Screening and Management Guidance Reviews Highlight Issue 2 of Qazi Corner

Taha Qazi, MD

In this second iteration of The Qazi Corner, we hope to present recent and not-so-recent research that has been both practice-changing and a cause for debate.

Highlighted by research reviews from fellows, Hassieb Din, MD, Chiara Maruggi, MD, and H. Jeffrey Schwartz, MD, this edition includes recently published work on the management of acute pancreatitis, a head-to-head comparison trial on medication for the management of Crohn’s disease, and the recently published Nordic-European Initiative on Colorectal Cancer (NordICC) trial highlighting the effectiveness of colonoscopy screening.

Rounding out this edition, we present a review of the American College of Gastroenterology’s (ACG) recently published guidelines on the management of Gastroesophageal Reflux Disease (GERD).

Leading this edition, Maruggi, a second-year clinical fellow, reports the recent evidence of NordICC—a population based, large multicenter, randomized control, evaluating the role of an opt-in population-based colonoscopy screening strategy and development of colorectal cancer as well as mortality related to colorectal cancer.

Surprisingly, neither colorectal cancer incidence nor the colorectal cancer-associated death were statistically different in the population that decided to undergo screening compared to the cohort that declined screening in the intention to treat analysis.

These results must be taken into account in the context of the positive results in the per-protocol adjusted analysis suggesting that colonoscopy screening does, in fact, reduce the risk of colorectal cancer and colorectal cancer death. Other limitation noted, include the homogenous European population, length of follow up time, low overall participation rate in screening, and the low adenoma-detection rate, as highlighted in the review by Maruggi.

Secondly, Schwartz reports the results of the SEAVUE study, a double-blind multicenter, randomized, parallel group trial comparing the efficacy of adalimumab with ustekinumab in newly diagnosed Crohn’s disease. This study represents the second study evaluating a head-to-head comparison between agents in patient with inflammatory bowel disease, and the first-ever study evaluating the role of first line tumor necrosis factor (TNF) inhibition compared to interleukin (IL)-12/23 inhibition in the management of Crohn’s disease.

Overall, there was no significant difference in the clinical remission, steroid-free remission, 1-year clinical response, and endoscopic remission. The data suggests that both agents are highly effective for the management of early Crohn’s disease, in a biologically-naïve population.

Din, a third-year clinical fellow, describes new evidence on fluid-management strategies in acute pancreatitis.

In an open-label, parallel-group, multicenter, randomized control trial comparing moderate fluid resuscitation compared to aggressive fluid hydration, adult patient patients presenting with mild acute pancreatitis were randomized to receive aggressive fluid hydration, a median of 7.8 L over the first 24 hours, or moderate fluid hydration, roughly 5 L over the first 24 hours.

There was no significant difference in the development of the primary outcome of moderately severe or severe acute pancreatitis. However, there was higher incidence of fluid overload, symptom intensity, longer hospital stay, and necrotizing pancreatitis in the aggressive fluid hydration group, suggesting the role of moderate fluid hydration in mild acute pancreatitis.

Lastly, Qin, current staff at the Cleveland clinic, presents a review on the recent guidelines for GERD, published by the ACG.

An important facet of the guidelines is the limiting reliance on the use of proton-pump inhibitors (PPIs) for management in non-erosive esophagitis, namely based on observational studies. PPIs continue to be recommended over the H2-receptor antagonists (HR2A) due to their superior ability in healing esophagitis. The guidelines continue to serve as a refresher on management of GERD with a comprehensive summary of newer developments.

The current Advanced Endoscopy fellow at the Cleveland Clinic reports the results of his recent study evaluating the imaging entity that is fatty pancreas. Often seen and also overlooked, fatty pancreas can result from a variety of etiologies.

Over a mean follow-up period of 3.9 years after a diagnosis of fatty pancreatitis, a significant portion developed pancreatic pathology outside of traditional risk factors such as acute pancreatitis. The study lends credence to the understanding that fatty pancreatitis may represent as continuum of disease and that large prospective studies are needed.