Articles You Don’t Wanna Miss (2016 Issue)

Francis Chan - The Chinese University of Hong Kong, Hong Kong
Henry Chan - The Chinese University of Hong Kong, Hong Kong
Philip Chiu - The Chinese University of Hong Kong, Hong Kong
Siew Ng - The Chinese University of Hong Kong, Hong Kong
Vincent Wong - The Chinese University of Hong Kong, Hong Kong
Grace Wong - The Chinese University of Hong Kong, Hong Kong



Amidst mountains of articles in a vast array of medical journals, it takes an indeterminate amount of time to sort and find those that are relevant to your research or interest. That makes a curated collection of articles particularly welcoming. In this issue of Scope, we have found editors of prestigious journals to suggest a list of recent articles that are worth reading. Read on to find out our experts’ recommendations.



“Recurrence and Mortality Among Patients Hospitalized for Acute Lower Gastrointestinal Bleeding”

Aoki T, Nagata N, Niikura R, et al. Clinical Gastroenterology and Hepatology 2015; 13: 488-494.


Recommended by FRANCIS CHAN, Editor of Clinical Gastroenterology and Hepatology


In this study, Aoki et al. reported the long-term recurrence and mortality rate in a retrospective cohort of 369 patients with overt lower gastrointestinal bleeding in a tertiary emergency hospital. The top 3 causes were diverticular disease (50%), ischemic colitis (13%), and colorectal cancer (9%). The cumulative rates of recurrent bleeding at 1 and 5 years were 19% and 46%, respectively. This study highlights the significant clinical impact of lower gastrointestinal bleeding in Asia. Unlike upper gastrointestinal bleeding, there is no effective pharmacologic therapy for the prevention of recurrent LGIB. Identification of high risk factors is crucial to the effective management. It has been observed that advanced age, comorbidity, dual antiplatelet drugs and warfarin use are all risk factors for long-term mortality. Looking ahead, the burden of LGIB will continue to increase because of old age, extensive use of antiplatelet drugs, and a decreasing incidence of upper gastrointestinal bleeding. Future research should focus on addressing these unmet clinical needs.



The long-term benefits of nucleos(t)ide analogs in compensated HBV cirrhotic patients with no or small esophageal varices: A 12-year prospective cohort study

Lampertico P, Invernizzi F, Vigano M, et al. Journal of Hepatology 2015; 63:1118-1125.


Recommended by HENRY CHAN, Associate Editor of Journal of Hepatology


A group of Italian investigators conducted a prospective study with repeated upper gastrointestinal endoscopies in one hundred and seven HBeAg-negative chronic hepatitis B patients with compensated liver cirrhosis on nucleos(t)ide analogs Among patients who had baseline F1 oesophageal varices, the 12-year cumulative incidence of varices regression was 83%. Nowadays, with entecavir and tenofovir being the recommended first line antiviral therapy for chronic hepatitis B, oesophageal varices is almost a preventable complication. Future recommendation for screening of oesophageal varices in chronic hepatitis B may need to change, taking the possibility of regression of varices into consideration. Regression of liver fibrosis associated with long-term NA use is likely the reason for regression of varices. The next important question is hence how non-invasive assessment of liver fibrosis can reduce the need of endoscopy surveillance in low-risk cirrhotic patients. The risk of HCC can be reduced by NA but not abolished; HCC will become the predominant cause of oesophageal variceal bleeding in the new era of chronic hepatitis B.



Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline”

Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, et al Endoscopy 2015; 47:829-854


Recommended by PHILIP CHIU, Editor of Endoscopy


This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system [1] [2] was adopted to define the strength of recommendations and the quality of evidence. Since the first report of endoscopic submucosal dissection (ESD) in 2001, there has been a collection of prospective and retrospective studies from Asia confirming the safety and efficacy of ESD for treatment of early gastrointestinal cancers. Compared to conventional endoscopic mucosal resection (EMR), ESD offers a significantly lower rate of local recurrence and higher rate of en-bloc resection. However, the adoption of ESD is slower than expected in Europe and United States. The differences in incidence of early gastrointestinal cancers, the higher technical demand for performance of ESD and the lack of expertise may be part of the reasons. This European Society of Gastrointestinal Endoscopy (ESGE) guidelines is thus important to clearly recommend indications for ESD on treatment of superficial esophageal squamous cell cancers, Barrett’s esophagus related neoplasia, as well as colon and rectal superficial lesions which are important GI neoplasia in European countries.



“Fecal Calprotectin Detects Endoscopic Recurrence in Postoperative Crohn’s Disease: How Many Colonoscopies Can We Avoid?”

Wright EK, Kamm MA, De Cruz P, et al. Gastroenterology 2015;148:938-947.


Recommended by SIEW NG, Editorial Board Member of Gastroenterology


In a prospective, randomized, controlled trial, serial fecal calprotectin level, serum C-reactive protein (CRP) levels, and Crohn’s disease activity index (CDAI) were used to predict endoscopic recurrence at 6, 12, and 18 months postoperatively. A cutoff of fecal calprotecin > 100 μg/g identified patients with endoscopic recurrence with 89% sensitivity and 58% specificity. Altogether colonoscopy could have been avoided in 47% of patients without endoscopic recurrence. The important prospective study consisting of a large sample size, endoscopic validation, and longitudinal measurements of fecal calprotectin showed that fecal calprotectin can effectively monitor Crohn’s disease after intestinal resection. So how should we use colonoscopy and fecal calprotectin in the management of Crohn’s patients after intestinal resection? The choice should be tailored based on risk stratification and patient characteristics. A combination of both modalities might prove to be useful.Such strategy needs to be tested in future studies for the prevention of both clinical relapse and subsequent surgical resections.




“Towards zero mother-to-infant transmission of hepatitis B virus”

Chen HL et al., Hepatology (Hong Kong Edition) 2016;1:13-22; Hepatology 2015; 62:375-386.


Recommended by GRACE WONG, Editor-in-Chief of Journal of Gastroenterology and Hepatology (Hong Kong Edition)


In a recently published randomized controlled trial from Taiwan, 118 pregnant women who had very high viral load (serum HBV DNA above 7.5 log10 IU/mL), were randomized to no treatment versus tenofovir disoproxil fumarate (TDF) from 30-32 weeks of gestation until 1 month postpartum. Newborns from the TDF group had lower rates of HBV DNA positivity at birth (6.15% vs. 31.48%) and hepatitis B surface antigen positivity at 6 months old (1.54% vs. 10.71%). This clinical trial provided level I evidence that a short course of TDF for 12 to 16 weeks may be able to reduce the risk of mother-to-infant transmission of HBV to as low as 1%. But is it possible to further bring the risk down to zero? Another randomized controlled trial in China of similar design suggested that starting TDF when serum HBV DNA was above 200,000 IU/mL (5.3 log10 IU/mL) might reduce MCTC to 0% (Pan C, et al. AASLD 2015; Oral #209). The latest American guidelines published November 2015 supported the use of antiviral therapy in HBV carrier mothers with HBV DNA above 200,000 IU/mL. Together with the universal vaccination, a generation of zero HBV infection is coming.



Global patterns of hepatocellular carcinoma management from diagnosis to death: the BRIDGE Study

Park JW, Chen M, Colombo M, et al. Liver International 2015;35:2155-2166.


Recommended by VINCENT WONG, Associate Editor of Liver International


In the Global HCC BRIDGE Study, 18 031 patients with newly diagnosed HCC from 14 countries were retrospectively evaluated for clinical features, treatment and outcomes. Most patients had Barcelona Clinic Liver Cancer stage C disease, but over half of the patients from Taiwan and Japan had stage 0 or A. As a result, more patients from Taiwan and Japan could undergo curative treatments with liver resection or local ablative therapy, and this led to better survival. Owing to the lack of conclusive data from randomized controlled trials, the role of HCC screening has been a matter of debate. Nonetheless, this impressive study, together with numerous observational studies, shows that countries with screening detect smaller HCCs at an earlier stage. These patients then benefit from curative treatment and have longer survival even after adjustment for lead time and length time bias. Furthermore, the younger age at HCC diagnosis in China probably reflects another phenomenon: inadequate treatment of chronic liver diseases (hepatitis B in this case) is associated with faster disease progression and earlier HCC development.



“The Diagnostic Value of a Digital Rectal Examination Compared With High-Resolution Anorectal Manometry in Patients With Chronic Constipation and Fecal Incontinence” 

Soh JS , Lee HJ , Jung KW, et al. American Journal of Gastroenterology 2015; 110:1197–1204.


Recommended by JUSTIN WU, Editor of The American Journal of Gastroenterology


In this study, 268 patients with chronic constipation and 41 patients with fecal incontinence underwent a standardized digital rectal examination (DRE), high resolution anorectal manometry (HRAM), and balloon expulsion test. In constipation patients, the sensitivity, specificity, and positive predictive value of DRE in the diagnosis of dyssynergia are 93.2%, 58.7%, and 91.0%, respectively. This is the first study that directly compares the diagnostic performance of DRE compared with HRAM in patients with functional anorectal disorders. In patients with chronic constipation, DRE has high sensitivity and positive predictive value (PPV) for the diagnosis of dyssynergia. In incontinent patients, DRE can also reliably assess the anal squeeze pressure. This study underscores the importance of this time-honored physical test even in the era of highly-sophisticated technology. This study is also highly relevant to the practice in the Asia Pacific region, where the expertise of high resolution manometry is limited.



These editors are professors from CUHK’s IDD—distinguished gastroenterologists, hepatologists and surgeons whose ability and dedication to scientific research have brought them to the top of their profession.