Gastroenterology Clinics of North America RSS feed: Current Issue. Gastroenterology Clinics of North America updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in gastroenterology and is presented under the direction of an experienced guest editor.http://www.gastro.theclinics.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Gastroenterology Clinics of North America0889-8553384December 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.gastro.theclinics.com/article/PIIS0889855309001046/abstract?rss=yesContents10.1016/S0889-8553(09)00104-6Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1vviihttp://www.gastro.theclinics.com/article/PIIS0889855309001058/abstract?rss=yesForthcoming issues10.1016/S0889-8553(09)00105-8Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1viiiviiihttp://www.gastro.theclinics.com/article/PIIS0889855309000983/abstract?rss=yes We are honored to serve as the editors for this issue of Gastroenterology Clinics of North America titled “Challenges in Inflammatory Bowel Disease.” The authors comprise a distinguished group of physician scientists and clinicians who are leaders in the field of inflammatory bowel disease (IBD). In this issue, they share their insights and expertise into how they manage challenging IBD presentations. We believe this issue provides an invaluable consulting reference for all health care providers.PrefaceMiguel Regueiro, Arthur M. Barrie10.1016/j.gtc.2009.09.001Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1ixxhttp://www.gastro.theclinics.com/article/PIIS0889855309000740/abstract?rss=yesCrohn disease (CD) and ulcerative colitis (UC) comprise a group of inflammatory disorders of the gastrointestinal tract that can vary in severity of disease, anatomic extent of inflammation, presence and nature of extraintestinal manifestations, and response to therapeutic approaches. There have been attempts to classify CD based on the location and behavior of disease. Advances in understanding of genetic susceptibility to inflammatory bowel disease (IBD) suggest that CD and UC may represent a continuum of overlapping disorders. This has led to an attempt to classify IBD on clinical, molecular, and serologic grounds. Differences in clinical, genetic, and immunologic profiles may require more targeted, refined treatment approaches to help clinicians make decisions regarding recently introduced biologic agents. This article provides an overview of the current approaches to therapy for CD and UC and focuses on the evidence supporting the rationale for changing paradigms in the management of IBD, including mucosal healing as an end point and earlier use of immunosuppressive and biologic agents, particularly in CD (so-called top-down therapy).Evolving Inflammatory Bowel Disease Treatment Paradigms: Top-Down Versus Step-UpShane M. Devlin, Remo Panaccione10.1016/j.gtc.2009.07.007Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1577594http://www.gastro.theclinics.com/article/PIIS0889855309000880/abstract?rss=yesFistulas manifest frequently in Crohn disease and can result in significant morbidity and often lead to the need for surgical intervention. Historically, it has been more difficult to obtain complete fistula closure in patients with perianal Crohn disease. Anti-tumor necrosis factor-alpha agents and the use of more accurate imaging modalities such as magnetic resonance imaging and rectal endoscopic ultrasound have enhanced the ability to manage fistulizing Crohn disease. A combined medical and surgical approach usually presents the best option for most patients.Treatment of Fistulizing Inflammatory Bowel DiseaseDavid A. Schwartz, Brad E. Maltz10.1016/j.gtc.2009.07.009Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1595610http://www.gastro.theclinics.com/article/PIIS0889855309000764/abstract?rss=yesInflammatory bowel disease (IBD) includes Crohn disease and ulcerative colitis, and is often diagnosed in late childhood and early adulthood. What determines the age of onset remains unexplained. Early onset may represent the “pure” form of the disease process and hence may hold secrets of the initiating events of IBD pathogenesis. Clinical scientists continue to focus on pediatric IBD because it may shed light on the cause and prevention of this lifelong disease. Over the last decade, data in pediatric IBD studies have demonstrated many similarities and differences between pediatric and adult onset, which continue to add pieces to an increasingly complex IBD puzzle. The mechanism responsible for these similarities and differences remains unanswered. This article discusses clinically relevant epidemiology and treatment aspects of pediatric IBD, with special focus on similarities and differences in pediatric and adult IBD. Evidence-based treatment algorithms, with special focus on pediatric studies and care for children, are also highlighted.Pediatric Inflammatory Bowel Disease: Highlighting Pediatric Differences in IBDCary G. Sauer, Subra Kugathasan10.1016/j.gtc.2009.07.010Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1611628http://www.gastro.theclinics.com/article/PIIS0889855309000739/abstract?rss=yesThis review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.Pregnancy and Inflammatory Bowel DiseaseUma Mahadevan10.1016/j.gtc.2009.07.006Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1629649http://www.gastro.theclinics.com/article/PIIS0889855309000697/abstract?rss=yesRestorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for most patients with ulcerative colitis who require surgery. Although the surgical procedure offers a cure in some patients, postoperative inflammatory and noninflammatory complications are common. Pouchitis is the most common long-term complication of the procedure. Pouchitis represents a spectrum of disease processes with heterogeneous risk factors, clinical phenotypes, natural history, and prognosis. Accurate diagnosis and classification are important for proper treatment and prognosis.Pouchitis and Pouch DysfunctionHao Wu, Bo Shen10.1016/j.gtc.2009.07.002Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1651668http://www.gastro.theclinics.com/article/PIIS0889855309000715/abstract?rss=yesThis article describes the cancer risks of commonly used inflammatory bowel disease (IBD) medications, with an emphasis on hematologic malignancy risks. The increasing use of immunosuppressant therapies in the treatment of IBD has raised this question to an even greater importance. Studies evaluating these medications are complicated due to varying disease severity and concomitant use of other immunosuppressant medication. The potential risks of all therapies must be weighed against the benefits these therapies can offer these patients.Safety Profile of IBD: Lymphoma RisksMeenakshi Bewtra, James D. Lewis10.1016/j.gtc.2009.07.004Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1669689http://www.gastro.theclinics.com/article/PIIS0889855309000727/abstract?rss=yesOver the last decade, the medical treatment of inflammatory bowel disease (IBD) has been revolutionized, with increasing use of both immunomodulatory and biologic medications. Corticosteroids have increasingly been associated with an elevated risk of serious and opportunistic infections, both independently and in combination with immunomodulator and biologic agents. There are limited data on the infectious risk of immunomodulators. It is unclear if anti-tumor necrosis factor agents increase overall infectious risk in patients with IBD, but the available literature has demonstrated an increased risk of opportunistic infections, particularly in terms of tuberculosis and histoplasmosis. Combination therapy likely increases the risk of opportunistic infections in patients with IBD but this has not yet been conclusively proved.Safety Profile of IBD Therapeutics: Infectious RisksWaqqas Afif, Edward V. Loftus10.1016/j.gtc.2009.07.005Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1691709http://www.gastro.theclinics.com/article/PIIS0889855309000703/abstract?rss=yesThe past decade has seen an alarming increase in the burden of disease associated with Clostridium difficile. Several studies have now demonstrated an increasing incidence of C difficile infection in patients with inflammatory bowel disease (IBD) with a more severe course of disease compared with the non-IBD population. This article summarizes the available literature on the impact of C difficile infection on IBD and discusses the various diagnostic testing and treatment options available. Also reviewed are clinical situations specific to patients with IBD that are important for the treating physician to recognize.Clostridium Difficile and Inflammatory Bowel DiseaseAshwin N. Ananthakrishnan, Mazen Issa, David G. Binion10.1016/j.gtc.2009.07.003Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1711728http://www.gastro.theclinics.com/article/PIIS0889855309000892/abstract?rss=yesInflammatory bowel disease remains a complex disease with variable clinical presentations and often nonspecific symptoms. Physicians must rely on diagnostic tools for clarification of disease diagnosis and for guiding management of patients with established disease. Advances in radiologic imaging modalities facilitate early and accurate detection of luminal disease and extraluminal complications. The introduction and dissemination of small bowel capsule endoscopy and double-balloon enteroscopy permit detailed visualization and sampling of the mucosa throughout the entire bowel. Serologic biomarkers are evolving as a valuable tool to clarify diagnosis and stratify patients by disease phenotypes and patterns of behavior. Neutrophil-derived fecal biomarkers are emerging as useful surrogate markers of intestinal inflammation with the potential for a variety of clinical applications, but their application to clinical management has not yet been clarified.Novel Diagnostic and Prognostic Modalities in Inflammatory Bowel DiseaseTimothy L. Zisman, David T. Rubin10.1016/j.gtc.2009.08.001Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1729752http://www.gastro.theclinics.com/article/PIIS0889855309000752/abstract?rss=yesCrohn disease often recurs after surgical resection. Despite extensive research in the prevention of postoperative Crohn disease, optimal management strategies have yet to be defined. Risk of disease recurrence needs to be carefully balanced against potential risks associated with treatment. Patients with low risk of postoperative recurrence may not require medication, whereas those at moderate risk may benefit from antibiotics or immunomodulators. Those at highest risk of recurrence may benefit from biologic therapy for maintenance of surgical remission. Postoperative colonoscopy within 1 year of resective surgery is important for identification of disease recurrence and modification of medications.Postoperative Management of Crohn DiseaseSu Min Cho, Sung W. Cho, Miguel Regueiro10.1016/j.gtc.2009.07.008Gastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1753762http://www.gastro.theclinics.com/article/PIIS088985530900106X/abstract?rss=yesIndex10.1016/S0889-8553(09)00106-XGastroenterology Clinics of North America 38, 4 (2009)2009-12-01Gastroenterology Clinics of North America2009-12-01384S0889-8553(09)X0005-1763773