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 © 2012 Published by Elsevier Inc. All rights reserved. Gastroenterology Clinics of North America0889-8553412June 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.gastro.theclinics.com/article/PIIS0889855312000490/abstract?rss=yesContributors10.1016/S0889-8553(12)00049-0Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9iiivhttp://www.gastro.theclinics.com/article/PIIS0889855312000507/abstract?rss=yesContents10.1016/S0889-8553(12)00050-7Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9viixihttp://www.gastro.theclinics.com/article/PIIS0889855312000519/abstract?rss=yesForthcoming Issues10.1016/S0889-8553(12)00051-9Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9xiixiihttp://www.gastro.theclinics.com/article/PIIS0889855312000118/abstract?rss=yes The diagnosis and management of inflammatory bowel disease (IBD) is often complex. Better techniques for assessing IBD are needed. In this issue of Gastroenterology Clinics of North America, we focus on methods of diagnosing and evaluating IBD to help guide optimal treatment to maximize clinical outcomes and minimize risks. We, the guest editors, are particularly thrilled and energized to have worked with such a distinguished set of authors---highly experienced clinicians, investigators, and nationally/internationally recognized thought leaders in IBD. We asked the authors to provide a state-of-the-art update with practical information/guidelines/algorithms and cutting edge data for incorporation into practice to benefit the IBD patients we all serve.Evaluation of Inflammatory Bowel DiseaseSamir A. Shah, Adam Harris, Edward Feller10.1016/j.gtc.2012.01.010Gastroenterology Clinics of North America 41, 2 (2012)2012-02-16Gastroenterology Clinics of North America2012-02-16412S0889-8553(11)X0007-9xiiixivhttp://www.gastro.theclinics.com/article/PIIS0889855312000155/abstract?rss=yesEndoscopy plays an essential role in the diagnosis, management, and surveillance of inflammatory bowel disease (IBD). Endoscopy in combination with clinical findings, blood tests, and stool analysis can help establish the diagnosis of IBD and distinguish between Crohn disease (CD) and ulcerative colitis (UC), as well as exclude other causes. Direct visual and histologic evaluation can define the distribution, severity, and disease activity. In patients with established IBD, endoscopy will help evaluate the response to treatment, thereby determining the course of medical and surgical therapy. Furthermore, endoscopy has a therapeutic role in IBD in the dilatation of strictures and management of bleeding. In patients with longstanding disease, endoscopy plays an integral role in dysplasia and colorectal cancer surveillance. This review updates the role of endoscopy in IBD, with particular reference to the initial diagnosis, disease monitoring and assessment, dysplasia surveillance, and therapeutic functions.Endoscopic Assessment of Inflammatory Bowel Disease: Colonoscopy/EsophagogastroduodenoscopyGrace Chan, David S. Fefferman, Richard J. Farrell10.1016/j.gtc.2012.01.014Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Endoscopy and capsule endoscopy271290http://www.gastro.theclinics.com/article/PIIS0889855312000179/abstract?rss=yesPatients with longstanding, extensive ulcerative colitis are at increased risk of developing colorectal cancer. The risk is lower than previously reported, but colonoscopic surveillance is recommended still to detect intraepithelial neoplasia early and to reduce colitis-associated mortality. Surveillance relies on the detection of premalignant dysplastic tissue. Here, adenomatous changes should be differentiated from colitis-associated dysplasia, because the management is fundamentally different. Adenomas can be removed safely endoscopically, whereas multiple low-grade or at least 1 high-grade, colitis-associated dysplastic tissue requires proctocolectomy.Chromoendoscopy in Inflammatory Bowel DiseaseRalf Kiesslich, Markus F. Neurath10.1016/j.gtc.2012.01.016Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Endoscopy and capsule endoscopy291302http://www.gastro.theclinics.com/article/PIIS088985531200012X/abstract?rss=yesCrohn disease is a chronic inflammatory condition, affecting the entire gastrointestinal tract, that follows a relapsing and remitting course. Approximately two-thirds of patients with Crohn disease undergo a resective surgery during their lifetime, often because of complications associated with the disease, including fistula, abscess, fibrostenotic stricture. Once patients undergo a surgical resection, they are at an increased risk for future reoperation, and 30% to 70% of patients with Crohn disease require reoperation within 10 years of their initial surgery. Although some risk factors have been associated with need for reoperation, the complexities of the timing and severity of disease recurrence are not well-understood.Evaluation for Postoperative Recurrence of Crohn DiseaseJason M. Swoger, Miguel Regueiro10.1016/j.gtc.2012.01.011Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Endoscopy and capsule endoscopy303314http://www.gastro.theclinics.com/article/PIIS0889855312000064/abstract?rss=yesInflammatory bowel disease (IBD) is a generic term used to describe Crohn disease (CD), ulcerative colitis (UC) or IBD type unclassified (IBDU), formerly known as indeterminate colitis. By definition, only CD has the possibility to involve the whole gastrointestinal tract. However, in 10% to 15% of cases, a change in diagnosis is made from UC to CD or vice versa.The Role of Capsule Endoscopy in Evaluating Inflammatory Bowel DiseaseSilvio W. de Melo, Jack A. Di Palma10.1016/j.gtc.2012.01.005Gastroenterology Clinics of North America 41, 2 (2012)2012-02-16Gastroenterology Clinics of North America2012-02-16412S0889-8553(11)X0007-9Endoscopy and capsule endoscopy315323http://www.gastro.theclinics.com/article/PIIS0889855312000076/abstract?rss=yesRecent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services with the same rigor as other medical patients, partly because their gastroenterologist is often the main care provider for patients with IBD and visits to the primary care physician (PCP) are often infrequent. As the treating gastroenterologist, it is incumbent on us to take a proactive role in the health care needs of our IBD patients, recognizing that we are oftentimes fulfilling both specialty and primary care roles. Although it is crucial to clarify with the patient the limits of your responsibilities and delegate routine health care issues to the PCP, it is even more important to alert the PCP to the unique health maintenance needs of the IBD patient.Health Maintenance in the Inflammatory Bowel Disease PatientJennifer A. Sinclair, Sharmeel K. Wasan, Francis A. Farraye10.1016/j.gtc.2012.01.006Gastroenterology Clinics of North America 41, 2 (2012)2012-02-27Gastroenterology Clinics of North America2012-02-27412S0889-8553(11)X0007-9Special situations325337http://www.gastro.theclinics.com/article/PIIS0889855312000040/abstract?rss=yesClostridium difficile is a Gram-positive anaerobe described as early as 1935 as being a member of the intestinal flora in neonates. It was not until 1978 that it was first described in association with antibiotic-associated pseudomembranous colitis (PMC). C difficile infection (CDI) is now the predominant cause of PMC and an important cause of health care–associated diarrhea. The last 2 decades have witnessed several shifts in its epidemiology. In addition to the nearly worldwide increase in its incidence, it has been increasingly recognized as an important cause of diarrhea in the community setting in individuals not previously considered at high risk, including in children, adults with no recent antibiotic or health care exposure, pregnant women, and, more recently, individuals with underlying inflammatory bowel diseases (IBD). The similarity in clinical presentation between CDI and an IBD flare but divergent treatment paradigms with directed antibiotic therapy in the case of CDI and escalation of immunosuppression in an IBD flare makes it important for the treating clinician to have a high index of suspicion for CDI in patients with IBD. This review attempts to summarize the changes in CDI epidemiology over the last 2 decades, its growing impact on patients with IBD, diagnostic algorithms, and treatment modalities.Detecting and Treating Clostridium Difficile Infections in Patients with Inflammatory Bowel DiseaseAshwin N. Ananthakrishnan10.1016/j.gtc.2012.01.003Gastroenterology Clinics of North America 41, 2 (2012)2012-02-16Gastroenterology Clinics of North America2012-02-16412S0889-8553(11)X0007-9Special situations339353http://www.gastro.theclinics.com/article/PIIS0889855312000143/abstract?rss=yesApproximately 20% to 30% of patients with ulcerative colitis (UC) eventually require surgery for failure of medical therapy or development of neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA), initially described in 1978, has become the surgical treatment of choice for the majority of patients with UC who require proctocolectomy. Pouch configuration with two (J), three (S), or four (W) loops of small intestine has been performed, and the J pouch has become the most commonly used one. The normal configurations of the J and S pouch are illustrated in and . The IPAA procedure preserves intestinal continuity, substantially decreases the risk for dysplasia, and improves health-related quality of life. However, adverse sequelae related to the ileal pouch occur frequently. Recognition and proper diagnosis of those conditions are key for maintaining a healthy pouch and prolonging pouch survival.Evaluating Pouch ProblemsYue Li, Bo Shen10.1016/j.gtc.2012.01.013Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Special situations355378http://www.gastro.theclinics.com/article/PIIS0889855312000106/abstract?rss=yesPerianal fistula, defined as an abnormal communication between the anal canal or lower rectum and the perianal or perineal skin, is among the more morbid manifestations of Crohn disease (CD). The development of a perianal fistula is usually accompanied by pain, fever, and purulent drainage, and may even be associated with fecal incontinence. The exact etiology of perianal fistulae in CD remains unclear, but it signifies a more aggressive and refractory disease phenotype. As a result, patients with fistulizing CD generally experience a lower quality of life than CD patients without perianal involvement.The Evaluation and Treatment of Crohn Perianal Fistulae: EUA, EUS, MRI, and Other Imaging ModalitiesPaul E. Wise, David A. Schwartz10.1016/j.gtc.2012.01.009Gastroenterology Clinics of North America 41, 2 (2012)2012-02-27Gastroenterology Clinics of North America2012-02-27412S0889-8553(11)X0007-9Special situations379391http://www.gastro.theclinics.com/article/PIIS0889855312000052/abstract?rss=yesRandomized controlled trials support the use of the thiopurines and anti-tumor necrosis factor α (anti-TNF) monoclonal antibodies (mAb's) in the treatment of Crohn disease (CD). Nonetheless, lack of response, loss of response, and toxicity pose significant clinical challenges. In this article, the authors review therapeutic approaches and laboratory assays that help optimize the use of these agents. The activity of the thiopurine methyltransferase (TPMT) enzyme should always be determined to avoid thiopurine use in individuals with absent TPMT. The role of metabolite-adjusted dosing in patients initiating thiopurine therapy is not settled. Metabolite concentrations help guide management in patients failing thiopurine therapy. Loss of response to anti-TNF mAb's is a common clinical scenario that is mitigated by scheduled maintenance therapy and by coadministration of immunomodulators. In the event of loss of response to infliximab, further management is guided by measuring the serum concentrations of infliximab and antibodies to infliximab. No commercial assays are presently available to guide therapy with adalimumab and certolizumab pegol. The effectiveness of the thiopurines and the anti-TNF mAb's is highest when these agents are (1) introduced earlier in the disease course, (2) continued indefinitely, and (3) combined as initial therapy.Optimizing Immunomodulators and Anti-TNF Agents in the Therapy of Crohn DiseaseThemistocles Dassopoulos, Charles A. Sninsky10.1016/j.gtc.2012.01.004Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Special situations393409http://www.gastro.theclinics.com/article/PIIS0889855312000131/abstract?rss=yesThere is little debate that monoclonal antibodies directed against tumor necrosis factor-α (anti-TNFα) represent important tools in our armamentarium in the management of inflammatory bowel disease (IBD). However, the beneficial effects of systemic therapy for IBD, including immunosuppressive (IS) agents such as azathioprine/6-mercaptopurine (AZA/6-MP), methotrexate (MTX), corticosteroids, and anti-TNFα therapy must be countered against established risks. Because of the wealth of data now supporting the use of anti-TNFα–based therapy, the debate has switched from whether or not to use such treatments to how to optimize their use in individual patients. The debate over the use of concomitant anti-TNFα and IS therapy (combination therapy) versus anti-TNFα monotherapy is central to this question and represents a point of significant consternation for clinicians. This review provides an overview and historical perspective on this question and also discusses a clinically useful approach for individualizing treatment decisions.Patient-Specific Approach to Combination Versus Monotherapy with the Use of Antitumor Necrosis Factor α Agents for Inflammatory Bowel DiseaseShane M. Devlin, Adam S. Cheifetz, Corey A. Siegel, BRIDGe group10.1016/j.gtc.2012.01.012Gastroenterology Clinics of North America 41, 2 (2012)2012-02-16Gastroenterology Clinics of North America2012-02-16412S0889-8553(11)X0007-9Special situations411428http://www.gastro.theclinics.com/article/PIIS0889855312000441/abstract?rss=yesIt is surprising how little is known about disability in patients with inflammatory bowel disease (IBD). There are sparse data on IBD-related disability compared with other chronic inflammatory diseases such as multiple sclerosis. Even advocacy organizations such as the Crohn and Colitis Foundation of America (CCFA) have little information on the extent of disability of its membership. Perhaps the reason for this shortage relates to the lack of a standardized instrument to evaluate disability as well as multiple challenges in defining disability in these patients. Although defining disability may be important in research that provides a better understanding of the impact of disease and treatment on those with IBD, the definition has real-world implications for those individuals in terms of their financial security, access to medical care, and the ability to work and function in society.Disability in Inflammatory Bowel DiseaseBincy P. Abraham, Joseph H. Sellin10.1016/j.gtc.2012.02.001Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Special situations429441http://www.gastro.theclinics.com/article/PIIS088985531200009X/abstract?rss=yesInflammatory bowel disease (IBD) is classically characterized by periods of remission and clinical relapse. In some patients disease may take an aggressive course that involves frequent relapses, continued active disease, intensified medical treatment, or even a surgical approach. It is important to determine clinical factors that predict the aggressive course of disease to implement appropriate therapy to prevent patients from developing complications and to improve their quality of life. This review discusses clinical factors that have been suggested to predict an aggressive course of disease in patients with ulcerative colitis (UC) and Crohn disease (CD).Clinical Predictors of Aggressive/Disabling Disease: Ulcerative Colitis and Crohn DiseaseWojciech Blonski, Anna M. Buchner, Gary R. Lichtenstein10.1016/j.gtc.2012.01.008Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Noninvasive evaluation443462http://www.gastro.theclinics.com/article/PIIS0889855312000027/abstract?rss=yesSerologies have well-established roles in the diagnosis of a variety of immunologically driven diseases; rheumatologists rely on an alphabet soup of antibodies, hepatologists depend on serologic tests to diagnose primary biliary cirrhosis (PBC) and autoimmune hepatitis, and celiac experts have used a battery of tests for diagnosis, adherence, and a better understanding of pathophysiology. In these specialties, serologies provide a robust diagnostic accuracy either by themselves or with a minimum of other studies to establish a diagnosis or guide therapeutic decision making.The Promise and Pitfalls of Serologic Testing in Inflammatory Bowel DiseaseJoseph H. Sellin, Rajesh R. Shah10.1016/j.gtc.2012.01.001Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Noninvasive evaluation463482http://www.gastro.theclinics.com/article/PIIS0889855312000088/abstract?rss=yesDifferentiating patients with inflammatory disease from those with functional disorders may be difficult in patients with nonspecific symptoms, such as diarrhea and abdominal pain. Most often, invasive procedures, such as endoscopy, with biopsies are required. A marker or a set of markers that can accurately detect inflammation and monitor disease activity would be useful clinically.Fecal Markers: Calprotectin and LactoferrinBincy P. Abraham, Sunanda Kane10.1016/j.gtc.2012.01.007Gastroenterology Clinics of North America 41, 2 (2012)2012-02-20Gastroenterology Clinics of North America2012-02-20412S0889-8553(11)X0007-9Noninvasive evaluation483495http://www.gastro.theclinics.com/article/PIIS0889855312000167/abstract?rss=yesIn the past decade, there has been a seismic shift in the use of imaging for Crohn disease (CD) away from small-bowel follow-through (SBFT) to cross-sectional techniques, most commonly computed tomography enterography (CTE) and magnetic resonance enterography (MRE). Because of rapid advances in CT and MRI hardware, as well as routine use of oral contrast agents designed to distend the lumen of the small bowel, cross-sectional techniques have become a first-line imaging modality, promising accurate assessment of the mucosa as well as the extraintestinal manifestations of penetrating disease. In most situations, the choice of cross-sectional modality (clinically) is essentially a tradeoff between the ease and cost of the study (which favor CTE) and the desire to minimize radiation exposure (which favors MRE).Imaging for Luminal Disease and Complications: CT Enterography, MR Enterography, Small-Bowel Follow-Through, and UltrasoundDavid J. Grand, Adam Harris, Edward V. Loftus10.1016/j.gtc.2012.01.015Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9Noninvasive evaluation497512http://www.gastro.theclinics.com/article/PIIS0889855312000039/abstract?rss=yesAlthough inflammatory bowel disease (IBD) is found worldwide, the majority of studies have focused on white populations in North America and Europe. The incidence (or number of new cases per year) and prevalence (total number of cases in the population) rates of IBD vary across populations and geographic locations. A number of publications have reviewed the differences in observed rates that have historically been attributed to social and economic development, industrialization, and a general conversion to the Western lifestyle. Although individual studies suggest different outcomes with regard to the incidence of IBD (from rates having hit a plateau to others suggesting both increases and decreases), collectively, these reports suggest that rates are increasing or at the very least stable across the populations that have been studied.Genetics in Diagnosing and Managing Inflammatory Bowel DiseaseJacob L. McCauley, Maria T. Abreu10.1016/j.gtc.2012.01.002Gastroenterology Clinics of North America 41, 2 (2012)2012-02-27Gastroenterology Clinics of North America2012-02-27412S0889-8553(11)X0007-9Noninvasive evaluation513522http://www.gastro.theclinics.com/article/PIIS0889855312000520/abstract?rss=yesIndex10.1016/S0889-8553(12)00052-0Gastroenterology Clinics of North America 41, 2 (2012)2012-06-01Gastroenterology Clinics of North America2012-06-01412S0889-8553(11)X0007-9523537