Endoscopic diagnosis and treatment of gastric dysplasia and early cancer:Current evidence and what the future may hold

Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality.The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage.In high prevalence regions such as Japan and Korea,this has led to the implementation of population screening programs.However,guidelines remain ambiguous in lower prevalence regions.In recent years,there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions.More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection.In addition,promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging.Data on endoscopic resection(ER)are particularly robust in Japan and Korea,with high rates of curative ER and markedly reduced procedural morbidity.However,there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries.Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER,as both technology and proceduralist expertise continue to grow.

Dysphagia: Thinking outside the box

Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux(GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno-as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pretest probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

Food,fibre,bile acids and the pelvic floor: An integrated low risk low cost approach to managing irritable bowel syndrome

Patients presenting with abdominal pain and diarrhea are often labelled as suffering from irritable bowel syndrome,and medications may be used often without success. Advances in the understanding of the causes of the symptoms(including pelvic floor weakness and incontinence,bile salt malabsorption and food intolerance) mean that effective,safe and well tolerated treatments are now available.

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

The role of endoscopic procedures,in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly.In this context,endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently.This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding.Thus,there is now greater importance on optimal pre,peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding,without increasing the risk of a thromboembolic event as a consequence of therapy interruption.Currently,there are position statements and guidelines from the major gastroenterology societies.These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures,to ensure optimal patient safety.However,since the publication of these guidelines,there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices.Most notably and divergent from current position statements,is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding,suggestive that this practice should be avoided.In addition,there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps(<10 mm).