shirin
    Published online: August 05, 2019
    Question: An 86-year-old man with a past medical history of squamous cell carcinoma of the larynx and total laryngectomy with tracheostomy presented for evaluation of severe iron deficiency anemia (hemoglobin of 6.4 g/dL). Our patient had no upper gastrointestinal symptoms and underwent upper endoscopy. Upon slowly endoscopic withdrawal, a foreign body in the upper esophagus was visualized. This looked like the bumper from a conventional percutaneous endoscopic gastrostomy (Figure A).
    Online Only
  • Unilateral Scrotal Swelling After Acute Pancreatitis of Pancreas Transplant Graft

    • Scott Ketcham,
    • Kevin D. Platt,
    • Matthew J. DiMagno
    Published online: September 24, 2019
    Question: A 49-year-old man with a past medical history significant for type 1 diabetes mellitus complicated by end-stage renal disease, status post kidney and pancreas transplant, presented after a brief syncopal episode. He was found to have moderate severity acute graft pancreatitis based on serum lipase >10,000 IU/L and transient hypotension, tachycardia, hypoxia requiring 4 L of nasal cannula, and bilateral pleural effusions on chest radiographs. The suspected etiology was trauma secondary to a fall versus ischemia in the setting of infectious diarrhea and volume depletion.
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  • Stony Cause of Gastrointestinal Bleeding

    • Vincent Zimmer,
    • Kai Emrich
    Published online: September 24, 2019
    Question: An 80-year-old woman presented with signs of lower GI bleeding under oral anticoagulation with apixaban. Previous history was significant for chronic atrial fibrillation, cholecystectomy and right hemicolectomy owing to colon ascendens cancer (UICC stage 2) 1 year before. Although her hemoglobin levels were only 6.7 g/dL, upper endoscopy was unremarkable. The initial ileocolonoscopy revealed large amounts of fresh blood and clots with a maximum at the surgical anastomosis. However, at the time no clear-cut bleeding source could be determined.
    Online Only
  • An Uncommon Cause of Cholecystitis

    • Laureline Moser,
    • Ismail Labgaa,
    • Luca Di Mare
    Published online: September 25, 2019
    Question: An 86-year-old woman with a history of open appendicectomy presented with epigastric and right upper quadrant pain, but no other symptoms. Physical examination showed right upper quadrant tenderness with positive Murphy sign. Laboratory tests revealed elevated white blood cell count of 16.1 g/L (normal, 4.5–11.5 g/L), C-reactive protein of 196 mg/L (normal, <10 mg/L), aspartate aminotransferase of 99 U/L (normal, 13-40 U/L), alanine aminotransferase of 80 U/L (normal, 7-40 U/L), gamma-glutamyl transferase of 127 U/L (normal, <38 U/L), alkaline phosphatase of 138 U/L (normal, 46-116 U/L), and total bilirubin of 26 μmol/L (normal, <21 μmol/L); pancreatic enzymes were within normal range.
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  • Unusual Case of Repeated Hospitalization of a Young Man

    • Abdelkader Taibi,
    • Anne GUYOT,
    • Jeremie Jacques
    Published online: September 24, 2019
    Question: A 32-year-old man was hospitalized in February 2019 for intense pelvic pain. On physical examination, he had sensitivity in the pelvic region but without abdominal guarding. He did not have a fever. His laboratory tests revealed a white blood cell count of 27.7 g/L, a platelet count of 428 g/L, and a hemoglobin level of 13.4 g/dL. He had no findings indicative of a coagulation disorder. Rectal endoscopy was not performed because the risk of rectal perforation was considered to be high.
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Practical Teaching Cases

  • Cachexia, Colitis, and Cancer

    • Arjun R. Sondhi,
    • Luke J. Nayak,
    • Jonathan Mowers
    Published online: July 16, 2019
    Question: A 54-year-old woman with a history of pneumonitis, bronchiectasis, and anal intraepithelial neoplasia III (AIN III) was transferred from an outside facility for a several-year history of chronic non-bloody diarrhea with up to 15 oily foul-smelling bowel movements per day and failure to thrive with an unintentional weight loss of 40 pounds over the preceding year. She used loperamide as needed without relief. Physical exam was notable for mild sinus tachycardia, otherwise normal vital signs, BMI of 12 kilograms per meter squared, cachexia, temporal wasting, dry mucus membranes, and mild diffuse abdominal tenderness to palpation.
    CME Quiz
  • Fever, Rash, and Abdominal Pain

    • Gretchen A. Colbenson,
    • Amrit K. Kamboj,
    • Virginia Dines
    Published online: July 31, 2019
    Question: A 35-year-old woman presented with a 1-week history of fevers, right upper quadrant and epigastric pain, and a non-pruritic, non-painful rash. Her past medical history was significant for a diagnosis of human immunodeficiency virus (HIV) 5 years prior, not currently on treatment, and hypertension, on Lisinopril. She had received highly active antiretroviral therapy (HAART) for one year after diagnosis but was subsequently lost to follow-up. Her last known CD4 count was 410 cells/mcL four years prior to presentation.

Original Research

Continuing Medical Education (CME)/MOC Activities

Clinical Practice Guidelines

  • AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia

    • Samir Gupta,
    • Dan Li,
    • Hashem B. El Serag,
    • ...
    • Shahnaz Sultan,
    • Yngve Falck-Ytter,
    • Reem A. Mustafa
    Published online: December 06, 2019
    Gastric cancer is the third leading cause of cancer death worldwide.1 In 2018, 1,033,701 incident cases were diagnosed globally,1 including 26,240 nationally in the United States.2 The majority of gastric cancers in the United States are non-cardia gastric cancers, arising from the antrum, incisura, body, and/or fundus.3 Chronic infection with Helicobacter pylori is the primary risk factor for (intestinal-type) non-cardia gastric cancer, with at least 80% of the global gastric cancer burden attributable to this pathogen.
    Editorial Accompanies Article
  • Gastric Intestinal Metaplasia (GIM)

    • American Gastroenterological Association
    Published online: January 11, 2020
  • Spotlight: Gastric Intestinal Metaplasia

    • Shailja C. Shah,
    • Samir Gupta,
    • Dan Li,
    • Douglas Morgan,
    • Reem A. Mustafa,
    • Andrew J. Gawron
    Published in issue: February 2020
  • AGA Technical Review on Gastric Intestinal Metaplasia—Natural History and Clinical Outcomes

    • Andrew J. Gawron,
    • Shailja C. Shah,
    • Osama Altayar,
    • ...
    • Douglas Morgan,
    • Kevin Turner,
    • Reem A. Mustafa
    Published online: December 06, 2019
    Gastric cancer is the third leading cause of cancer-related mortality and the fifth most common cancer globally. An estimated 1 million new cases and 750,000 related deaths are projected to occur annually, with the majority of cases in East Asia and developing or recently developed countries.1 In the United States, which is considered a low-incidence country overall, 27,510 incident gastric cancer cases and 11,140 related deaths were estimated to occur in 2019, representing 1.6% and 1.8% of all new cancer diagnoses and deaths, respectively.
    Online ExtraEditorial Accompanies ArticleAdditional Online Content Available
  • AGA Technical Review on Gastric Intestinal Metaplasia—Epidemiology and Risk Factors

    • Osama Altayar,
    • Perica Davitkov,
    • Shailja C. Shah,
    • ...
    • Douglas R. Morgan,
    • Kevin Turner,
    • Reem A. Mustafa
    Published online: December 06, 2019
    Gastric cancer remains the third leading cause of cancer-related mortality and the fifth most common cancer worldwide.1 There is marked global variation of disease with areas of high vs low incidence. In the United States, gastric cancer is the 15th most common cancer, with estimated 26,240 new cases and 10,800 deaths in 2018.2
    Online ExtraEditorial Accompanies ArticleAdditional Online Content Available
  • Histologic Subtyping of Gastric Intestinal Metaplasia: Overview and Considerations for Clinical Practice

    • Shailja C. Shah,
    • Andrew J. Gawron,
    • Reem A. Mustafa,
    • M. Blanca Piazuelo
    Published online: December 06, 2019
    Gastric cancer remains the third leading cause of cancer-related mortality and the fifth most common cancer worldwide, responsible for an estimated 1 million new cases and more than 780,000 deaths in 2018 alone.1 Gastric adenocarcinoma is the most common form of gastric cancer, of which there are 2 histologic subtypes: intestinal-type and diffuse-type. Intestinal-type gastric adenocarcinoma is the final stage of the chronic inflammation to dysplasia–carcinoma sequence, known as the Correa cascade, with Helicobacter pylori–induced gastritis as the most common initial trigger.
  • Advancing the Science in Gastric Pre-Neoplasia: Study Design Considerations

    • Perica Davitkov,
    • Osama Altayar,
    • Shailja C. Shah,
    • ...
    • Reem A. Mustafa,
    • Shahnaz Sultan,
    • Douglas R. Morgan
    Published online: December 06, 2019
    Gastric cancer is the third leading cause of cancer-related mortality and the leading infection associated cancer worldwide. In the US, there are estimated 27,510 new cases and 11,140 gastric-cancer related deaths in 2019.1 Gastric adenocarcinoma (GA) is the most common form of gastric cancer. Histologically, by the Lauren classification, GA can be divided into 2 types: intestinal GA and diffuse GA.2 The Cancer Genome Atlas initiative has identified 4 molecular subtypes of gastric cancers: genomically stable (diffuse), chromosomally stable (intestinal), microsatellite instability, and Epstein-Barr virus subtypes.

Clinical Practice Update

Brief Communications

  • Time Trends in Adherence to Surveillance Intervals and Biopsy Protocol Among Patients With Barrett’s Esophagus

    • Sachin Wani,
    • J. Lucas Williams,
    • Srinadh Komanduri,
    • V. Raman Muthusamy,
    • Nicholas J. Shaheen
    Published online: October 14, 2019
    In this era of value-based and quality-based health care, quality indicators that benchmark performance in patients with Barrett’s esophagus (BE) have been defined.1,2 These have been established to ensure the delivery of high-quality care, reduce variability, allow all stakeholders to assess quality of care, and ultimately to improve patient outcomes.1 To reduce unnecessary endoscopy in patients with nondysplastic BE (NDBE), the frequency of surveillance endoscopies at appropriate intervals (no sooner than 3–5 years) has been proposed as a quality indicator by the American Gastroenterological Association and included in 1 of 5 issues that physicians and patients should use to assess appropriateness of care by the Choosing Wisely campaign.
    Online ExtraAdditional Online Content Available
  • Utilization of Surveillance Endoscopy for Barrett’s Esophagus in Medicare Enrollees

    • Joel H. Rubenstein,
    • Mohamed Noureldin,
    • Anna Tavakkoli,
    • Chin Hur,
    • Amir-Houshang Omidvari,
    • Akbar K. Waljee
    Published online: October 30, 2019
    Guidelines recommend surveillance of nondysplastic Barrett’s esophagus (BE) every 3 to 5 years, but do not provide guidance on when to discontinue surveillance.1 There is limited understanding of practice patterns in surveillance of BE. We hypothesized that surveillance of BE persists through older age, even in individuals with substantially diminished life expectancy.
    Online ExtraAdditional Online Content Available
  • Opioid Prescription Patterns Among US Gastroenterologists From 2013 to 2017

    • Frank W. Chen,
    • Wendi G. LeBrett,
    • Liu Yang,
    • Lin Chang
    Published online: October 21, 2019
    The opioid epidemic has led to a crisis in the United States, with chronic use associated with increased morbidity and mortality.1 However, there are limited data on specialty-wide prescription practice patterns specifically among gastroenterologists in the United States. It is unknown whether gastroenterologists have modified their use of prescription opioids during the opioid epidemic and the extent to which they have adopted alternate nonopioid therapies, such as gut-brain neuromodulators and antispasmodics.
    Online ExtraAdditional Online Content Available