Esophageal disorders of gut–brain interaction (e-DGBIs), including functional heartburn, reflux hypersensitivity, functional chest pain, globus, and functional dysphagia, are characterized by chronic esophageal symptoms in the absence of structural, inflammatory, or major motor abnormalities. Esophageal hypersensitivity represents the unifying pathophysiologic mechanism across these conditions. This review outlines the current approaches to managing esophageal DGBI, emphasizing both evidence-based treatments and emerging therapeutic options. Emerging therapeutic strategies include novel neuromodulators such as pregabalin and low-dose naltrexone, noninvasive neuromodulation techniques including transcranial magnetic stimulation, and microbiome-targeted interventions. Digital therapeutics and artificial intelligence–supported collaborative care models represent promising approaches to scale evidence-based treatment delivery. Management of e-DGBIs requires a patient-centered approach that prioritizes the therapeutic relationship between the provider and the patient, early introduction of the brain–gut model, and multidisciplinary collaboration. Pharmacologic neuromodulation remains the cornerstone of therapy, with tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin–norepinephrine reuptake inhibitors demonstrating efficacy across the different e-DGBIs. For reflux hypersensitivity, proton pump inhibitors and potassium-competitive acid blockers may reduce symptom-triggering reflux events, while antireflux surgery and endoscopic interventions may benefit carefully selected patients. Brain–gut behavioral therapies, particularly cognitive behavioral therapy and gut-directed hypnotherapy, have shown meaningful improvements in symptom severity and quality of life in patients with functional heartburn, functional chest pain, and globus. Future progress will depend on rigorous randomized controlled trials and translational research to develop personalized treatment algorithms that incorporate genetic, microbial, and neurophysiologic biomarkers.
Structured exercise (SE) and physical therapy (PT) are integral components of disease management. Older adults with inflammatory bowel disease (IBD) represent a growing proportion of patients, and are at disproportionate risk of functional decline due to the combined effects of aging, chronic inflammation, malnutrition, and inactivity. Despite the well-established benefits of SE and PT, most gastroenterologists report feeling inadequately equipped to counsel and refer patients with physical function limitations, and thus these therapies remain underutilized. The purpose of this review is to synthesize the existing evidence and provide practical, actionable guidance for gastroenterologists to incorporate SE and PT into IBD care. Initial studies suggest complementary SE and PT may significantly improve IBD-related musculoskeletal extraintestinal manifestations (EIMs), such as joint pain, fatigue, sarcopenia, frailty, and improve exercise confidence as compared with standard care alone. Additionally, multimodal prehabilitation strategies may significantly reduce severe postoperative complications and shorten hospital stays in older patients undergoing IBD-related surgery. SE and PT are low-cost, low-risk interventions with benefits spanning multiple domains of physical function and morbidity in older adults with IBD. This article highlights pertinent SE and PT literature in the aging IBD population, including underlying pathophysiology, interventions, and scope of practice. Gastroenterologists are provided evidence-based, condition-specific assessments and PT referral pathways that can be implemented in routine practice. Integrating this into the multidisciplinary IBD care team may improve patients’ physical function and quality of life. Older adults with IBD are at disproportionate risk of functional decline due to chronic inflammation, malnutrition, and EIMs, which can accelerate frailty in this population. Structured exercise and physical therapy are low-cost and low-risk interventions that meaningfully improve function, symptoms, and quality of life in older adults with IBD, yet remain underused in routine care. Evidence supports the use of structured exercise and physical therapy across multiple domains including fatigue, arthropathy, pelvic floor dysfunction, bone loss, and perioperative outcomes. Gastroenterologists can implement condition-specific screening to trigger targeted PT referral pathways, particularly for older adults with identified functional deficits or frailty. Intervening before overt frailty or disability across the IBD lifespan may alter trajectory and improve long-term outcomes.
With the rising age of the population worldwide, the burden on healthcare and inpatient medicine will substantially increase. In these patients, gastrointestinal conditions are frequently the reason for their admission or prolonged hospitalization. This review provides a pragmatic approach to the most common gastrointestinal conditions affecting hospitalized older patients including gastrointestinal bleeding, dysphagia, constipation, and diarrhea. Older adult patients can have atypical presentations of gastrointestinal disorders. Recognition of special signs and symptoms is important to prevent morbidity and mortality. Importantly, these patients can be complex. As patients age, they have more co-morbidities and take more medications. The interplay between this and their functional status, quality-of-life, and goals-of-care is of paramount importance. The decision to proceed with medical therapy, endoscopy, or surgery requires a thoughtful risk-benefit assessment. An overarching principle is that the ideal management of these patients requires consideration of the multiple factors prevalent in this population: co-morbidities, polypharmacy, functional status, frailty, and goals-of-care. The older adult population is heterogeneous, and treatment should be tailored based on weighing all these factors.
Disorders of gut-brain interaction (DGBIs), including irritable bowel syndrome, functional dyspepsia, chronic constipation, functional fecal incontinence, are common and clinically impactful in older adults, often intersecting with multimorbidity, polypharmacy, sensory impairment, cognitive decline, and social constraints, a constellation known in geriatrics as multicomplexity. New-onset symptoms later in life also carry high pre-test probability of organic disease, requiring careful evaluation before diagnosing DGBIs. Despite these considerations, most evidence guiding DGBI management is extrapolated from trials conducted in younger adults. This review summarizes current non-pharmacologic and pharmacologic treatment strategies for common DGBIs in the older adult. We focus on safety, feasibility, and alignment with patient-centered goals of care. Emerging evidence supports non-pharmacologic therapies, including dietary optimization, pelvic floor rehabilitation, and brain-gut behavioral therapies. Technology delivery formats, including phone-, web-, and device-based interventions have emerged as scalable approaches to expand access to evidence-based care while reducing medication burden. Pharmacologic therapies remain important for select patients but require conservative dosing and proactive monitoring due to age-related vulnerability to adverse effects to medications. Management of DGBIs in the older adult should be individualized, function oriented, and aligned with patient goals. Low-risk and feasible non-pharmacologic strategies should be prioritized, and medications should be used judiciously and monitored proactively for complications. Integrating principles of geriatric multicomplexity into DGBI care can improve function, preserve independence, and enhance quality of life in this growing and heterogeneous population. Future research should incorporate geriatric-relevant outcomes to better inform care in this growing and heterogeneous population.
Numerous biologic and small molecule therapies have been approved in recent decades for use in the treatment of Crohn’s disease and ulcerative colitis. This review will summarize recent data on comparativeness effectiveness of advanced therapies in inflammatory bowel disease. Multiple head-to-head, randomized comparisons of biologic therapies have had data published in recent years (Table 1). Ustekinumab and adalimumab for the treatment of moderate to severe Crohn’s disease were compared in the SEAVUE study, with findings of similar rates of clinical remission at week 52, endoscopic improvement, and endoscopic remission between the two agents. In the VARSITY study, vedolizumab demonstrated superior rates of achieving clinical remission and endoscopic improvement at week 52 when compared to adalimumab for the treatment of moderate to severe ulcerative colitis. Several network meta-analyses have been completed to compare individual biologic and small molecule therapies. Vedolizumab demonstrates less favorable efficacy in previously anti-TNF exposed patients, supportive of previously published data. Key findings from the SEQUENCE study found that, compared to ustekinumab, risankizumab demonstrated non-inferiority in achieving clinical remission at week 24 and superior in attaining endoscopic remission at week 48. GALAXI 2-3 and VIVID-1 demonstrated no clear superiority of guselkumab or mirikizumab to ustekinumab in patients in both clinical and endoscopic outcomes assessed in these studies. There is a relatively limited body of randomized, head-to-head trials comparing biologic agents and/or small molecules for the treatment of inflammatory bowel disease, with available data largely limited to network meta-analyses. Additional prospective, head-to-head trials are needed to address these knowledge gaps and allow for more evidence-based positioning of therapies.
Acute gastrointestinal perforations were historically managed surgically. However, advances in endoscopic closure devices have shifted management toward minimally invasive approaches. This review summarizes recent developments in clip-based systems and endoscopic suturing platforms, as well as their expanding role in endoluminal antireflux interventions. The evolution of clip-based systems and endoscopic suturing platforms has expanded the therapeutic spectrum, allowing prompt defect closure with reduced morbidity and decreased need for surgical intervention. These innovations have positioned endoscopy as a primary modality for the treatment of procedure-related perforations, particularly in the context of increasingly complex therapeutic interventions. New-generation through-the-scope clips, over-the-scope clips, and advanced suturing systems have broadened indications for endoscopic full-thickness closure. Improved tissue capture, enhanced tensile strength, and better maneuverability have increased technical and clinical success across a range of defect sizes and challenging anatomical locations. Moreover, refinement of tissue approximation techniques has extended beyond defect closure to include novel endoluminal approaches for the management of gastroesophageal reflux disease. Endoscopic technologies have transformed the management of post-resection closure and gastrointestinal acute perforations and have also expanded the scope of minimally invasive gastroesophageal reflux disease treatment.
Esophageal lichen planus is an underrecognized manifestation of lichen planus that is frequently overlooked in clinical practice. Though it is associated with substantial morbidity, there is a lack of strong data to guide management. This review summarizes evidence on the pathophysiology, presentation, and treatment of esophageal lichen planus, to improve recognition and care in community practice. Esophageal lichen planus has variable clinical presentation, high rates of asymptomatic disease, and significant diagnostic overlap with other esophagitis disorders. Endoscopic findings may be subtle or absent, and histopathology alone is often insufficient for definitive diagnosis, necessitating a multimodal approach. Proposed frameworks and severity grading systems may help standardize evaluation and guide clinical decision-making. Management approach is largely extrapolated from other lichen planus manifestations and rely on expert consensus given limited data. Topical corticosteroids remain first-line therapy and are associated with symptomatic and endoscopic improvement in most patients, while immunomodulators like Janus Kinase inhibitors and tacrolimus have shown promise in refractory disease. Endoscopic dilation is frequently required for stenotic complications, and surveillance remains recommended given concerns for malignant squamous cell transformation. Esophageal lichen planus is a diagnostically challenging condition with limited evidence-based therapies. Increased clinical awareness and structured diagnostic approaches are essential to reducing delays in diagnosis and preventing complications. Further prospective studies and randomized controlled trials are needed to refine diagnostic criteria, evaluate emerging treatments, and define long-term management strategies.
Advances in the understanding of esophageal diseases as well as the diffusion of new technology for both diagnosis and treatment have increased complexity and variability in care delivery. As a result, there is an increasing motivation to monitor and improve care by tracking established quality metrics. This review will summarize the quality indicators and measures currently used for both benign and pre-malignant esophageal diseases focusing on endoscopic quality. Endoscopic quality metrics exist for gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), achalasia, and Barrett’s esophagus (BE). The focus of these metrics is on consistent photodocumentation, use of validated classification systems, and emphasizing a standardized approach to tissue sampling. However, adherence to current best practices is suboptimal. In addition to quality improvement efforts, best practices for adjunctive testing during endoscopy, such as functional luminal imaging probe (FLIP), are needed. While management recommendations and evidence-based guidelines from professional gastrointestinal societies have been translated into quality metrics to improve care delivery, there remain opportunities for improvement in care and wider adoption of monitoring outcomes. Future work should address strategies to augment adherence and methods to track quality for novel technology.
Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death worldwide. While screening colonoscopy reduces CRC incidence and mortality in adults aged 45–75, its role beyond age 75 remains uncertain. This review examines how to determine which older adults may still benefit from screening. Guidelines from the USPSTF and ACG recommend individualized screening for adults aged 76–85, considering overall health, prior screening, and preferences. The benefits of colonoscopy decline with age, as polypectomy effects may take 7–10 years to appear, and procedural risks increase. Tools such as the Clinical Frailty Scale and ePrognosis help assess life expectancy and guide decisions. Evidence suggests benefit primarily for those with fewer than three comorbidities, good functional status, and ≥ 10 years of expected survival. Screening decisions for adults over 75 should focus on health status rather than age alone. Colonoscopy is reasonable for healthy, unscreened individuals with adequate life expectancy, but the risks outweigh the benefits for frail adults or those with limited survival. Shared decision-making using prognostic and frailty tools ensures screening aligns with patient goals.
Gastroparesis is a debilitating gastrointestinal motility disorder characterised by delayed gastric emptying in the absence of mechanical obstruction. Among the various pathophysiological mechanisms associated with gastroparesis, malignancy-associated gastroparesis (MG) represents a distinct yet under-recognised clinical entity. This review aims to synthesise current knowledge on the pathophysiology, diagnostic challenges, and management of MG, highlighting recent advances and knowledge gaps in this emerging area. The exact prevalence of MG remains unknown; It is often underdiagnosed and inadequately managed in both oncology and gastroenterology contexts. Malignancies associated with gastroparesis most commonly involve the pancreas, stomach, and gallbladder or paraneoplastic syndromes. The mechanisms underlying malignant gastroparesis are complex and not yet fully understood. These may involve autonomic neuropathy caused by chemotherapy, immunosuppression leading to opportunistic viral infections, paraneoplastic gastroparesis characterised by autoimmune-mediated neuropathy or myopathy, and palliative procedures such as celiac plexus blocks. Furthermore, malignancies can worsen pre-existing metabolic conditions like diabetes mellitus and hypothyroidism, thereby aggravating gastric dysmotility. Management of MG depends on clinical severity; metoclopramide is the only medication approved by the U.S. Food and Drug Administration for the treatment of gastroparesis. Endoscopic and surgical procedures are usually reserved for refractory cases. Malignant gastroparesis is a complex, multifactorial, and often overlooked cause of gastric dysmotility in cancer patients. A thorough understanding of its varied pathophysiological mechanisms is crucial for early, accurate diagnosis and customised management. Further research is required to define diagnostic algorithms and develop targeted therapies to enhance patient outcomes and quality of life.
Achalasia is a chronic esophageal motility disorder for which available therapies are palliative rather than curative. Although lower esophageal sphincter-directed interventions provide excellent short-term relief, recurrence and late complications are common. This review aims to synthesize current evidence on mechanisms of recurrent or persistent symptoms after achalasia treatment, outline a pragmatic framework for longitudinal monitoring, and summarize management strategies for recurrent and advanced disease. Recent studies emphasize the limitations of symptom-based follow-up and highlight the need for longitudinal follow-up with the utilization of complementary physiologic and anatomic assessment. Timed barium esophagram, endoscopy, high-resolution manometry, and EndoFLIP provide distinct but interrelated insights into esophagogastric junction function, esophageal emptying, and structural remodeling. Current emerging data underscores the role of anatomy-driven bolus retention, including pseudodiverticula, sigmoid deformity, and sump configurations, in late treatment failure, even when esophagogastric junction opening appears adequate. Comparative data on re-intervention demonstrate that pneumatic dilation, redo myotomy, and peroral endoscopic myotomy can be effective when appropriately matched to the primary failure mechanism. Achalasia requires lifelong surveillance and individualized management approaches. Effective longitudinal care depends on mechanism-based evaluation that distinguishes recurrent outflow obstruction from anatomy-driven retention and functional overlap syndromes. Integrating objective anatomical and physiological diagnostic tools with clinical context clarifies the underlying etiology and allows for more rational selection of re-intervention. Future research should focus on refining surveillance strategies, validating approaches to etiology-based re-intervention, and further investigating emerging esophagus-preserving therapies for advanced disease.
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease that affects all age groups across the lifespan. However, this disease has been incompletely studied in older EoE patients. This review synthesizes current evidence regarding epidemiology, clinical presentation, and treatment outcomes of EoE in older adult patients and highlights ongoing gaps in clinical knowledge. While historically considered a disease of children and young adults, EoE is becoming more recognized in individuals over the age of 65, which may reflect heightened awareness as well as an aging population. While the underlying disease pathogenesis is the same regardless of age, in older adults EoE often presents with long-standing esophageal dysfunction which may differ in severity and chronicity, be subjected to longer diagnostic delays, and be complicated by comorbid conditions. Eosinophilic esophagitis in older adult patients is underrecognized, but the older population can have clinically significant manifestations of this disease which traditionally is associated with younger populations. Greater awareness of age-specific presentation and treatment challenges is essential to improve outcomes, and keeping EoE on the differential diagnosis in older patients is critical to making a timely diagnosis. Future studies tailored to this population are essential.
IBS can significantly impact older adults; however, we do not currently understand how age-related changes affect the diagnosis and treatment of IBS in older adults compared to their younger counterparts. This review aims to combine a systematic review of the literature focused on IBS in the older adult, defined as those aged ≥ 60, with practical recommendations for clinical practice. PubMed and Embase were searched May 2025. The primary search terms were “irritable bowel” and “Rome” (to catch articles using the Rome Criteria), combined with an extensive list of synonyms for “older adult.” Only eight studies were identified that directly addressed the pathophysiology, assessment, diagnosis, and treatment of IBS in the older adult. We discuss how older age can affect the multifactorial pathophysiology of IBS, including its effects on motility and brain-gut dysregulation. We also give practical advice on: (1) Differential diagnoses not to be missed especially in older adult including malignancy, inflammatory bowel diseases and other non-GI etiologies such as mesenteric ischemia, and (2) Therapeutic options for older adult patients with IBS using a step-up approach to therapy (e.g., diets, supplements, motility medications, and brain-gut behavior therapies, meditative movement practices, and neuromodulators). It is important to consider the unique characteristics of aging patients with IBS, which include lifestyle factors, comorbid conditions particularly affecting the older adult, and medication side effects in optimizing evidence-based treatment options for this population. Very few studies have focused on IBS in older adults. More studies are needed to understand the impact of aging on the brain-gut axis and to inform treatment recommendations for this group of patients.
Crohn’s disease is a heterogenous disease of the gastrointestinal tract. New treatments have emerged in the last few decades, which raises the question as to what the best treatment recommendations would be for patients with mild disease. We sought to integrate both historical treatment strategies with recent evidence to propose a comprehensive approach. Advanced therapies such as biologics and small molecules have been developed to treat Crohn’s disease, which could be useful in a top-down approach to treat even mild cases and prevent future complications. While traditional approaches such as budesonide and sulfasalazine are efficacious in inducing and maintaining immune suppression in Crohn’s disease, strong consideration should be given for a top-down approach with advanced therapies such as infliximab. Selection of high-risk individuals would be important for advanced therapy. Future research should additionally include a focus on mild presentations of disease to determine if these advanced therapies would be appropriate first line therapeutic options, especially in patients who are diagnosed at a younger age.
Exocrine pancreatic insufficiency (EPI) may occur due to a variety of causes depending on the age of the patient, and making the diagnosis can be challenging due to a lack of reliable diagnostic testing approaches. This review summarizes the approach to diagnosis and treatment of patients with EPI. In patients at risk of EPI, timely diagnosis and treatment are important to optimize nutritional status, quality of life, and survival. EPI without overt steatorrhea may be subclinical with nutritional impacts such as weight loss or growth failure and nutrient malabsorption. Providers should be familiar with available indirect and direct tests and know when such tests will facilitate accurate diagnosis and appropriate, prompt treatment. Identification of at-risk patients, appropriate diagnostic testing, and appropriate PERT dosing are necessary to provide quality care for patients with EPI.
Inflammatory bowel disease (IBD) poses a looming global health burden characterized by increasing prevalence and healthcare costs. This is despite significant advances in available therapeutics and disease monitoring strategies over the past 25 years. A precision medicine approach promises to enhance personalized medicine through improved prediction models, precise diagnoses, and individualized treatment strategies. Recent advances in artificial intelligence (AI) are now being incorporated into endoscopy, histology, and radiology research with the aim of improving objective, reproducible, and timely assessments of IBD. High-throughput platforms – including genetics (e.g. single nucleotide polymorphisms and polygenic risk scores), messenger RNA expression (e.g. transcript sets), and comprehensive protein and metabolite measurements – have the potential to uncover biomarkers that aim to resolve ambiguous disease states, provide risk stratification (e.g. of disease complications and response to treatment), and reveal mechanistic insight. This review highlights recent advances in AI and high-dimensional molecular profiling in IBD, focusing on methodological and translational challenges that will need to be addressed to fully realize precision medicine’s potential in clinical care.
This review article discusses the latest updates in the pathophysiology, classification, diagnostic work-up, and therapeutic strategies for achalasia, with an emphasis on individualized, evidence-based approaches and future directions in care. The advancement in and implementation of high resolution manometry in patients with dysphagia have revolutionized the diagnostic accuracy and classification of achalasia. Additionally, manometry plays a critical role in guiding treatment selection both in the pre-procedural evaluation and even intraoperatively. Peroral Endoscopic Myotomy has emerged as a minimally invasive endoscopic treatment modality that is both effective and safe when compared to traditional treatment modalities. Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absence of peristalsis. Achalasia symptoms include dysphagia to solids and liquids, weight loss, regurgitation, and chest pain. Recent advances especially in high resolution manometry have significantly improved our understanding of achalasia pathophysiology, the diagnostic accuracy and sub-classification. Current treatment options include pharmacological, endoscopic, and surgical modalities. Our review summarizes the diagnostic tools of achalasia in addition to the evidence supporting different treatment modalities. There is a need for a more tailored approach to individual patients with achalasia while accounting for their age, comorbidities, achalasia classification and prior used treatment modalities.
Janus kinase inhibitors (JAKi) have emerged as an effective oral therapy with a rapid onset of action for moderate to severe ulcerative colitis (UC) and Crohn’s disease (CD). Targeting the JAK-STAT pathway, therapies such as tofacitinib (pan-JAK inhibitor), and selective JAK1 inhibitors like upadacitinib and filgotinib, demonstrate benefit in treating active inflammation and extraintestinal manifestations of inflammatory bowel disease (IBD). However, safety concerns, including risks of infection, herpes zoster reactivation, lipid abnormalities, major adverse cardiovascular events (MACE), venous thromboembolism (VTE), malignancy, and gastrointestinal perforations, have led to increased regulatory scrutiny. Despite these concerns, JAKi can be safely and effectively incorporated into IBD treatment algorithms, with individualized risk evaluation and close monitoring. These risks appear dose-dependent and are more pronounced in high-risk populations, such as older adults or those with pre-existing cardiovascular risk. Preventive strategies, including vaccinations, cardiovascular screening, TB testing, and regular lab monitoring, are essential. JAKi are contraindicated during pregnancy and breastfeeding due to limited safety data. This review highlights the evolving safety profile of JAKi and provides recommendations to optimize their use in clinical practice.
• Individuals with IBD are at an increased risk of developing certain malignancies, both from disease activity as well as certain immunosuppressive medications. • Withholding some immunosuppressive agents, such as thiopurine, anti-TNF agents, and JAK inhibitors should be considered in patients with active or prior cancers. • Certain anti-neoplastic regimens, such as hormonal deprivation therapy, immune checkpoint inhibitors (ICIs), and pelvic radiation, can increase the risk of IBD flares during cancer treatment. • Decisions regarding cancer treatments and IBD therapy should be individualized and made with cooperation between gastroenterologists and oncologists.
Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease often diagnosed too late for effective intervention. Early detection offers the best opportunity to improve survival, but no universal screening strategy exists. This review highlights recent advancements in risk stratification, diagnostic modalities, and artificial intelligence (AI)-based approaches for early detection, focusing on their clinical utility, current state, and future potential. Advances in risk stratification have improved identification of high-risk cohorts based on familial and germline risk, resulting in expert consensus supporting clinical screening. New-onset diabetes (NOD) risk modeling has emerged as a promising tool for identifying sporadic PDAC. AI-driven models using electronic medical records and multimodal datasets are in development, showing promise for individualized risk prediction. Imaging modalities (CT, MRI, EUS) are being refined for higher sensitivity, with AI applications enhancing detection of subtle, pre-diagnostic tumors. Biomarker research is advancing, with multi-omic panels and liquid biopsy assays improving early-stage detection. Novel molecular analyses of pancreatic juice and cyst fluid aid in identifying high-grade precursor lesions and early PDAC. Innovations in imaging, biomarkers, and AI are reshaping PDAC early detection. A multimodal strategy targeting broader high-risk groups may enable earlier diagnosis and improved outcomes.
