Spotlight on new guidelines

The American Association for the Study of Liver Diseases, the American Gastroenterological Association, the American College of Gastroenterology, and the U.S. Preventive Services Task Force all released new guidelines this month.

Four medical groups recently made recommendations on alcohol-related liver diseases, the laboratory evaluation of patients presenting with chronic diarrhea, hereditary hemochromatosis, and hepatitis B virus (HBV) infection screening.

First, the American Association for the Study of Liver Diseases (AASLD) published practice guidance on July 17 in Hepatology on the diagnosis and treatment of alcohol-related liver diseases and alcohol use disorders. To reduce the stigma of the term “alcoholic,” the guidance suggested a change to the term “alcohol-related” (e.g., alcohol-related liver disease, alcohol-related steatohepatitis, and alcohol-related cirrhosis). However, the term alcoholic hepatitis will likely persist due to longstanding usage, according to the guidance, which also includes a new consensus definition of alcoholic hepatitis (definite, probable, and possible) that was previously published in 2016.

Other updates to the previous AASLD guidance, issued in 2010, include an emphasis on alcohol use disorder definition, screening, and treatment, as well as the use of new alcohol biomarkers. All patients should be routinely screened for alcohol use with validated questionnaires in primary care and gastroenterology/hepatology outpatient clinics, EDs, and hospitals, the guidance said. The preferred alcohol biomarkers, which can be used to aid in diagnosis and treatment and are not affected by liver disease, are urine and hair ethyl glucuronide, urine ethyl sulfate, and phosphatidylethanol.

Second, the American Gastroenterological Association (AGA) issued recommendations on the laboratory evaluation of functional diarrhea and diarrhea-predominant irritable bowel syndrome (IBS) in adults. The guideline was published on July 19 by Gastroenterology.

In patients presenting with chronic diarrhea, the AGA strongly recommended testing for Giardia (high-quality evidence) and for celiac disease with IgA-tTG and a second test to detect celiac disease in the setting of IgA deficiency (moderate-quality evidence). It also suggested testing for bile acid diarrhea (conditional recommendation; low-quality evidence). While the AGA suggested using either fecal calprotectin or fecal lactoferrin to screen for inflammatory bowel disease (IBD) in these patients (conditional recommendation; low-quality evidence), it suggested against the use of erythrocyte sedimentation rate or C-reactive protein to screen for IBD (conditional recommendation; low-quality evidence). In patients who present with chronic diarrhea but have no travel history to or recent immigration from high-risk areas, the guideline suggested against testing stools for ova and parasites other than Giardia (conditional recommendation; low-quality evidence). The AGA made no recommendation for the use of currently available serologic tests for the diagnosis of IBS due to gaps in the evidence.

Third, the American College of Gastroenterology (ACG) published a clinical guideline on hereditary hemochromatosis on July 22 in the American Journal of Gastroenterology. The guideline strongly recommended screening for hereditary hemochromatosis in family members (particularly first-degree relatives) of patients diagnosed with the condition (moderate-quality evidence).

Other strong recommendations were related to treatment and liver transplantation. The ACG strongly recommended phlebotomy as first-line treatment in patients diagnosed with hereditary hemochromatosis, as determined by C282Y homozygosity or C282Y/H63D compound heterozygosity (moderate-quality evidence). While the ACG strongly recommended against iron chelation as first-line therapy (low-quality evidence), it strongly recommended the treatment in patients who are intolerant of or refractory to phlebotomy or when phlebotomy has the potential for harm, such as in patients with severe anemia or congestive heart failure (low-quality evidence). The guideline also strongly recommended against the routine use of proton-pump inhibitors as the primary treatment (low-quality evidence). Finally, the ACG strongly recommended considering liver transplantation in patients with hereditary hemochromatosis who have decompensated cirrhosis or hepatocellular carcinoma (low-quality evidence).

Finally, the U.S. Preventive Services Task Force (USPSTF) updated its 2009 recommendation statement on screening for HBV infection in pregnant women. The Task Force found no new substantial evidence to change its recommendation. The USPSTF continues to recommend routine screening for HBV infection in pregnant women at their first prenatal visit (Grade A recommendation). To maximize benefit, primary care clinicians and delivery settings must establish effective systems for the accurate and timely transfer of maternal hepatitis B surface antigen test results to labor, delivery, and newborn medical records, according to the statement, which was published in the July 23/30 JAMA.