Functional Dyspepsia in the Elderly Abstract Purpose of Review Functional dyspepsia is a common condition, and the condition is defined by symptoms using Rome IV criteria. This review addresses the issue of functional dyspepsia in elderly patients, epidemiology, investigation, and treatment. Recent Findings Recent studies show that while the prevalence of dyspepsia declines in the elderly, it is still prevalant investigations to confirm the diagnosis (including mandatory upper gastrointestinal endoscopy) must exclude organic disease. These include ulcers (particularly associated with nonsteroidal antiinflammatory drugs), Helicobacter pylori pathologies, cancer, coeliac disease, and autoimmune gastritis. Recent research is unraveling pathophysiology beyond symptom-only definitions, focusing on the duodenum with innate immune disturbance (duodenal eosinophilia) and microbial disruption as possible cause. Management of functional dyspepsia includes making a secure diagnosis, treatment with first-line proton pump inhibitors (PPI), then tricyclic antidepressants, and careful choice of prokinetics. Herbal treatments (peppermint oil) and STW-5 have in this age group limited efficacy. Summary Further studies are needed to define the prevalence of functional dyspepsia in the elderly and of prime importance, to exclude organic disease as a cause for symptoms of dyspepsia.

Drug-Induced Small Bowel Injury: a Challenging and Often Forgotten Clinical Condition Abstract Purpose of Review Most drugs are given by the oral route. Oral intake allows direct contact between the drug and the entire GI tract mucosa, exposing it to potential topical damage until absorption. Medication-induced GI symptoms and lesions are therefore commonly encountered in clinical practice. This review will examine the most common drugs or classes of drugs affecting small bowel function and/or structure. Recent Findings Since non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used medicines, NSAID enteropathy is highly prevalent and brings about considerable morbidity. Antimicrobials and proton-pump inhibitors profoundly modify intestinal microbiota, affecting gut sensory and motor functions, while other drugs (like iron and gold derivatives) impair intestinal permeability. Olmesartan (and likely ACE inhibitors) induce villous atrophy and consequent malabsorption. Mycophenolate mofetil, cancer chemotherapeutic agents, and immune checkpoint inhibitors cause intestinal inflammation, abdominal pain, and diarrhea. Potassium chloride supplements may induce small bowel ulceration, stenosis, and perforation while the cotraceptive pill and anticoagulants are associated with intestinal ischemia and spontaneous intramural hematoma, respectively. Summary In clinical practice, a deep knowledge of clinical pharmacology and toxicology and a high degree of suspicion of drug-related adverse events are mandatory. Only then, the practicing physician will be able to diagnose medication-induced small bowel lesions correctly and will implement the best strategies to treat them.

Cryptogenic Multifocal Ulcerating Stenosing Enteropathy(CMUSE) and/or Chronic Non-specific Multiple Ulcers of the Small Intestine(CNSU) and Non-granulomatous Ulcerating Jejunoileitis (NGUJI) Abstract Purpose of Review The purpose is to make aware of the existence of the rare and exclusive small intestine (SI) diseases, namely cryptogenic multifocal ulcerating stenosing enteropathy (CMUSE) or chronic non-specific multiple ulcers of the small intestine (CNSU) and non-granulomatous ulcerating jejunoileitis (NGUJI). The article will elucidate their epidemiology, pathogenesis, clinical features, diagnosis, differentiating features and management. Recent Findings Recent papers have published the clinical features and diagnostic criteria of CMUSE/CNSU and NGUJI. CNSU/CMUSE is caused by gene mutations involved in the prostaglandin pathways. Although capsule endoscopy can detect these lesions, it carries a risk of retention. TNF antagonists and azathioprine have shown response in few cases. Summary CMUSE/CNSU and NGUJI are uncommon diseases that cause relapsing SI obstruction and bleed due to short-segment strictures and multiple shallow ulcers. This article focuses on current knowledge and novel insights regarding their pathogenesis, genetics, clinical features, diagnostic criteria and management. Multicentric clinical and genetic studies are the need of the hour.

Maneuvering Clinical Pathways for Ulcerative Colitis Abstract Purpose of Review Recent years have brought about several advances in the treatment of patients with ulcerative colitis (UC). Here, we discuss salient recommendations of recent treatment guidelines; review the efficacy, safety, and real-world data of vedolizumab and tofacitinib; appraise their place vis-à-vis established agents; and consider the newly proposed approaches of risk-stratified and treat-to-target therapy. Recent Findings Once daily oral mesalamine dosing is equivalent to split dosing in mild–moderate UC. Real-world data are accumulating on the effectiveness and safety of vedolizumab for moderate to severe UC, while there are few such data on the most recently approved agent, tofacitinib. High-dose infliximab is being investigated for severe UC. New approaches are challenging the established paradigm of selecting therapy based on current disease activity. The risk-stratified approach incorporates long-term risk as well as the current burden of inflammation. The treat-to-target approach aims at improved long-term outcomes by adjusting therapy to resolve intestinal inflammation. Summary The therapeutic options for UC are continually expanding. Risk-stratified therapy and the treat-to-target approach represent paradigm shifts in UC management. Optimal disease control requires an individualized approach that takes into consideration current inflammatory burden, long-term risk, patient preferences, and ongoing assessment of response to treatment.

Microbial Profiles of Cirrhosis in the Human Small Intestine Abstract Purpose of Review The aim of this review is to summarize the recent literature on associations of small intestinal microbial and bile acid profiles with liver cirrhosis and its complications. Recent Findings Recent studies into the duodenal microbiome of patients with cirrhosis have linked the microbiome to certain etiologies of chronic liver disease as well as complications of cirrhosis. In particular, microbial differences in the duodenum of patients with cirrhosis have been linked to the presence of hepatic encephalopathy and varices. Summary While the fecal microbiome of patients with liver cirrhosis is well characterized, the small intestinal microbiome of cirrhotic patients is an active area of research. This review focuses on the current understanding of the small intestinal microbiome in human cirrhosis as well as future directions of the field.

A Functional Approach to Feeding Difficulties in Children Abstract Purpose of Review This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders. Recent Findings Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. Summary While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

How I Approach Dysphagia Abstract Purpose of Review This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements. Recent Findings The evaluation of dysphagia begins with a detailed history followed by endoscopy to evaluate for any structural abnormalities including malignancy. This is especially true given the emergence of eosinophilic esophagitis (EoE) as a dominant cause of esophageal dysphagia. In fact, it is now standard practice to obtain esophageal biopsies during endoscopy performed to evaluate dysphagia, since EoE can present without the characteristic mucosal features of rings, furrows, and exudate. Achalasia is also more frequently encountered since the introduction of high-resolution manometry (HRM) and the Chicago Classification into clinical practice. The Chicago Classification provides a stepwise diagnostic algorithm for evaluating HRM studies and systematically diagnosing esophageal motility disorders. Lastly, the functional lumen imaging probe (FLIP) is a novel technology that has added insight into both achalasia and EoE. Measuring esophageal distensibility with FLIP has useful prognostic implications for both diseases, and FLIP can identify motility abnormalities in achalasics not detected with HRM. Summary A careful history is key to the efficient evaluation of dysphagia, and endoscopy is usually the first diagnostic study to obtain. For patients with prominent reflux symptoms, an empiric trial with proton pump inhibitors is reasonable then because reflux disease is such a common cause of dysphagia. Thereafter, patients should undergo HRM to evaluate for a motility disorder, and FLIP can provide complementary data to guide management.

Classifying Enteral Nutrition: Tailored for Clinical Practice Abstract Purpose of Review To discuss the different forms of enteral nutrition, while outlining available evidence for its use in specific conditions and how enteral nutrition composition may or may not influence relevant outcomes. Recent Findings Enteral nutrition formulas were originally conceived as a liquid form of nutrition for individuals who otherwise could not consume adequate calories through solid food. Over time, the emergence of specialty formulas marketed to benefit specific diseases or conditions has led to a broad range of potentially confusing options. While most options have theoretical benefit for their marketed conditions, the evidence demonstrating practical benefit is not consistent. Summary Overall, the certainty of evidence for specialty formulas remains low or very low. In most instances, one could begin with standard polymeric formula, except in cases where disease-specific formulas are recommended. Much research is nonetheless still needed to clarify whether some disease-specific formulas are truly beneficial or merely theoretical features.

Treatment of Pruritus Secondary to Liver Disease Abstract Purpose of Review Pruritus is a common extrahepatic symptom in various liver disorders, in particularly those with cholestatic features. This review summarizes epidemiology, pathophysiology, evidence-based therapeutic recommendations and currently investigated drugs for pruritus in hepatobiliary disorders. Recent Findings Recent epidemiological data suggest pruritus as a common and relevant symptom in immune-mediated liver diseases, i.e., primary biliary cholangitis (PBC) with over 70% affected patients, up to 56% suffering from chronic pruritus. The better pathophysiological understanding of hepatic pruritus has led to the identification of novel therapeutic targets, addressed in drug trials using KOR agonists, PPAR agonists, and ileal bile acid transporter inhibitors. Summary Hepatic itch remains among the most agonizing symptoms for affected patients and a clinical challenge for physicians. Therapeutic recommendations include a guideline-based stepwise approach starting with cholestyramine, followed by rifampicin, naltrexone, and sertraline. Bezafibrate and ileal bile acid transporter inhibitors represent promising future anti-pruritic treatment options.

Salvage Options for Fundoplication Failure Abstract Purpose of Review Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients. Recent Findings A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Summary Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.