NEJM Journal Watch Gastroenterology Top Stories of 2019

Dear Readers,

Another year has passed, and once again, we have selected our top picks from among our summaries of high-impact, high-quality research in gastroenterology. With the many interesting summaries published this year, choosing only 10 was difficult. Below I explain my choices, made with input from our associate editors.

For several years, observational studies have suggested an association between long-term proton-pump inhibitor (PPI) use and a host of potential adverse events. This year, we finally saw results from a well-designed, randomized, prospective study demonstrating no relationship between PPI use and the range of previously documented adverse events, with the exception of enteric infections. This may reassure patients who require long-term PPI therapy and will hopefully avoid unnecessary discontinuation of PPIs in these patients.

In the management of acute upper gastrointestinal bleeding, a new guideline changed or clarified recommendations for the route and dosing of PPI therapy in high-risk lesions after endoscopic therapy. The same guideline updated recommendations on risk assessment, the timing of endoscopy, and the use of hemostatic sprays and transfusion thresholds, while offering an excellent overview of the evidence to support all of the clinical recommendations.

Another new guideline focuses on diagnostic testing for the highly prevalent conditions of functional diarrhea and diarrhea-predominant irritable bowel syndrome. Providing recommendations on targeting testing for specific disorders (celiac disease, Giardia) and stool studies to rule out inflammatory bowel disease (IBD), it should help us avoid a shotgun approach to diagnostic testing.

Several key studies on biologic therapies for IBD made the list. These include the first head-to-head comparison of biologic therapies for ulcerative colitis (vedolizumab was superior to adalimumab for the treatment of moderately to severely active ulcerative colitis). Also published are much-needed data on biosimilars of biologic therapies in patients with IBD (vs. other disease states). In 5000 treatment-naive patients, an equivalence trial showed similar efficacy and safety of infliximab and a biosimilar (CT-P13) in the treatment of Crohn disease at 18 months, suggesting that biosimilars are effective in real-world clinical settings.

With recent optimization of treatments for hepatitis B and hepatitis C infections, other liver diseases have received relatively more attention, and less-aggressive therapy seems to be effective in some. Specifically, early treatment (within 8 hours) of acetaminophen overdose with N-acetylcysteine may require only a 12-hour infusion, rather than the traditionally used 72-hour infusion. Also, lower doses of corticosteroids appear to be as effective as higher doses for inducing remission of autoimmune hepatitis.

We learned more about how smoking and alcohol might result in different phenotypes of chronic pancreatitis, which can result from multiple causes. A large (1000-participant), retrospective, multicenter study showed that different complications of chronic pancreatitis (inflammatory, fibrotic, or insufficiency) are associated with different patterns of exposure to alcohol and cigarette smoking, suggesting that these exposures may influence the ultimate phenotype of chronic pancreatitis in individual patients.

Other new data inform the elusive challenge of finding the optimal therapy for chronic heartburn. A prospective randomized trial in highly selected U.S. veterans with documentation of acid-related symptoms showed that 1-year symptom relief was superior with surgical therapy compared with two medical therapies that included PPIs. It is unclear if similar results can be achieved in a broader set of patients in whom the role of acid exposure may be less clear.

Finally, in spite of strong evidence that the overwhelming majority of nonmalignant colorectal polyps can be removed endoscopically, the frequency of surgical resection is increasing. A retrospective study in 250,000 inpatients over a 10-year period demonstrated higher morbidity and mortality with surgery compared with endoscopic resection. Along with other recent studies demonstrating the success and relative safety of endoscopic resection, these data suggest that endoscopic removal is the treatment of choice for nonmalignant colorectal polyps.

I hope that you will find these summaries informative. We look forward to sharing the latest advances in gastroenterology with you in 2020.

Here are the NEJM Journal Watch Gastroenterology top stories of 2019:

• Randomized Trial Supports Long-Term Safety of Proton-Pump Inhibitors

• Unraveling the Safety Profile of Proton-Pump Inhibitors

• Updated International Guideline on Nonvariceal Upper Gastrointestinal Bleeding

• Testing for Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome

• First Head-to-Head Trial of Biologics for Ulcerative Colitis

• Infliximab Biosimilar CT-P13 for Crohn Disease Appears Effective

• Shorter Therapy Duration in Low-Risk Patients with Acetaminophen Overdose

• Effect of Predniso(lo)ne Induction Dose on Remission in Autoimmune Hepatitis

• Different Toxins Lead to Different Complications of Chronic Pancreatitis

• Comparing Treatments for Refractory Heartburn: A Randomized Trial

• Surgery for Nonmalignant Colorectal Polyps: Not Good Medicine