Reviews & Analysis

Acute liver failure is the abrupt loss of hepatocellular function in a patient with a previously normal liver. In this Review, Stravitz and Kramer discuss the intensive care management of patients with acute liver failure, the treatment of complications to prevent multi-organ-system failure, and the role of orthotopic liver transplantation in this setting.

Acute cholangitis is a bacterial infection of the biliary tract that occurs in an obstructed system and is characterized by fever, abdominal pain and jaundice. No universally accepted consensus for the diagnosis of acute cholangitis exists. This Review describes current recommendations for the diagnosis and management of this disease and discusses the merits and drawbacks of the most comprehensive guidelines available.

Clostridium difficileinfection is increasingly recognized in patients who have undergone restorative proctocolectomy with ileal-pouch–anal anastomosis. The effect of this infection on patient outcomes is not clear. In this Case Study, Shen and colleagues describe a case of fulminantC. difficile-associated pouchitis with a fatal outcome that occurred after ileostomy closure.

Diagnosis of celiac disease in children under 2 years of age at first biopsy currently requires a small-bowel biopsy to be taken after a gluten challenge. The authors of a new study question these recommendations, and suggest that gluten challenge and biopsy are not required in this group of patients.

Findings from a new, multinational, randomized, controlled trial suggest that histamine receptor 2 antagonists and PPIs are equal in their ability to control peptic ulcer rebleeding. However, several methodological issues of this study limit the conclusions that can be drawn from it.

Detection of polyps by colonoscopy is commonly performed during slow withdrawal of the colonoscope, after its rapid insertion. The authors of a new study found that considerably more polyps were identified during endoscope insertion, rather than withdrawal, and suggest that further investigation of polyp inspection during the insertion phase is warranted.

Severe infections are an established risk of immunosuppressive therapy; however, the risk of opportunistic infections in patients with IBD who receive immunosuppressive therapy has so far only been studied retrospectively. The increased incidence of herpes flares and development or worsening of viral warts in patients with IBD who receive azathioprine has now been demonstrated for the first time in a prospective study.

Two very different studies have recently been published, which indicate that use of intravenous PPIs as an adjunct to endoscopic hemostasis might effectively prevent recurrent ulcer bleeding. What do these studies add to our current knowledge, and what are their practical implications for gastroenterologists?

Two multicenter trials have evaluated the potential of capsule endoscopy as a diagnostic tool for screening and surveillance of esophageal varices in cirrhotic patients. Their results are similar and show that capsule endoscopy has good performance characteristics, although it is somewhat inferior to esophagogastroduodenoscopy.

The optimal timing of endoscopy after presentation with upper gastrointestinal bleeding is a matter for debate. Tsoi and colleagues examine the findings of randomized clinical trials and retrospective cohort studies, and conclude that endoscopy within 24 h of admission to hospital aids risk stratification of patients and reduces the need for hospitalization. However, very early endoscopy shows no evidence of benefit in terms of the risk of rebleeding or improved survival.

Barrett esophagus involves the replacement of normal esophageal squamous epithelium with metaplastic columnar epithelium and is a major precursor to adenocarcinoma of the esophagus. Histological evaluation of biopsy samples from the esophagus and gastroesophageal junction for the presence of goblet cells and extent of dysplasia is the mainstay of surveillance for Barrett esophagus. This Review discusses the histological features of Barrett esophagus and its neoplastic complications.

Replication of HBV occurs through reverse transcription, but inherent lack of proofreading causes a high rate of mutations. The most common naturally occurring HBV mutations are those in the precore and core promoter regions that abolish or decrease the production of hepatitis B e antigen. In this Review article, Chotiyaputta and Lok discuss these mutations and those that confer resistance to antiviral agents and/or facilitate escape from host immunity.

The late consequences of acute pancreatitis refer to the complications that can arise after the convalescence period of acute pancreatitis, that is, 3–6 months after the initial pancreatitis episode. The development of late complications correlates with disease recurrence. This Review discusses risk factors for the recurrence of acute pancreatitis and the late consequences associated with this disease.

The low success rates of standard triple-therapy regimens for eradication of Helicobacter pylori infection have led to development of alternative approaches. Findings from a new meta-analysis that compared the efficacy of concomitant quadruple therapy with that of standard triple therapy revealed the concomitant approach to be superior for eradication of H. pylori.

The routine use of diagnostic laparoscopy for young women who present with right iliac fossa pain reduces the rate of negative appendectomy, according to a new study. However, the implementation of laparoscopy as a routine approach for the diagnosis of suspected acute appendicitis would probably increase morbidity and mortality for these patients.

Selection of an optimum treatment regimen for patients with ulcerative colitis depends on several factors, including the natural history of the disease. A new study indicates that prognosis for patients with newly diagnosed ulcerative colitis might not be as bad as typically thought—an important finding that should be taken into account when the risks and benefits of future treatment strategies are discussed.

Current recommendations for the performance of laparoscopic sigmoidectomy in patients with diverticulitis reserve this procedure for individuals who have complications of the disease or have had numerous, severe disease episodes. Findings from a 2009 study challenge this dogma and suggest that patients' quality of life should also be considered.

Several novel antiviral treatments for HCV are in preclinical or clinical development, and most target viral enzymes and their functions. These new drugs all potentially select for resistant viral variants, both in vitro and in vivo; viral resistance is, therefore, likely to become an important issue in clinical practice.

This article considers the case of a 58-year-old man who presented with a 35-year history of Crohn's disease, pararectal fistulas and abscess formation. He had been taking azathioprine therapy for approximately 5.5 years. He was started on infliximab; however, his fistulas persisted and the abscess recurred. He was, therefore, switched to adalimumab. After development of pancytopenia, a bone marrow biopsy and a diagnostic splenectomy were performed, leading to a diagnosis of hepatosplenic T-cell lymphoma.

Standard treatment with pegylated interferon and ribavirin only cures just over half of patients with HCV infection. Pereira and Jacobson review the evidence on the efficacy and promise of several specifically targeted antiviral therapies, which, most likely in combination with interferon and ribavirin, may improve the success rate of HCV therapy.