New frontiers in digestive diseases

Attendees of the 2010 Spring postgraduate course were treated to a glimpse of the future of gastroenterology in the session entitled “New Frontiers in Digestive Diseases.” Notable speakers from around the nation gave their perspective on cutting edge issues, covering topics ranging from the evolving epidemics of obesity and C. difficile infection, to novel approaches to screening for colorectal cancer, and prospects for new endoscopic modalities and NOTES (natural orifice tran-sendoscopic surgery).

They described some of the limitations of optical colonoscopy in screening for colorectal cancer. At least three studies have now reported decreased protection against colorectal cancers in the right colon, as compared to the left colon. The importance of technical issues that may limit the sensitivity of colonoscopy in the right colon, including poor preparation, missing flat or serrated lesions, and failure to document examination of the cecum. The growing evidence support the use of fecal immunochemical tests (FITs) and novel serum tests for colorectal cancer.

The changing epidemiology of C. difficile was highlighted. Affected individuals have broadened from those who received antibiotics during hospitalization to include community acquisition with or without antibiotic exposure, as well as the elderly, those who are immune suppressed, and people with multiple co morbid illnesses. Maintaining a high index of suspicion for the diagnosis, even when stool test for the bacterial toxin are not positive, and to treat those with oral vancomycin as the initial therapy.

The Pennington Biomedical Research Center in Baton Rouge, La., presented the evidence in favor of gastroenterologist taking an active role in the treatment of obesity, as well as the many diseases affecting the GI tract that are related to obesity. Based upon an improving understanding of the causes of obesity, new pharmacologic interventions are being studied and are likely to be reviewed by the FDA in the next year. These include lorcaserin, 5HT-2C serotonin receptor agonist, and two combinations of drugs, namely bupropion with naltrexone and phentermine with topiramate. Endoscopic approaches, such as the duodenal sleeve, are also being studied. NOTES continues to be an area of intense activity, according to Massachusetts General Hospital professor of medicine at Harvard Medical School. NOTES holds promise achieving less pain, no surgical scars, faster recovery, and the potential to perform surgical procedures under circumstances of less stringent sterility. Although rarely performed, the first human NOTES procedures have been transvaginal cholecystectomy. Whether NOTES will become a common surgical approach remains to be seen, but spinoff technologies will likely broaden the capabilities for intraluminal procedures in the realm of gastroenterology.

Finally, a panoply of novel endoscopic technologies was described. Techniques that go beyond the capabilities of white light videoendoscopy include optical coherence tomography (OCT), narrow band imaging, capsule endoscopy, balloon or spiral enteroscopy, retrograde viewing devices, and confocal microscopy. The studies are needed to prove the incremental benefit of these new technologies over the existing modalities.