Principles and Practice of Oral Rehydration Abstract Purpose of Review An understanding of fluid and electrolyte losses from diarrhea and mechanisms of solute cotransport led to development of oral rehydration solution (ORS), representing a watershed in efforts to reduce diarrheal disease morbidity and mortality. This report reviews the scientific rationale and modifications of ORS and barriers to universal application. Recent Findings Solutions with osmolality and electrolyte composition different from original ORS for routine and unique pathophysiology such as in malnutrition have met with varying success. Following the conceptual rationale of sodium-glucose cotransportation to facilitate water absorption, other cotransporters and formulations have been explored with the aim to improve ORS efficacy and acceptance. Summary ORS remains the anchor of acute watery diarrhea and dehydration management worldwide. Despite development of different formulations, the current standard solution is the mainstay of treatment for nearly all situations. Efforts to improve oral hydration solution and to increase acceptance and usage are ongoing.

Tips for the Budding Esophagologist Abstract Purpose of Review The specialty of gastroenterology has evolved such that there are now multiple areas of “superspecialty” within the field. Interest in “esophagology” has expanded as options for medical therapy, advanced optics, motility testing and reflux monitoring, and minimally invasive and endoscopic therapeutics have grown. For a multitude of reasons, academic and private practices alike are looking to expand in this growing superspecialty. Recent Findings Several articles offer criteria for competency in manometry. Summary This article discusses in detail multiple options for developing skills in diagnosis and treatment of esophageal disease with “tips for the budding esophagologist.”

EUS-Guided Portal Venous Sampling of Circulating Tumor Cells Abstract Purpose of Review Although liquid biopsies hold significant promise in the management of patients with cancer, peripheral blood analyses remain dependent on the degree of tumor burden with prohibitively low yields until the cancer is widely metastatic. Multiple lines of evidence support a dynamic, spatiotemporal localization of circulating tumor cells (CTCs) supporting specific targeting of vascular compartments, such as the portal vein. This review discusses the literature evaluating the possibility of portal venous blood as a new, potentially higher yield liquid biopsy and the current devices and techniques for endoscopic ultrasound (EUS)-guided portal venous sampling for CTC detection. Recent Findings Two recent studies in pancreatic cancer have demonstrated that portal venous blood can be safely sampled via EUS and consistently yields significantly higher CTC counts compared with matched peripheral blood. EUS-acquired samples can be used for molecular testing, clinical prognostication, and drug sensitivity analyses. Summary Portal venous CTCs are identified in higher quantity relative to peripheral blood and can be safely obtained via EUS. Further studies are required to demonstrate the clinical utility of EUS-guided portal venous tumor material enrichment and analysis; however, obtaining EUS-guided “liquid biopsies” appears to merit significant consideration for procedural adoption.

Controversy in Nutrition Recommendations for Short Bowel Syndrome: How Type of SBS Impacts Response Abstract Purpose of Review This review examines the current recommendations for dietary management of patients living with short bowel syndrome (SBS) and outlines the need for future research to provide optimal care for this unique group of patients. Recent Findings Providers caring for patients with SBS lack sufficient data to help guide recommendations regarding diet. The majority of studies are conducted at a single medical institution on a small number of anatomically diverse patients. Multi-center studies would allow for inclusion of a larger number of patients and may lead to more individualized dietary recommendations. Summary Patients with short bowel syndrome should be evaluated on an individual basis by a multidisciplinary team including physicians, dieticians, pharmacists, and nurses specializing in the care of these complex patients. Tailoring both medical and nutritional therapy will help realize the overarching goal for these patients of maintaining adequate nutrition with diet and medications, and achieving independence from parenteral support.

Proton Pump Inhibitors in the Elderly, Balancing Risk and Benefit: an Age-Old Problem Abstract Purpose of Review Proton pump inhibitors (PPIs) are one of the most prescribed drugs in the developed world and elderly patients are particularly likely to be prescribed acid suppression. There have been reports of many diseases being associated with PPI therapy and the elderly would be particular at risk of any harms these drugs may cause. This review therefore reviews the evidence of the risks and benefits of these drugs. Recent Findings PPIs are very effective at treating acid-related disorders. Recent randomized trials have suggested that the associations between PPI and various diseases are likely to be related to bias and residual confounding and these drugs appear to be safe apart from a possible increase risk of enteric infections. Summary PPIs should be used at the lowest dose and for the shortest duration possible. They are still relatively safe drugs but should only be prescribed for proven indications.

Management of Pancreatic Duct Stones Abstract Purpose of Review Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Recent Findings Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Summary Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

Fiber, Fat, and Colorectal Cancer: New Insight into Modifiable Dietary Risk Factors Abstract Purpose of Review To review recent data on the role and interactions of fiber and fat as dietary risk factors associated with colorectal cancer (CRC) risk in humans. Recent Findings Fiber intake shows convincing and linear dose-response negative correlation with CRC risk. Dietary fiber stimulates butyrogenic activity of the gut microbiota, providing high amounts of butyrate that shows extensive anti-neoplastic effects. A high-fat diet promotes CRC risk through stimulated bile acid metabolism, facilitating bile acid conversion by the gut microbiota to tumor-promoting deoxycholic acid. Comprehensive interactions of these microbial metabolites are likely to underlie mechanisms driving diet-dependent CRC risk in different populations, but require further experimental investigation. Summary Dietary fiber and fat shape the composition and metabolic function of the gut microbiota, resulting in altered amounts of butyrate and deoxycholic acid in the colon. Fiber supplementation and restriction of fat intake represent promising strategies to reduce CRC risk in healthy individuals.

Increased Use of Emulsifiers in Processed Foods and the Links to Obesity Abstract Purpose of Review The purpose of this review is to discuss the implications of the increased prevalence of emulsifiers in processed foods in daily consumption, the links to obesity both in mice and in vitro studies, and how those findings correlate with humans. Recent Findings There is rising interest in understanding the contributors to the obesity epidemic. One potential component recently studied has been the consumption of processed foods causing inflammatory changes leading to metabolic syndrome. This phenomenon has been shown in several mice and in vitro studies with changes in microbiome composition, elevated fasting blood glucose, hyperphagia, increased weight gain and adiposity, hepatic steatosis increased inflammatory markers, and a correlation with increased incidence of colorectal cancer. Summary Emulsifiers are found in most foods consumed in the US population, which has increased over the years. This review focuses on understanding the initial approved safe levels of emulsifier consumption, the preceding increased use in foods with higher daily consumption than was previously tested, measuring these levels in animal models, and the positive association with obesity and metabolic syndrome. Future research will require prospectively studying emulsifier consumption more accurately along with the associated respective changes in the microbiome to determine the relationship to obesity.

IBD in the Elderly: Management Challenges and Therapeutic Considerations Abstract Purpose of review Elderly patients with inflammatory bowel disease (IBD) are increasing in prevalence as our population ages and the incidence of IBD increases. The purpose of this review is to describe the management challenges in elderly IBD patients, including comorbid conditions and therapeutic considerations unique to the elderly population. Recent findings The elderly experience coexisting comorbidities that complicate IBD management. The disease course and potential side effects of treatments can impact the elderly IBD patient differently than younger IBD patients. The duration for colorectal cancer surveillance (CRC) also remains controversial and should be individualized to determine when discontinuation is appropriate. Summary Given greater safety considerations in the elderly IBD population, treatment targets and management goals require a more personalized approach in the elderly, taking into account coexisting comorbidities, inflammatory burden, and functional limitations.

Neuronal Control of Esophageal Peristalsis and Its Role in Esophageal Disease Abstract Purpose of Review Esophageal peristalsis is a highly sophisticated function that involves the coordinated contraction and relaxation of striated and smooth muscles in a cephalocaudal fashion, under the control of central and peripheral neuronal mechanisms and a number of neurotransmitters. Esophageal peristalsis is determined by the balance of the intrinsic excitatory cholinergic, inhibitory nitrergic and post-inhibitory rebound excitatory output to the esophageal musculature. Recent Findings Dissociation of the longitudinal and circular muscle contractions characterizes different major esophageal disorders and leads to esophageal symptoms. Provocative testing during esophageal high-resolution manometry is commonly employed to assess esophageal body peristaltic reserve and underpin clinical diagnosis. Summary Herein, we summarize the main factors that determine esophageal peristalsis and examine their role in major and minor esophageal motility disorders and eosinophilic esophagitis.