1. Home
  2. Gastroenterology

Gastroenterology

Gastric Cancer: A Review

Author/s: 
Anuj Kishor Patel, Nilay S. Sethi

Importance Globally, 968 350 new cases and 659 853 deaths from gastric cancer were reported in 2022. In the US, 30 300 new cases and 10 780 deaths were estimated in 2025.

Observations Gastric cancer is more common in men, and the median age at diagnosis is 68 years. Most gastric cancers (>90%) are adenocarcinomas. Worldwide, 85% of cases arise from the stomach body or antrum and 15% from the cardia. In the US, more than 90% of patients diagnosed with gastric cancer present with symptoms such as weight loss and abdominal pain. At presentation, approximately 13% have localized disease (limited to the stomach), 15% to 25% have locally advanced disease, defined as a tumor that has spread to regional lymph nodes, and 35% to 65% have metastatic disease. Helicobacter pylori infection is a treatable risk factor associated with 90% of gastric body and antrum cancers globally. Additional modifiable risk factors include smoking, alcohol, obesity, and salt intake. In countries with high incidence such as Japan and Korea, routine endoscopic screening beginning at age 40 years is associated with improved survival. Diagnosis is made by endoscopic biopsy. Patients with localized gastric cancer are treated with surgical resection and have a 5-year relative survival rate of 75% with treatment. Patients with more advanced-stage disease should receive gastrectomy, perioperative chemotherapy with 5-fluorouracil, oxaliplatin, and docetaxel and immunotherapy (durvalumab). Metastatic or unresectable disease may be treated with chemotherapy, immunotherapy, and/or targeted therapy depending on biomarkers, including programmed cell death ligand 1 (PD-L1), human epidermal growth factor receptor 2 (ERBB2; formerly HER2 or HER2/neu), and claudin-18, isoform 2 (CLDN18.2). For PD-L1–expressing gastric cancer, adding immune checkpoint inhibitors, such as nivolumab and pembrolizumab, is associated with an additional 3 months of survival when compared with chemotherapy alone. For gastric cancers overexpressing the ERBB2 or CLDN18.2 proteins, the addition of trastuzumab or zolbetuximab, respectively, is associated with an additional 3 to 4 months’ survival. Early supportive care focusing on symptom management and on nutritional and psychosocial support is associated with 3 months of survival benefit. Less than 10% of patients with metastatic gastric cancer survive more than 5 years.

Conclusions and Relevance Approximately 30 300 new cases of gastric cancer are diagnosed annually in the US. Localized gastric cancer is treated with gastrectomy, and locally advanced disease is treated with surgery and chemoimmunotherapy. For patients with unresectable or metastatic gastric cancer, chemotherapy with immune checkpoint inhibitors and targeted therapies such as trastuzumab or zolbetuximab improves survival by several months.

Keywords 
oncology Gastroenterology Stomach Neoplasms adenocarcinoma Helicobacter Infections abdominal pain

Diagnosis and Management of Celiac Disease

Author/s: 
Kerstin Austin, Nimrod Deiss-Yehiely, Jason T Alexander

Guideline title American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease

Release date January 2023

Prior version May 2013

Developer and funding source American College of Gastroenterology

Target population Children and adults with celiac disease

Selected recommendations

Screening for celiac disease in asymptomatic people in the general population is not recommended (strong recommendation; low quality of evidence).

Upper endoscopy with multiple (≥4) duodenal biopsies is recommended for diagnostic confirmation in both children and adults who have characteristic signs and symptoms of celiac disease (strong recommendation; moderate quality of evidence).

In symptomatic children, a blood test with high-level tissue transglutaminase antibody (tTG) IgA (>10 times the upper limit of normal) and presence of endomysial antibody (EMA) in a second blood sample are suggested for diagnosis of celiac disease. In symptomatic adults who are unwilling or unable to undergo upper endoscopy, high-level tTG IgA and presence of EMA can be used to establish a diagnosis of likely celiac disease (conditional recommendation; moderate quality of evidence).

A gluten-free diet is required (strong recommendation; moderate quality of evidence) to achieve the treatment goal of resolution of histologic mucosal lesions in adults (conditional recommendation; low quality of evidence).

Keywords 
Gastroenterology celiac disease

Infectious Diseases Society of America Guidelines on Infection Prevention for Healthcare Personnel Caring for Patients with Suspected or Known COVID-19

Author/s: 
Lynch, J. B., Davitkov, P., Anderson, D. J., Bhimraj, A., Cheng, V. C. C., Guzman-Cottrill, J., Dhindsa, J., Duggal, A., Jain, M. K., Lee, G. M., Liang, S. Y., McGeer, A., Varghese, J., Lavergne, V., Murad, M. H., Mustafa, R. A., Sultan, S., Falck-Ytter, Y., Morgan, R. L.

Background: Since its emergence in late 2019, SARS-CoV-2 continues to pose a risk to healthcare personnel (HCP) and patients in healthcare settings. Although all clinical interactions likely carry some risk of transmission, human actions like coughing and care activities like aerosol-generating procedures likely have a higher risk of transmission. The rapid emergence and global spread of SARS-CoV-2 continues to create significant challenges in healthcare facilities, particularly with shortages of personal protective equipment (PPE) used by HCP. Evidence-based recommendations for what PPE to use in conventional, contingency, and crisis standards of care continue to be needed. Where evidence is lacking, the development of specific research questions can help direct funders and investigators.

Objective: Develop evidence-based rapid guidelines intended to support HCP in their decisions about infection prevention when caring for patients with suspected or known COVID-19.

Methods: IDSA formed a multidisciplinary guideline panel including frontline clinicians, infectious disease specialists, experts in infection control, and guideline methodologists with representation from the disciplines of public health, medical microbiology, pediatrics, critical care medicine and gastroenterology. The process followed a rapid recommendation checklist. The panel prioritized questions and outcomes. Then a systematic review of the peer-reviewed and grey literature was conducted. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations.

Results: The IDSA guideline panel agreed on eight recommendations, including two updated recommendations and one new recommendation added since the first version of the guideline. Narrative summaries of other interventions undergoing evaluations are also included.

Conclusions: Using a combination of direct and indirect evidence, the panel was able to provide recommendations for eight specific questions on the use of PPE for HCP providing care for patients with suspected or known COVID-19. Where evidence was lacking, attempts were made to provide potential avenues for investigation. There remain significant gaps in the understanding of the transmission dynamics of SARS-CoV-2 and PPE recommendations may need to be modified in response to new evidence. These recommendations should serve as a minimum for PPE use in healthcare facilities and do not preclude decisions based on local risk assessments or requirements of local health jurisdictions or other regulatory bodies.

Subscribe to Gastroenterology