Measuring outcomes in complicated intra-abdominal infections Purpose of review Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. Clinical trials should help guide and improve the management of cIAIs. However, inappropriate selection or measurement of outcomes in cIAIs clinical trials can lead to misleading results on the effectiveness of interventions. This review aims to describe how outcomes are reported in randomized controlled trials evaluating antibiotic treatment for cIAIs and discuss how outcome reporting may be improved. Recent findings Commonly used primary outcomes are treatment success or failure, and these outcomes are endorsed by regulatory bodies. However, a consensus objective definition of either is not available and current measures are prone to bias. Variation exists in timing of outcome evaluation and analysis populations, which can lead to further bias. Use of core outcome sets can help standardize outcome reporting. Summary Inconsistency in outcome selection and reporting can lead to misleading results and impedes meta-analysis of data. Further progress, engaging clinical trialists, regulatory authorities, clinicians and patients is required to achieve consensus on which outcomes should be reported and how and when to measure them.

Foodborne transmission of Clostridioides difficile: a review Purpose of review The epidemiology of Clostridioides difficile infection (CDI) is changing, with increasing rates of community-acquired infections. In light of recent advances in understanding C. difficile transmission networks with whole-genome sequencing, new routes of spread outside the hospital need to be considered. This review examines the evidence behind food as a driver of C. difficile dissemination. Recent findings Recently published studies adding to the existing body of literature supporting C. difficile as a foodborne pathogen are discussed. Specifically, new evidence on the presence of C. difficile in root vegetables is reviewed. Whole genome sequencing studies delineating local and global transmission networks, in which the food chain may play a large role, are presented. Additional research implicating trehalose in the food industry and C. difficile is examined. Summary Genomic studies show that a new approach to studying C. difficile transmission is needed. Further research on C. difficile epidemiology should shift from a primarily nosocomial setting to include the community and environment at large, and attention given to implications of the food chain in the spread of this pathogen.

Carbapenemase-producing Enterobacteriaceae – once positive always positive? Purpose of review This review provides an overview of gastrointestinal tract colonization with carbapenemase-producing Enterobacteriaceae (CPE), including risk factors for colonization, determinants for duration of colonization, and whether patients can decolonize, either spontaneously or via targeted interventions. Recent findings CPE colonization is disseminating globally with increasing numbers of carbapenemases being identified in increasing patient cohorts. Numerous risk factors including repeated healthcare contact, patient co-morbidities and international travel have all been linked to increased rates of colonization. Duration of colonization has been investigated in various healthcare settings and ranges many months or even years. Although new methods for expediting decolonization are being investigated, including faecal microbiota transplantation, high quality evidence of impact is lacking. Summary Current evidence indicates that CPE colonization usually persists throughout the duration of most hospital admissions, although the majority of patients will subsequently spontaneously decolonize. Difficulties remain in determining the point at which patients can be considered decolonized because of the lack acceptable criteria for defining eradication. This has significance implications for infection prevention and control measures during the initial and subsequent hospital admissions. Strategies to reduce the healthcare burden of CPE colonization continue to rely predominantly on preventing acquisition, whereas decolonization efforts remain a focus of research.

Editorial: Colon updates 2020 – some old, some new but novel insights throughout No abstract available

Anal fissure management by the gastroenterologist Purpose of review Anal fissures are very common. They are easy to diagnose and treat in the office setting. They may coexist with hemorrhoids. In fact 20% of patients with hemorrhoids have anal fissures also. The purpose of this review is to highlight current diagnosis and treatment of anal fissures using diet, ointments and botulinum toxin to enable healing. Medical treatment relies on reducing anal sphincter spasm to allow improved blood flow and healing. Recent findings Many anorectal disorders can be managed in the office. Most anal fissures can be managed without the need for surgery. The need for anorectal examination, including use of anoscopy is stressed in the current literature. The use of calcium channel blockers in preference to nitroglycerin is highlighted as well as the use of botulinum toxin when ointments don’t work. Summary Anal fissure can be managed nonsurgically most of the time and gastroenterologists should be able to manage them. This article should help in preventing unnecessary surgery and its complications, mainly incontinence in a small but significant number. The search for more effective drugs and options for managing this disorder continues.

Immune-checkpoint inhibitors induced diarrhea and colitis: a review of incidence, pathogenesis and management Purpose of review Diarrhea and colitis are among the most commonly encountered immune-mediated adverse events among patients receiving antiprogrammed cell death protein/ligand-1 (PD-1/L1) as well as anticytotoxic T-lymphocyte-associated protein 4 (CTLA-4) antibodies. With growing indications and widespread use of immune checkpoint inhibitors, it is imperative to summarize the current body of evidence concerning the incidence, pathogenesis, risk factors, diagnostic challenges, and treatment options currently available for the management of immune-mediated diarrhea and colitis. Additionally, with emerging evidence analyzing the resumption of immune checkpoint inhibitors, it is pivotal to summarize our current understanding and future challenges. Recent findings Immune-mediated diarrhea and colitis can potentially be a viable surrogate marker for improved survival as it is validated further in large-scale studies. Early endoscopic evaluation can aid in the identification of patients at risk of developing steroid refractory immune-mediated colitis, and hence can be chosen to receive early add-on therapy with infliximab, vedolizumab or fecal microbiota transplantation, an emerging treatment option for immune-mediated diarrhea and colitis. Resuming immune checkpoint inhibitors carries a manageable risk of recurrent diarrhea and colitis, with most cases being mild and effectively managed with immunosuppressive therapy. Summary As our understanding of immune-mediated diarrhea and colitis grows, it is likely that this clinicopathologic entity will represent more than just an adverse event. With a growing number of treatment options, the management algorithms for immune-mediated diarrhea/colitis are likely to evolve in the future.

Endoscopic management of inflammatory bowel disease-associated complications Purpose of review The main complications of inflammatory bowel disease (IBD) are strictures, fistulas, abscesses, and colitis-associated neoplasia. In addition to diagnosis, disease monitoring, and surveillance, endoscopy plays an important role in the management of those complications. This review is to provide up-to-date information in endoscopic treatment modalities for those complications. Recent findings The endoscopic therapy of IBD complication has evolved from balloon dilation of strictures to endoscopic stricturotomy, strictureplasty, stenting, fistulotomy, sinusotomy, and neoplasia ablation. These endoscopic approaches have provided minimally invasive treatment for those complications. Summary The advances in interventional IBD may be credited to our better understanding of the disease process and nature of targeted lesion, and execution of updated principles and techniques of endoscopy.

Pouchitis: diagnosis and management Purpose of review Pouchitis is the most common complication in patients who undergo ileal pouch-anal anastomosis (IPAA), occurring more frequently in patients with ulcerative colitis. Pouchitis – the inflammation of the pouch – can be due to idiopathic or secondary causes. Chronic antibiotic-dependent pouchitis (CADP) and chronic antibiotic-resistant pouchitis (CARP) are the most difficult forms of chronic idiopathic pouchitis to treat. Crohn's disease of the pouch may develop de novo in ulcerative colitis patients following colectomy with IPAA. It carries a high risk for pouch failure, and its diagnosis and management are challenging. The purpose of this review is to illustrate the present trends in the diagnosis and treatment of idiopathic pouchitis and Crohn's disease of the pouch. Recent findings The use of the newer biologic agents, vedolizumab and ustekinumab, has shown promising results in patients with CADP, CARP, and Crohn's disease of the pouch. Fecal microbiota transplantation has also been reported to have encouraging preliminary results in small studies and case series for the treatment of chronic pouchitis. Summary Promising new treatments are emerging for difficult-to-treat forms of pouchitis. Larger prospective and head-to-head comparative studies among the various treatments are needed to evaluate the efficacy and safety of these agents across the pouchitis subgroups, and to identify predictors of response.

Appendiceal neuroendrocrine neoplasms: incidentaloma or something we should worry about? Purpose of review To synthesize the current knowledge and guidelines on the management of appendiceal neuroendocrine neoplasms (ANENs). Recent findings Most recent guidelines are essentially based on heterogeneous retrospective series. With the advent of a more precise classification of neuroendocrine neoplasms, this heterogeneity is rightly criticized and many ‘grey areas’ are now debated in expert literature. The only way to solve these issues is through the conduct of large prospective multicentre studies, but this seems somewhat utopian, given the rarity of this disease. Summary ANENs are rare tumours with a favourable prognosis, and mainly diagnosed in young patients. They are predominantly localized, and diagnosed incidentally on appendectomy. This procedure is curative for the vast majority of patients but ANENs can relapse even a significant time after the first diagnosis. Identifying the risks for recurrence is challenging, with some factors thought to be predictive of nodal involvement. The presence of one or more of these factors justifies an oncological radicalization of the surgical procedure (right hemicolectomy with lymphadenectomy). However, the beneficial impact of this surgical procedure on survival is still unproven.