Best Practice & Research Clinical Gastroenterology RSS feed: Current Issue. In practical paperback format, each 200 page topic-based issue of Best Practice & Research Clinical Gastroenterology will provide a comprehensive review of current clinical practice and thinking within the specialty of gastroenterology. All chapters are commissioned and written by an international team of practising clinicians with the Guest Editors for each issue drawn from a pool of renowned experts and opinion leaders. Reference is made to: • the latest original research • Cochrane Reviews • audits and confidential enquiries • national and international conferences • national and international guidelines • personal communications All chapters take the form of practical, evidence-based reviews that seek to address key clinical issues of diagnosis, treatment and patient management. Each issue follows a problem-orientated approach that focuses on the key questions to be addressed, clearly defining what is known and not known. Management will be described in practical terms so that it can be applied to the individual patient. Boxed and bulleted Learning Objectives and Practice Points are features within each chapter and will highlight the core and essential knowledge that will help the physician to provide the best care to their patients. The series' objective is to provide a continuous update for the busy clinician and researcher. 2010 topics Vol 24:1 February - Gastrointestinal lymphomas W. Fischbach and H. Boot Vol 24:2 April - Adverse events of GI Pharmacology C. Beglinger Vol 24:3 June - Chronic Pancreatitis M. Bruno Volume 24:4 August - New developments in colorectal cancer Screening G. Hoff and N. Segnan Vol 24:5 October - Hereditary liver disease F. Lammert Vol 24:6 December - Not yet confirmed 2009 topics Vol 23:1 February - Emerging Diseases of the Gastrointestinal Tract Ernst J. Kuipers (The Netherlands) Vol 23:2 April - Genetic Testing in Gastroenterology Hans Vasen Vol 23:3 June - Mandatory and Optional Functions Tests in Gastroenterology and Hepatology Jutta Keller, Ansgar Lohse and Peter Layer Vol 23:4 August - special issue devoted to common proctology scenarios Vol 23:5 October - Endosonography in Gastroenterology G.N.J. Tytgat Vol 23:6 December - Management of GI Diseases in the Elderly A. Pilotto 2008 topics Vol 22:3 June - Eosinophils in Healthy Gut and Gastrointestinal Diseases S. C. Bischoff (Germany) and A. Straumann (Switzerland) Vol 22:4 April - Advances in diagnostic assessment of the oesophageal mucosa J Dent (Australia), P Sharma (USA), G N Tytgat (The Netherlands) Vol 22: 5 October - Gastrointestinal Endoscopy G N Tytgat (The Netherlands) Vol 22: 6 December - Recent Developments in Hepatitis B & C S. W. Schalm and H. L. A. Janssen (The Netherlands) 2007 topics, volume 21, issues 1-6 Vol 21:1 February - Complications of cirrhosis D Lebrec (France) Vol 21:2 April - Helicobacter Pylori A Axon (UK) Vol 21:3 June - The difficult patient in gastroenterology J Tack (Belgium) and J Scholmerich (Germany) Vol 21:4 August - Severe gastrointestinal motor disorders G E Boeckxstaens (The Netherlands) Vol 21:5 October - Pregnancy-related gastroenterological and hepatological diseases and complications F Shanahan (Ireland) Vol 21:6 December - The multidisciplinary management of gastrointestinal cancer E. van Gutsem (Belgium) 2006 topics, volume 20, issues 1-6 Vol 20:1 February - Advances in imaging of the GI tract G Bianchi Porro (Italy) Vol 20:2 April - Pancreatic cancer J Neoptolemos UK) Vol 20:3 June - Novel developments in GI nutrition L Mathus-Vliegen (The Netherlands)and A Thomson (UK) Vol 20:4 August - Gastric cancer K McColl (UK) Vol 20:5 October - Oesophageal cancer J van Lanschot and G Tytgat (The Netherlands) Vol 20:6 December - Gallstone disease K van Erpecum and P Portincasa (The Netherlands) http://www.bpgastro.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. All rights reserved. Best Practice & Research Clinical Gastroenterology1521-6918243June 2010 © 2010 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.bpgastro.com/article/PIIS152169181000051X/abstract?rss=yesAims & Scope/ Editorial Board10.1016/S1521-6918(10)00051-XBest Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-Xiiiiiihttp://www.bpgastro.com/article/PIIS1521691810000430/abstract?rss=yesChronic pancreatitis remains an intriguing and challenging disease entity. Over the years tremendous progress has been made regarding our insights into its pathology and aetiology. In addition, more and more evidence emerges from well conducted studies about treatment strategies that improve disease outcome. Nevertheless, from a patients’ perspective chronic pancreatitis still remains a troublesome condition affecting well being, general health, and life expectancy. Quality of life is evidently impaired and this disease continues to disrupt many patients’ lives, both personally and professionally. It is pivotal therefore that we continue our efforts to try to improve the lives of these patients, in particular by controlling pain which is often severe and debilitating. It is also important to recognise the long term complications of chronic pancreatitis which include exo- and endocrine insufficiency and deal with these conditions effectively.PrefaceMarco Bruno10.1016/j.bpg.2010.04.001Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X217217http://www.bpgastro.com/article/PIIS1521691810000399/abstract?rss=yesEpidemiological studies have been published worldwide in recent decades describing the incidence, mortality, aetiology and trends of chronic pancreatitis. Accumulated evidence suggests that chronic pancreatitis is increasing in incidence and hospital admission rates are rising accordingly. Alcoholic chronic pancreatitis was previously more common in the developed world than elsewhere, but is now increasing worldwide due to growing per capita alcohol consumption in each nation. Supporting alcohol and smoking cessation in individual patients is essential to slow disease progression and improve overall health, as most patients will die of cirrhosis, cardiovascular disease or smoking related cancers rather than chronic pancreatitis. The socioeconomic impact of chronic pancreatitis is difficult to quantify as little data exists, however given the rising incidence the costs to health care and society are likely to increase. This chapter will describe the epidemiology and aetiology of chronic pancreatitis worldwide and discusses the factors that influence its socioeconomic impact.The epidemiology and socioeconomic impact of chronic pancreatitisJames Jupp, David Fine, Colin D. Johnson10.1016/j.bpg.2010.03.005Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X219231http://www.bpgastro.com/article/PIIS1521691810000429/abstract?rss=yesThe diagnosis of chronic pancreatitis is mainly based on imaging procedures (e.g., endoscopic ultrasound, magnetic resonance cholangiopancreatography (MRCP) and magnetic resonance imaging (MRI)). Functional testing in this context could however be still of help in cases of inconclusive morphological findings. With this aim, only the secretin–pancreozymin test and the endoscopic test are sensitive enough. The role of other function tests, such as the quantification of the coefficient of fat absorption (CFA) and the 13C-mixed triglyceride breath test, is limited to the diagnosis of exocrine pancreatic insufficiency with maldigestion. Faecal elastase and chymotrypsin are still useful for detecting reduction of pancreatic secretion in patients with different pancreatic diseases and patients’ compliance to enzyme replacement therapy, respectively. Other tests used in the past (e.g., Lundh test, N-benzoyl-tryosyl para-aminobenzoic acid (NBT-PABA) test, pancreolauryl test and amino acid consumption test) are neither available now nor useful for clinical practice. This article reviews the different pancreatic function tests commercially available and their role in clinical practice.Diagnosis of chronic pancreatitis: Functional testingJ. Enrique Domínguez Muñoz10.1016/j.bpg.2010.03.008Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X233241http://www.bpgastro.com/article/PIIS1521691810000387/abstract?rss=yesChronic pancreatitis (CP) is a progressive inflammatory disease that is difficult to diagnose due to the paucity of a diagnostic gold standard. For almost two decades, early-stage CP has been recognised in the context of endoscopic ultrasound (EUS) when a patient presents with typical pancreatic-type pain, normal conventional imaging examinations, and subtle findings of CP by EUS. Whether these EUS findings represent true early-stage CP that will progress or whether they are false positive findings remain unclear. The key to enhancing the diagnostic precision of EUS in CP is to use objective, widely-accepted criteria that are reproducible. The Rosemont Criteria is a significant step towards achieving this goal and needs to be validated in conjunction with long-term studies of early-stage CP.EUS in the diagnosis of early-stage chronic pancreatitisLyndon V. Hernandez, Marc F. Catalano10.1016/j.bpg.2010.03.004Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X243249http://www.bpgastro.com/article/PIIS1521691810000156/abstract?rss=yesChronic pancreatitis (CP) is a clinical situation with persisting inflammation leading to destruction of the pancreas ensuing endocrine and exocrine failure. There are 4 subtypes: hereditary, idiopathic, alcoholic and tropical pancreatitis. Genetic factors can explain a significant proportion of CP cases. The PRSS1 gene, encoding cationic trypsinogen, was found to be correlated with hereditary CP. This signalled the extensive search for other candidate genes within the trypsin pathway. Genes like SPINK1 and CTRC are associated with CP and should be considered as important contributing factors rather than causative. The search for candidate genes not part of the trypsin pathway has been less successful and the only gene consistently associated with CP is the Cystic Fibrosis Transmembrane Regulator. In this review we will discuss the various CP subtypes in relation to the respective genetic variants. This review will also address the implications of genetic testing in daily clinical practise.Genetic factors in chronic pancreatitis; implications for diagnosis, management and prognosisMonique H.M. Derikx, Joost P.H. Drenth10.1016/j.bpg.2010.02.001Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X251270http://www.bpgastro.com/article/PIIS1521691810000594/abstract?rss=yesIt is well known that adenomas represent the morphologically categorised precursor of the vast majority of colorectal cancers. Only few adenomas actually develop invasive cancer (progressive adenomas), although every adenoma has the capacity of malignant evolution. Most adenomas stabilise their progression or even regress. Easily identifiable but widely ranged pathological features (size, architectural growth, type, grade and gross organisation of dysplasia) are predictive of their natural history in terms of potential of cancerisation and duration of the adenoma–carcinoma sequence. Knowledge of the biological machineries sustaining the progression rates and times could be crucial to refine the natural history assumptions in screening modelling.The natural history of adenomasMauro Risio10.1016/j.bpg.2010.04.005Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X271280http://www.bpgastro.com/article/PIIS1521691810000363/abstract?rss=yesEndoscopic treatment of chronic pancreatitis (CP) aims to relieve pain by draining the main pancreatic duct (MPD) and to treat loco-regional complications. Half of patients have complete pain relief five years after treatment, with best results obtained if treatment is performed early after the first pain attack. If MPD obstruction is caused by calcifications, ambulatory extracorporeal shock wave lithotripsy has become a first-line treatment (9–30% of patients require ERCP during follow-up). If MPD obstruction is caused by stricture(s), insertion of single plastic stent is effective but it requires multiple ERCPs for stent exchanges; other protocols are being investigated. Pseudocysts represent an excellent indication for endoscopic treatment with long-term results similar to those of surgery; endosonography-guided techniques allow treatment of almost any pancreatic pseudocyst. Biliary strictures related to CP are challenging due to a high relapse rate and requirement for multiple ERCP sessions. Significant progress has recently been made with new protocols of temporary biliary stenting (multiple simultaneous plastic stents or covered metallic stents).Endoscopic treatment in chronic pancreatitis, timing, duration and type of interventionThai Nguyen-Tang, Jean-Marc Dumonceau10.1016/j.bpg.2010.03.002Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X281298http://www.bpgastro.com/article/PIIS1521691810000375/abstract?rss=yesPain relief and improvement in the quality of life are of paramount importance for any intervention in chronic pancreatitis. In several trial good results have been published after different drainage procedures and resections.An optimal surgical intervention should manage mainly the intractable pain, resolve the complications of the adjacent organs and achieve the drainage of the main pancreatic duct. An optimal procedure should guarantee a low relapse rate, preserve a maximum of endocrine and exocrine function, and most importantly, restore quality of life. Thus an ideal operation should representing a one-stop-shopping. According to the trials conducted so far, Duodenum-preserving resection of the pancreatic head offers the best short-term outcome. It combines the highest safety of all surgical procedures with the highest efficacy. By varying the extent of the cephalic resection, it offers the possibility of customizing surgery according to the individual patient’s morphology.Surgical treatment in chronic pancreatitis timing and type of procedureKai Bachmann, Asad Kutup, Oliver Mann, Emre Yekebas, Jakob R. Izbicki10.1016/j.bpg.2010.03.003Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X299310http://www.bpgastro.com/article/PIIS1521691810000351/abstract?rss=yesThere is probably no other gastrointestinal disorder which is as much characterized by concomitant local, intra-organ and central neuropathic and neuroplastic alterations as chronic pancreatitis (CP). While some key features of this neuropathy have recently been elucidated, there is still no satisfying pathophysiological explanation for the generation of neuropathic pain in CP. It is becoming increasingly clear that an effective pain treatment in CP can probably not be achieved without consideration of the exact fate of intrapancreatic nerves and central neuroplastic alterations. This review is intended to illustrate the temporal and spatial alterations of intrapancreatic nerves in the course of CP. At the same time, it depicts the reciprocal relationship between these plastic changes and thus underlines the notion of a ‘common fate’ for all these alterations. Moreover, it points out numerous aspects of this fate that are yet to be unveiled and should therefore be subject to future investigation.Fate of nerves in chronic pancreatitis: Neural remodeling and pancreatic neuropathyGüralp O. Ceyhan, Ihsan Ekin Demir, Matthias Maak, Helmut Friess10.1016/j.bpg.2010.03.001Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X311322http://www.bpgastro.com/article/PIIS1521691810000417/abstract?rss=yesAbdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.Pain management in chronic pancreatitis: A treatment algorithmShailendra Chauhan, Chris E. Forsmark10.1016/j.bpg.2010.03.007Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X323335http://www.bpgastro.com/article/PIIS1521691810000405/abstract?rss=yesExocrine pancreatic insufficiency (EPI) is a serious condition which occurs in several diseases including chronic pancreatitis (CP), cystic fibrosis, pancreatic cancer, and as a result of pancreatic surgery. The lack or absence of pancreatic enzymes leads to an inadequate absorption of fat, proteins, and carbohydrates, causing steatorrhoea and creathorrhea which results in abdominal discomfort, weight loss, and nutritional deficiencies. To avoid malnutrition related morbidity and mortality, it is pivotal to commence pancreatic enzyme replacement therapy (PERT) as soon as EPI is diagnosed. Factors as early acidic inactivation of ingested enzymes, under dosage, and patient incompliance may prevent normalisation of nutrient absorption, in particular of fat digestion. This review focuses on the current status of how to diagnose and treat EPI.Pancreatic enzyme replacement therapy in chronic pancreatitisE.C.M. Sikkens, D.L. Cahen, E.J. Kuipers, M.J. Bruno10.1016/j.bpg.2010.03.006Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X337347http://www.bpgastro.com/article/PIIS1521691810000211/abstract?rss=yesAcute pancreatitis, chronic pancreatitis and pancreatic cancer are responsible for most of the burden of exocrine pancreatic disease. Glandular damage from recurrent bouts of acute pancreatitis can lead to irreversible changes characteristic of chronic pancreatitis. In recent decades accumulating evidence has defined longstanding pre-existing chronic pancreatitis as a strong risk factor for pancreatic cancer. The lag period between diagnosis of chronic pancreatitis and pancreatic cancer is usually one or two decades: pancreatitis appearing a year or two before the diagnosis of pancreatic cancer is often the result of tumour-related ductal obstruction. The risk of developing pancreatic cancer appears to be highest in rare types of pancreatitis with an early onset, such as hereditary pancreatitis and tropical pancreatitis. Even though there is a strong link between chronic pancreatitis and pancreatic cancer, over a 20 year period only around five percent of patients with chronic pancreatitis will develop pancreatic cancer. Until the development of more sophisticated screening procedures, screening is not recommended for patients with chronic pancreatitis.Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detectionSara Raimondi, Albert B. Lowenfels, Antonio M. Morselli-Labate, Patrick Maisonneuve, Raffaele Pezzilli10.1016/j.bpg.2010.02.007Best Practice & Research Clinical Gastroenterology 24, 3 (2010)2010-06-01Best Practice & Research Clinical Gastroenterology2010-06-01243S1521-6918(10)X0004-X349358