Gastroenterology

Hemorrhoidal Disease: A Review

Author/s: 
Jean H Ashburn

Importance Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US. Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse.

Observations Hemorrhoids are classified as internal, external, or mixed (concurrent internal and external hemorrhoidal disease). Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal. Internal hemorrhoid prolapse is classified as grade I (into anal canal), grade II (beyond the anus with spontaneous reduction), grade III (requiring manual reduction), and grade IV (irreducible). External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed. Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation. Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation. If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions. Rubber band ligation—placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow—resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%. Sclerotherapy, which induces fibrosis with a sclerosant injection, is efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients. Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse. Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days). External hemorrhoidal disease rarely requires surgery unless acutely thrombosed. Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis. Patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine).

Conclusions and Relevance Hemorrhoidal disease affects 10 million people in the US. First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics. In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies. Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.

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).

Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss

Author/s: 
Mohit Sodhi, Ramin Rezaeianzadeh, Abbas Kezouh, Mahyar Etminan

This database study examines the association between glucagon-like peptide 1 agonists (eg, semaglutide, liraglutide) used for weight loss and reports of gastrointestinal adverse events.

A “no-biopsy” approach to diagnosing celiac disease

Author/s: 
Mott, T., Gray, C., Storey, J.

PRACTICE CHANGER
CONSIDER A “NO-BIOPSY” APPROACH BY EVALUATING SERUM IMMUNOGLOBULIN (IG) A ANTI-TISSUE TRANSGLUTAMINASE (TTG-IGA) ANTIBODY TITERS IN ADULT PATIENTS WHO PRESENT WITH SYMPTOMS CONCERNING FOR CELIAC DISEASE (CD). AN INCREASE OF ≥ 10 TIMES THE UPPER LIMIT OF NORMAL (ULN) FOR TTG-IGA HAS A POSITIVE PREDICTIVE VALUE (PPV) OF ≥ 95% FOR DIAGNOSING CD WHEN COMPARED WITH ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH DUODENAL BIOPSY—THE CURRENT GOLD STANDARD.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan

Author/s: 
Reeves, Patrick T., Kolasinski, Nathan T., Shonna YIn, H., Alqurashi, Waleed, Echelmeyer, Sofia, Chumpitazi, Bruno P., Rogers, Philip L., Burklow, Carolyn S., Nylund, Cade M.

Objective: To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation.

Study design: The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating).

Results: All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability.

Conclusions: The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

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