Gastroenterology & Hepatology Clinical Practice Updates
Welcome to the Gastroenterology and Hepatology Updates section of our Hospital Medicine Cheat Sheets blog! We summarize recent practice-changing research in gastrointestinal and liver diseases from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application. Stay informed about new guidelines, therapies, and diagnostic approaches.
1. Upadacitinib for Moderate-to-Severe Crohn’s Disease
The U-EXCEL program in New England Journal of Medicine shows upadacitinib, a JAK inhibitor, induces higher clinical remission vs placebo in moderate-to-severe Crohn’s disease and maintains remission on longer-term therapy.
Statistical Robustness
Large phase 3 program (U-EXCEL/U-EXCEED/U-ENDURE); strong significance with narrow CIs across primary endpoints.
Strengths
Includes biologic-refractory patients; consistent efficacy across subgroups.
Provides an effective oral option after anti-TNF/other biologic failure, potentially reducing admissions for flares.
Practical Example
A 40-year-old with Crohn’s and prior infliximab failure is admitted for abdominal pain. Discuss upadacitinib 45 mg daily induction with GI; monitor for infections and lipids.
Reference: Loftus EV Jr, et al. Upadacitinib induction and maintenance therapy for Crohn’s disease. N Engl J Med. 2023.
2. Non-Invasive Fibrosis Assessment in NAFLD (FIB-4)
Prospective and meta-analytic data support FIB-4 as a practical first-line tool to stage fibrosis in NAFLD, with high sensitivity for ruling out advanced fibrosis in many settings; performance varies in T2DM and extremes of age.
Statistical Robustness
Large cohorts and meta-analyses; sensitivity and AUC values generally strong, though heterogeneity exists across populations (e.g., T2DM).
Strengths
Non-invasive, inexpensive, bedside-calculable; enables triage and reduces unnecessary biopsies.
Pitfalls
Lower specificity in obesity/T2DM; age-dependent cutoffs; requires second-tier testing (e.g., VCTE) when indeterminate.
Clinical Implication
Use FIB-4 to stratify NAFLD admissions; escalate to VCTE/MRE or hepatology when FIB-4 is indeterminate or high.
Practical Example
A 55-year-old with NAFLD and elevated ALT is admitted for chest pain. Calculate FIB-4; if >3.25, consult hepatology for advanced fibrosis evaluation.
Reference: Han JW, et al. Diagnostic accuracy of FIB-4 for advanced fibrosis in NAFLD with type 2 diabetes. Clin Mol Hepatol. 2024.
Randomized trials show vonoprazan achieves high healing rates and robust maintenance in erosive esophagitis, with particular benefit in more severe disease and rapid symptom relief versus lansoprazole in some analyses.
Statistical Robustness
Phase 3 RCTs and recent meta-analyses; tight CIs around healing endpoints; long-term safety still accruing.
Strengths
Potent acid suppression; head-to-head data vs PPI; potential option in PPI-refractory cases.
Pitfalls
Cost and coverage considerations; monitor for rare adverse effects.
Clinical Implication
Consider vonoprazan for PPI-refractory erosive esophagitis and for maintenance after healing.
Practical Example
A 50-year-old with persistent esophagitis on omeprazole is admitted for dysphagia. Switch to vonoprazan 20 mg daily; arrange endoscopic follow-up.
Reference: Laine L, et al. Vonoprazan vs lansoprazole for healing and maintenance of erosive esophagitis. Gastroenterology. 2023. | Simadibrata DM, et al. Meta-analysis. J Gastroenterol Hepatol. 2024.
In high-risk variceal bleeding (Child-Pugh C or B with active bleeding), early TIPS within ~72 hours reduces rebleeding and improves outcomes compared with standard therapy.
Statistical Robustness
Randomized trials demonstrate benefit; effect consistent across key subgroups.
Requires interventional expertise; risk of encephalopathy; careful selection essential.
Clinical Implication
Adopt early-TIPS pathways for high-risk profiles; coordinate with hepatology and IR at admission.
Practical Example
A 60-year-old with cirrhosis and active variceal bleed (Child-Pugh C): start octreotide, antibiotics, banding; consult IR for early TIPS within 72 hours.
Reference: García-Pagán JC, et al. Early TIPS vs standard therapy in high-risk variceal bleeding. NEJM. 2010. | Lv Y, et al. Early-TIPS RCT. Lancet Gastroenterol Hepatol. 2019.
5. Fecal Microbiota Transplantation for Recurrent C. difficile
Double-blind RCT data show FMT significantly reduces recurrence of C. difficile infection compared with standard therapy; real-world availability may vary by product and center.
Statistical Robustness
Phase 3 RCT with strong effect size; subsequent corrections addressed reporting details without altering primary findings.
Orodispersible budesonide induces and maintains histologic remission in EoE in randomized trials; newer data suggest durable control with longer-term therapy.
Statistical Robustness
Phase 3 induction and maintenance RCTs; open-label extensions support durability; high remission rates vs placebo in pivotal trials.
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