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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

Antibiotic prophylaxis prior to ERCP for biliary obstruction (February 2024)

For patients with biliary obstruction undergoing endoscopic retrograde cholangiopancreatography (ERCP), the benefit of antibiotic prophylaxis in all versus selected patients is uncertain. In a randomized trial including 378 patients with biliary obstruction undergoing ERCP, antibiotic prophylaxis resulted in lower risk of cholangitis compared with no prophylaxis (2 versus 6 percent) [ 1 ]. Based on these and older data, we reserve antibiotic prophylaxis for patients who are at risk for incomplete biliary drainage with ERCP and await further data before administering antibiotic prophylaxis to all patients with biliary obstruction. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures", section on 'Endoscopic retrograde cholangiopancreatography (ERCP)' .)

Pancreatic stenting for preventing pancreatitis after ERCP (February 2024)

Patients with difficult biliary access are at increased risk for pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), which may be prevented by prophylactic pancreatic stenting. In a trial including 1950 patients at high risk for post-ERCP pancreatitis, individuals assigned to pancreatic stent placement plus indomethacin had lower rates of post-ERCP pancreatitis compared with those assigned to indomethacin alone (11 versus 15 percent) [ 2 ]. Rates of serious adverse events were not significantly different between groups. These data support our approach of prophylactic pancreatic stenting in high-risk patients undergoing ERCP. (See "Management of difficult biliary access during ERCP in adults", section on 'Efficacy' .)

Motorized spiral enteroscopy for evaluating small bowel disorders (October 2023)

Device-assisted enteroscopy facilitates direct access to the small bowel, but studies on motorized spiral enteroscopy are limited. In a trial comparing motorized spiral enteroscopy with single balloon enteroscopy in 110 adults with suspected small bowel disorders, rates of complete small bowel examination were higher with motorized spiral enteroscopy (71 versus 11 percent) [ 3 ]. Motorized spiral enteroscopy also resulted in higher diagnostic yield (80 versus 62 percent) and shorter mean procedure times (58 versus 114 minutes). No major adverse events occurred in either group. These data show promise, but further studies on safety are needed before performing motorized spiral enteroscopy routinely in clinical practice. In addition, its use may be limited by equipment availability and endoscopic expertise. (See "Overview of deep small bowel enteroscopy", section on 'Motorized spiral enteroscopy' .)

ESOPHAGEAL AND GASTRIC DISEASE

Budesonide oral suspension for eosinophilic esophagitis (March 2024)

In patients with eosinophilic esophagitis (EoE), use of topical glucocorticoids has been limited by lack of regulatory approval and potentially inconsistent drug delivery. Budesonide oral suspension is a formulation that was recently approved by the US Food and Drug Administration for treating EoE in adults and pediatric patients ages 11 years and older [ 4,5 ]. Approval was informed by clinical trials showing that topical budesonide resulted in higher rates of histologic remission and symptomatic improvement compared with placebo. We anticipate using budesonide oral suspension as the preferred topical glucocorticoid for treating EoE. (See "Treatment of eosinophilic esophagitis (EoE)", section on 'Topical glucocorticoids' .)

Dupilumab for refractory eosinophilic esophagitis (February 2024)

Few data are available on the use of dupilumab (a monoclonal antibody) for treating refractory eosinophilic esophagitis. In a cohort study of 46 patients with refractory eosinophilic esophagitis, dupilumab therapy was associated with histologic remission (defined as <15 eosinophils/high-power field) in 37 patients (80 percent) and with symptomatic improvement in 42 patients (91 percent) after a median of six months [ 6 ]. These data support our approach of using dupilumab for patients with eosinophilic esophagitis who have not responded to other therapies (eg, topical glucocorticoids). (See "Treatment of eosinophilic esophagitis (EoE)", section on 'Dupilumab' .)

Rifabutin triple therapy for Helicobacter pylori (October 2023)

Management of patients who have failed multiple antibiotic regimens for Helicobacter pylori is an increasingly frequent challenge. In a randomized trial in which 364 subjects with H. pylori who failed at least two prior treatments were assigned to rifabutin triple therapy or bismuth quadruple therapy for 14 days, H. pylori eradication rates were similar in both groups [ 7 ]. However, the rifabutin group had a higher compliance rate and a lower rate of adverse effects. This trial supports current guidelines and our recommendation to use rifabutin triple therapy as a salvage treatment for H. pylori. (See "Treatment regimens for Helicobacter pylori in adults", section on 'Salvage regimens' .)

New guidelines for protoporphyria (March 2024)

Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are rare cutaneous porphyrias that cause severe, nonblistering photosensitivity and liver disease; their rarity makes evidence-based management challenging. Two new guidelines from the Rare Diseases Clinical Research Network are available to help guide diagnosis and management of EPP and XLP:

● Consensus guidelines discuss use of biochemical and genetic testing, use of afamelanotide , avoidance of ineffective therapies, methods of sun protection, and prevention of liver disease [ 8 ].

● Liver-specific guidelines discuss screening, prevention, and treatment of liver disease, including liver and hematopoietic stem cell transplantation for advanced disease [ 9 ].

● (See "Erythropoietic protoporphyria and X-linked protoporphyria", section on 'Management' .)

Elafibranor for treating primary biliary cholangitis (March 2024)

Elafibranor, a dual peroxisome proliferator-activated receptor (PPAR)-alpha and PPAR-delta agonist, is under investigation for treating primary biliary cholangitis (PBC). In a trial including 161 patients with PBC who had intolerance or inadequate response with ursodeoxycholic acid , elafibranor resulted in higher rates of biochemical response compared with placebo after 52 weeks (51 versus 4 percent) [ 10 ]. Elafibranor also resulted in higher rates of normalized alkaline phosphatase (15 versus 0 percent). Gastrointestinal side effects (eg, abdominal pain) occurred more frequently in the elafibranor group. Further studies and regulatory approval are needed to clarify the role of elafibranor in treating PBC. (See "Overview of the management of primary biliary cholangitis", section on 'Peroxisome proliferator-activated receptor [PPAR] agonists' .)

Seladelpar for treating primary biliary cholangitis (March 2024)

Seladelpar, a peroxisome proliferator-activated receptor-delta agonist, is under investigation for treating primary biliary cholangitis (PBC). In a trial including 193 patients with PBC who had intolerance or inadequate response with ursodeoxycholic acid , seladelpar resulted in higher rates of biochemical response compared with placebo after 12 months (62 versus 20 percent) [ 11 ]. In addition, seladelpar resulted in higher rates of normalized alkaline phosphatase (25 versus 0 percent). For patients with moderate to severe pruritus, seladelpar reduced symptom severity. These data show promise, but further studies and regulatory approval are needed before incorporating seladelpar into clinical practice. (See "Overview of the management of primary biliary cholangitis", section on 'Peroxisome proliferator-activated receptor [PPAR] agonists' .)

Pyogenic liver abscess and colorectal cancer (February 2024)

Studies from Asia suggest that pyogenic liver abscess is associated with increased incidence of colorectal cancer, but studies outside Asia are scarce. In a 10-year retrospective study from 120 hospitals in the United States, the incidence of colorectal cancer among over 8000 patients with liver abscess was almost fourfold higher during the first six months after diagnosis of liver abscess compared with 23,000 matched controls without liver abscess [ 12 ]. The correlation was not observed among patients whose liver abscess was due to cholangitis or cholecystitis, and the type of organism causing the abscess did not correlate with the incidence of cancer. These findings support prompt screening for colorectal cancer in patients with pyogenic liver abscess, particularly in patients without an underlying hepatobiliary cause. (See "Pyogenic liver abscess", section on 'Association with colorectal cancer' .)

Mortality risk in alcohol-associated liver disease (January 2024)

Few studies have reported the long-term outcomes of patients with alcohol-associated liver disease (ALD). In a national registry study including over 23,000 patients with ALD diagnosed at median age 58 years, 67 percent died during >100,000 person-years of follow-up and liver disease was the primary cause of death in 45 percent [ 13 ]. The 5- and 10-year mortality rates due to liver disease were 26 and 31 percent, respectively. These data emphasize the importance of treating patients with alcohol use disorder and may inform strategies to prevent liver-related mortality in those with ALD. (See "Management of alcohol-associated steatosis and alcohol-associated cirrhosis", section on 'Mortality' .)

Model for End-stage Liver Disease (MELD) 3.0 for liver transplantation (October 2023, Modified December 2023)

The Model for End-stage Liver Disease (MELD) score is used to allocate livers for transplantation. Recently, the Organ Procurement and Transplantation Network implemented an updated score, MELD 3.0, for prioritizing liver transplantation candidates who are ages 12 and older [ 14 ]. MELD 3.0 includes variables from the original model (ie, serum bilirubin, serum creatinine, and international normalized ratio) in addition to other inputs (ie, serum sodium, patient sex, and serum albumin) and a lower creatinine ceiling. Goals of using MELD 3.0 include reducing overall waitlist mortality and improving access for female liver transplant candidates. (See "Model for End-stage Liver Disease (MELD)", section on 'MELD 3.0' . and "Liver transplantation for hepatocellular carcinoma", section on 'MELD 3.0' .)

Paracentesis for hospitalized patients with cirrhosis and ascites (November 2023)

Patients with cirrhosis complicated by ascites are at risk for spontaneous bacterial peritonitis and other complications. However, the magnitude of risk associated with deferring diagnostic paracentesis in such patients when they are hospitalized is uncertain. In a large database study comparing late (ie, ≥24 hours) or no paracentesis with early paracentesis in hospitalized patients with ascites, late paracentesis or no paracentesis was associated with higher risk of acute kidney injury (odds ratio [OR] 2.2 and 1.3, respectively) and inpatient mortality (OR 1.5 and 1.4, respectively) [ 15 ]. These data support performing diagnostic paracentesis within 24 hours of hospital admission, which is consistent with our practice. (See "Diagnostic and therapeutic abdominal paracentesis", section on 'Indications' .)

PANCREATIC AND BILIARY DISEASE

Risk of pancreatic cancer in stable intraductal papillary mucinous neoplasms (November 2023)

The optimal duration of pancreatic cancer surveillance in patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) is unclear. In a study of over 3800 such patients without worrisome features (WFs) or high-risk stigmata (HRS), 42 percent had BD-IPMNs that remained stable in size and did not develop WF/HRS for at least five years [ 16 ]. Within this group, patients ≥75 years with cysts <30 mm and those ≥65 years with cysts <15 mm had a standardized incidence ratio for pancreatic cancer comparable to the general population and low disease-specific mortality. These data suggest that this subgroup may be able to discontinue pancreatic cancer surveillance; however, further studies are needed to validate these results. (See "Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Pathophysiology and clinical manifestations", section on 'Pancreatic malignancy' .)

Microscopic colitis and acute pancreatitis (November 2023)

Microscopic colitis has been associated with several other conditions. In a recent population-based study including >12,000 patients with microscopic colitis, these individuals had a twofold increased risk for acute pancreatitis unrelated to gallstones but no increase in gallstone-related acute pancreatitis compared with matched controls [ 17 ]. The increased risk persisted for more than 10 years after diagnosis. Whether the increase in acute pancreatitis was due to active disease or a side effect of budesonide is unclear. Further studies are needed to evaluate this association. (See "Microscopic (lymphocytic and collagenous) colitis: Clinical manifestations, diagnosis, and management", section on 'Associated conditions' .)

Clinical practice update on exocrine pancreatic insufficiency (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on exocrine pancreatic insufficiency (EPI) [ 18 ]. The AGA Clinical Practice Update advises considering a diagnosis of EPI in individuals with moderate-risk clinical conditions (eg, celiac disease, previous intestinal surgery, longstanding diabetes mellitus, Zollinger-Ellison syndrome). It emphasizes the importance of testing for EPI in patients with nonspecific symptoms and cautions against relying on a response to an empiric trial of pancreatic enzymes to diagnose EPI as this may be due to a placebo effect. Our approach is consistent with this guidance. (See "Exocrine pancreatic insufficiency", section on 'Diagnostic approach' .)

SMALL BOWEL AND COLONIC DISEASE

New guidelines on management of pouchitis (March 2024)

Pouchitis is common in patients with ulcerative colitis who have undergone restorative proctocolectomy with ileal pouch-anal anastomosis. The American Gastroenterological Association (AGA) has published new guidelines to address management of pouchitis [ 19 ]. The guidelines endorse several strategies including antibiotic therapy for initial treatment and glucocorticoids or advanced immunosuppressive agents (eg, biologic therapy) for patients who do not respond to antibiotics. For patients who respond to antibiotics but relapse frequently, AGA suggests use of probiotics or long-term antibiotics to prevent recurrence. Our approach to managing pouchitis is generally consistent with these guidelines. (See "Management of acute and chronic pouchitis", section on 'Introduction' .)

De-escalating combination therapy in patients with inflammatory bowel disease (March 2024)

In patients with inflammatory bowel disease (IBD), the goal of de-escalating combination therapy (anti-tumor necrosis factor [TNF] agent plus an immunomodulator) is preventing relapse while minimizing adverse effects. However, the magnitude of risk for relapse is uncertain. In a meta-analysis of randomized trials of patients with sustained, glucocorticoid-free IBD remission on combination therapy (5 trials, 404 patients), relapse rates at one to two years were more than twofold higher following withdrawal of the anti-TNF agent compared with continuing combination therapy (32 versus 11 percent) [ 20 ]. Relapse rates did not increase following immunomodulator withdrawal. These data support our approach to de-escalating combination therapy by withdrawing the immunomodulator while continuing anti-TNF maintenance therapy. (See "Medical management of moderate to severe Crohn disease in adults", section on 'Remission achieved with anti-TNF-based regimen' .)

Mirikizumab for moderate to severe ulcerative colitis (August 2023, Modified January 2024)

Therapeutic options for adults with moderate to severe ulcerative colitis (UC) are expanding. In an induction trial comparing mirikizumab (a monoclonal antibody that targets the p19 subunit of interleukin-23) with placebo in nearly 1300 patients, mirikizumab (300 mg intravenously every four weeks) resulted in higher rates of clinical remission after 12 weeks (24 versus 13 percent) [ 21 ]. In the maintenance trial including over 500 patients, mirikizumab (200 mg subcutaneously every four weeks) resulted in higher rates of clinical remission after 40 weeks (50 versus 25 percent). Based on these data, the US Food and Drug Administration approved mirikizumab for moderate to severe UC [ 22 ]. We anticipate using mirikizumab as first- or second-line therapy for adults with moderate to severe UC. (See "Management of moderate to severe ulcerative colitis in adults", section on 'Anti-interleukin antibody-based therapy' .)

Clinical practice update on risk stratification for colorectal cancer screening and postpolypectomy surveillance (December 2023)

The American Gastroenterological Association (AGA) recently published nine statements of best practice advice on risk stratification for colorectal cancer (CRC) screening and postpolypectomy surveillance [ 23 ]. They advise basing risk stratification on an individual's age, a known or suspected predisposing hereditary CRC syndrome, other CRC predisposing conditions (eg, inflammatory bowel disease), and/or a family history of CRC. They also suggest that the decision to continue postpolypectomy surveillance for individuals older than 75 years should be individualized. Shared decision-making discussions should include an assessment of the risks of incident CRC, procedure-related risks, comorbidities, and life expectancy (>5 years). Our approach is consistent with this guidance. (See "Overview of colon polyps", section on 'Risk assessment for subsequent colorectal cancer' .)

Investigational therapy for irritable bowel syndrome with bile acid diarrhea (November 2023)

Patients with irritable bowel syndrome with predominant diarrhea (IBS-D) frequently have concurrent bile acid malabsorption. In a randomized trial in which 31 patients with IBS and bile acid diarrhea were assigned to aldafermin (an investigational analogue of recombinant human fibroblast growth factor 19) or placebo for 28 days, the aldafermin group had lower bile acid synthesis and improved stool consistency during week 4 of treatment, but abdominal pain and stool frequency were not significantly different for the two groups [ 24 ]. Treatment-related adverse events were significantly higher in patients in the aldafermin group, and four patients on aldafermin had a clinically significant increase in low-density lipoprotein cholesterol. More studies are needed to clarify if aldafermin has a role in the treatment of IBS-D. (See "Treatment of irritable bowel syndrome in adults", section on 'Other therapies' .)

Low-dose tricyclic antidepressants in irritable bowel syndrome (October 2023)

The efficacy of tricyclic antidepressants (TCAs) in the management of irritable bowel syndrome (IBS) has not been well established in the primary care setting. In a pragmatic randomized trial, 463 patients with IBS unresponsive to dietary advice and first-line therapies in primary care practices were assigned to titrated low-dose amitriptyline or placebo as a second-line therapy [ 25 ]. At six months, patients treated with low-dose amitriptyline had lower IBS-symptom severity scores and a higher rate of symptom relief. The most common side effects were related to the anticholinergic effects of amitriptyline, but the majority were mild. These data support current guidelines and our recommendation to use TCAs in the management of patients with IBS. (See "Treatment of irritable bowel syndrome in adults", section on 'Antidepressants' .)

Pozelimab for CD55-deficient protein losing enteropathy (October 2023)

Protein-losing enteropathies (PLE) are characterized by excessive loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinemia, edema, and pleural and pericardial effusions. Pozelimab , a C5 inhibitor, has been approved by the US Food and Drug Administration (FDA) to treat patients with CD55-deficient PLE (CHAPLE syndrome) based on an ongoing single-arm phase II/III clinical trial of 10 patients with CHAPLE syndrome and symptomatic hypoalbuminemia [ 26 ]. All patients achieved normalization of albumin by week 12 of treatment with pozelimab and maintained serum albumin concentrations within the normal range through at least 72 weeks. Improvements were also reported in serum IgG levels and total iron-binding capacity. Although FDA approved, long-term safety data are still needed. (See "Protein-losing gastroenteropathy", section on 'Treatment of the underlying disease' .)

OTHER GASTROENTEROLOGY AND NUTRITION

Clinical practice update on bloating and distention (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on the evaluation and management of bloating and distention [ 27 ]. The AGA Clinical Practice Update endorses serologic evaluation for celiac disease and exclusion of carbohydrate enzyme deficiencies with dietary restriction and/or breath testing, but emphasizes reserving additional evaluation with abdominal imaging and upper endoscopy for patients with alarm features, recent worsening symptoms, or an abnormal physical examination. Our approach is consistent with this guidance. (See "Overview of intestinal gas and bloating", section on 'Evaluation' .)

• Leem G, Sung MJ, Park JH, et al. Randomized Trial of Prophylactic Antibiotics for Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction. Am J Gastroenterol 2024; 119:183.
• Elmunzer BJ, Foster LD, Serrano J, et al. Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial. Lancet 2024; 403:450.
• Rughwani H, Singh AP, Ramchandani M, et al. A Randomized, Controlled Trial Comparing the Total Enteroscopy Rate and Diagnostic Efficacy of Novel Motorized Spiral Enteroscopy and Single-Balloon Enteroscopy in Patients With Small-Bowel Disorders: The Motor Trial (NCT 05548140). Am J Gastroenterol 2023; 118:1855.
• Budesonide oral suspension. US Food & Drug Administration, approval letter. February 2024. https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2024/213976Orig1s000ltr.pdf (Accessed on February 12, 2024).
• Budesonide oral suspension. United States Prescribing Information, February 2024. US Food & Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/213976s000lbl.pdf (Accessed on February 13, 2024).
• Lee CJ, Dellon ES. Real-World Efficacy of Dupilumab in Severe, Treatment-Refractory, and Fibrostenotic Patients With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2024; 22:252.
• Chen J, Guo Y, Huang Y, et al. Rifabutin-Containing Triple Therapy Versus Bismuth Quadruple Therapy for Helicobacter pylori Rescue Treatment: A Multicenter, Randomized Controlled Trial. J Infect Dis 2023; 228:511.
• Dickey AK, Naik H, Keel SB, et al. Evidence-based consensus guidelines for the diagnosis and management of erythropoietic protoporphyria and X-linked protoporphyria. J Am Acad Dermatol 2023; 89:1227.
• Levy C, Dickey AK, Wang B, et al. Evidence-based consensus guidelines for the diagnosis and management of protoporphyria-related liver dysfunction in erythropoietic protoporphyria and X-linked protoporphyria. Hepatology 2024; 79:731.
• Kowdley KV, Bowlus CL, Levy C, et al. Efficacy and Safety of Elafibranor in Primary Biliary Cholangitis. N Engl J Med 2024; 390:795.
• Hirschfield GM, Bowlus CL, Mayo MJ, et al. A Phase 3 Trial of Seladelpar in Primary Biliary Cholangitis. N Engl J Med 2024; 390:783.
• Suzuki H, Kidder I, Tanaka T, Goto M. Incidence of Colorectal Cancer in Patients Diagnosed With Pyogenic Liver Abscess. JAMA Netw Open 2023; 6:e2348218.
• Kann AE, Jepsen P, Madsen LG, et al. Cause-specific mortality in patients with alcohol-related liver disease in Denmark: a population-based study. Lancet Gastroenterol Hepatol 2023; 8:1028.
• Improvements to MELD, PELD, Status 1A and Status 1B to take effect July 13. United Network for Organ Sharing, 2023. Available at: https://unos.org/news/improvements-to-meld-and-peld-phase-1-data-entry-in-effect-june-15/ (Accessed on September 04, 2023).
• Patel N, Silvey S, O'Leary JG, et al. Early paracentesis is associated with better prognosis compared with late or no-paracentesis in hospitalized veterans with cirrhosis and ascites. Liver Transpl 2023; 29:919.
• Marchegiani G, Pollini T, Burelli A, et al. Surveillance for Presumed BD-IPMN of the Pancreas: Stability, Size, and Age Identify Targets for Discontinuation. Gastroenterology 2023; 165:1016.
• Bergman D, Roelstraete B, Olén O, et al. Microscopic Colitis and Risk of Incident Acute Pancreatitis: A Nationwide Population-Based Matched Cohort Study. Am J Gastroenterol 2023; 118:2041.
• Whitcomb DC, Buchner AM, Forsmark CE. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency: Expert Review. Gastroenterology 2023; 165:1292.
• Barnes EL, Agrawal M, Syal G, et al. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology 2024; 166:59.
• Katibian DJ, Solitano V, Polk DB, et al. Withdrawal of Immunomodulators or TNF Antagonists in Patients With Inflammatory Bowel Diseases in Remission on Combination Therapy: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:22.
• D'Haens G, Dubinsky M, Kobayashi T, et al. Mirikizumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med 2023; 388:2444.
• Mirikizumab. United States Prescribing Information. Revised November, 2023. US Food & Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761279s000lbl.pdf (Accessed on November 20, 2023).
• Issaka RB, Chan AT, Gupta S. AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review. Gastroenterology 2023; 165:1280.
• BouSaba J, Torres M, Dilmaghani S, et al. Effects of FGF19 Analogue Aldafermin in Patients With Bile Acid Diarrhea: A Randomized, Placebo-Control Trial. Gastroenterology 2023; 165:499.
• Alderson SL, Wright-Hughes A, Ford AC, et al. Amitriptyline at low-dose and titrated for irritable bowel syndrome as second-line treatment (The ATLANTIS trial): protocol for a randomised double-blind placebo-controlled trial in primary care. Trials 2022; 23:552.
• U.S. Food and Drug Administration. FDA approves first treatment for CD55-deficient protein-losing enteropathy (CHAPLE disease). Available at https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-first-treatment-cd55-deficient-protein-losing-enteropathy-chaple-disease (Accessed on October 23, 2023).
• Moshiree B, Drossman D, Shaukat A. AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review. Gastroenterology 2023; 165:791.

Gastroenterology

Explore the latest in gastroenterology, including topics in GI reflux, cancer, and management of inflammatory bowel and pancreatic disease.

Publication

Article type.

• Immunotherapy in Gastric Cancer—Choosing Methods or Results JAMA Oncology Opinion April 4, 2024 Gastrointestinal Cancer Targeted and Immune Therapy Oncology Gastric Cancer Gastroenterology and Hepatology Full Text | pdf link PDF

This cohort study analyzes the demographic characteristics, treatment duration, and survival of patients who received imatinib and/or sunitinib for gastrointestinal stromal tumors through global access programs.

• Strategies for Equality in Cancer Care in Low- and Middle-Income Countries JAMA Network Open Opinion April 3, 2024 Oncology Gastroenterology and Hepatology Gastrointestinal Cancer Targeted and Immune Therapy Global Health Full Text | pdf link PDF open access

This randomized clinical trial evaluates the safety and efficacy of transarterial chemoembolization plus sorafenib vs sorafenib alone for patients with hepatocellular carcinoma and portal vein tumor thrombus after surgery.

• Studying Adjuvant Therapy for Hepatocellular Carcinoma JAMA Surgery Opinion April 3, 2024 Hepatobiliary Disease Gastroenterology and Hepatology Gastrointestinal Cancer Hepatobiliary Cancer Oncology Full Text | pdf link PDF

This cross-sectional study estimates advanced neoplasia yields during surveillance colonoscopy procedures among adults aged 70 years or older with a history of colorectal adenoma.

This cross-sectional study estimates the number of average-risk colorectal cancer screening–eligible individuals in the US since the US Preventive Services Task Force updated its recommendations in 2021.

This cohort study of patients with gastric cancer in China examines the survival benefit associated with anti– Helicobacter pylori treatment after radical gastrectomy.

This essay describes how a dog played a role in one physicians process of being diagnosed with hepatocellular carcinoma.

This quality improvement study investigates whether implementation of the Centers for Disease Control and Prevention’s Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities Framework is associated with a decrease in hospital-onset C difficile infections.

This study evaluates the validity of the Scoring System of Appendicitis Severity and proposes improvements.

• Improved Tool to Assess Complicated Appendicitis Probability JAMA Surgery Opinion March 27, 2024 Gastrointestinal Surgery Surgery Gastroenterology and Hepatology Emergency Medicine Full Text | pdf link PDF
• Closing a Gap in Colorectal Cancer Screening JAMA Network Open Opinion March 25, 2024 Public Health Gastroenterology and Hepatology Health Policy Colorectal Cancer Colorectal Surgery Full Text | pdf link PDF open access

This quality improvement study describes the measure development, testing process, and results for a screening completion measure among patients with positive results of a stool-based screening test for colorectal cancer (CRC).

This JAMA Insights Clinical Update discusses the symptoms, diagnosis, and management of eosinophilic gastrointestinal diseases.

This cross-sectional study uses Surveillance, Epidemiology, and End Results registry data to analyze colorectal adenocarcinoma staging incidence of patients aged 46 to 49 years from 2000 to 2020.

This cohort study investigates whether there is a long-term association between the Veterans Affairs (VA) Patient-Aligned Cancer Team implementation and timely follow-up of abnormal diagnostic test results for 6 different cancers.

This Surgical Innovation describes the use of anatomic resection of the liver based on portal territory with margin priority for the treatment of hepatocellular carcinoma.

In this narrative medicine essay, a medical student participating in a study learns she has Lynch syndrome, setting off a cascade of emotions of dread, fear, and some hope in diagnostic plans and future breakthroughs in cancer treatment.

This cohort study uses data from the National Cancer Database to examine trends in incidence, stage, and survival among patients with high-risk gastrointestinal cancer during the COVID-19 pandemic.

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Articles on Gastroenterology

Displaying 1 - 20 of 25 articles.

Your body already has a built-in weight loss system that works like Wegovy, Ozempic and Mounjaro – food and your gut microbiome

Christopher Damman , University of Washington

Why does alcohol make my poo go weird?

Vincent Ho , Western Sydney University

Curious Kids: why do some farts smell and some don’t? And why do some farts feel hot?

Clare Collins , University of Newcastle

Why holding back your urge to poop can wreak havoc on your insides – a gastroenterologist explains

Martin Veysey , University of Newcastle

Boosting your ‘gut health’ sounds great. But this wellness trend is vague and often misunderstood

Amy Loughman , Deakin University and Heidi Staudacher , Deakin University

Do men really take longer to poo?

Diarrhoea, stomach ache and nausea: the many ways COVID-19 can affect your gut

What goes into the toilet doesn’t always stay there, and other coronavirus risks in public bathrooms

William Petri , University of Virginia

Curious Kids: why do we burp?

Why do burps make noise?

George Saffouri , University of California, Riverside

Health Check: what causes bloating and gassiness?

Health Check: when should you throw away leftovers?

Enzo Palombo , Swinburne University of Technology

Explainer: why do people get haemorrhoids and how do you get rid of them?

Research Check: can tea towels cause food poisoning?

What is listeria and how does it spread in rockmelons?

How to keep school lunches safe in the heat

Poo transplants beyond the yuck factor: what works, what doesn’t and what we still don’t know

Nadeem O. Kaakoush , UNSW Sydney and Hazel Mitchell , UNSW Sydney

What’s the best way to go to the toilet – squatting or sitting?

Health Check: what to eat and drink when you have gastro

Stomach and mood disorders: how your gut may be playing with your mind

Nicholas Talley , University of Newcastle

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Associate Professor and clinical academic gastroenterologist, Western Sydney University

Infectious Diseases Physician, Senior Lecturer, James Cook University and, The University of Queensland

Professor of Infectious Diseases, Monash University

Distinguished Laureate Professor of Medicine University of Newcastle, University of Newcastle

Senior Lecturer in Molecular Gastroenterology, University of Leeds

Professor of Microbiology, Swinburne University of Technology

Senior Research Fellow, Deakin University

Neuroscientist, Lecturer, University of Tasmania

Scientia Associate Professor, UNSW Sydney

Professor, School of Biotechnology and Biomolecular Sciences, UNSW Sydney

Honorary Professor, University of Newcastle

Assistant Clinical Professor of Health Sciences, Gastroenterology & Hepatology, University of California, Riverside

Professor of Medicine, University of Virginia

Postdoctoral Research Fellow, Food & Mood Centre, Deakin University

Gastroenterologist, Hunter New England Local Health District

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Innovation in Gastroenterology—Can We Do Better?

1 Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel, and Sackler Medical School, Tel Aviv University, Tel Aviv 6997801, Israel; [email protected]

2 Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel, and Sackler Medical School, Tel Aviv University, Tel Aviv 6997801, Israel

3 DeepVision Lab, Sheba Medical Center, Tel Aviv 6997801, Israel

4 Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY 10016, USA

Shelly Soffer

5 Internal Medicine B, Assuta Medical Center, Ashdod, Israel, and Ben-Gurion University of the Negev, Be’er Sheva 8410501, Israel

6 Samson Assuta Ashdod University Hospital, Ha-Refu’a St 7, Ashdod 7747629, Israel

Abraham Tsur

7 Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel, and Sackler Medical School, Tel Aviv University, Tel Aviv 6997801, Israel; [email protected]

Eyal Shachar

8 Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel, and Sackler Medical School, Tel Aviv University, Tel Aviv 6997801, Israel; [email protected] (E.S.); moc.liamg@idakoz (A.L.)

The health system can reap significant benefits by adopting and implementing innovative measures, as was recently demonstrated and emphasized during the COVID-19 pandemic. Herein, we present our bird’s eye view of gastroenterology’s innovative technologies via utilizing a text-mining technique. We analyzed five research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy. According to gastroenterology literature, the two most innovative fields were the microbiome and advanced endoscopy. Though artificial intelligence (AI), virtual reality (VR), and telemedicine trailed behind, the number of AI publications in gastroenterology has shown an exponential trend in the last couple of years. While VR and telemedicine are neglected compared to other fields, their implementation could improve physician and patient training, patient access to care, cost reduction, and patient outcomes.

1. Introduction

Innovation has multiple definitions in scientific papers and is highly addressed and valued in many life disciplines [ 1 ].

Following the Organization for Economic Co-operation and Development (OECD) manual’s definition, innovation is defined as: “the production or adoption, assimilation, and exploitation of a value-added novelty in economic and social spheres; renewal and enlargement of products, services, and markets; development of new methods of production; and the establishment of new management systems. It is both a process and an outcome” [ 2 ].

Undoubtedly, the health system can benefit immensely from adopting and implementing innovative measures, and the mega-challenges that arose from the Coronavirus disease 2019 (COVID-19) pandemic further emphasized the importance of healthcare innovations. However, in real life, specifically under stressful working loads and sub-optimal physical, economic and regulatory conditions, implementing new working strategies might become exceedingly challenging.

Illuminating the advances, and on the other hand, the drawbacks in innovation employment may help improve and enhance its use in daily practice. The “text-mining” technique, incited by current computational power and machine learning, enables broad-scale data extraction [ 3 ] and can be employed to characterize trends and examine dynamics in a research field [ 4 ].

Our aim was to present a bird’s-eye view of innovative technologies’ status in gastroenterology. Our survey focused on five important research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy.

2.1. Dataset

The U.S. National Center for Biotechnology Information (NCBI) provides public application programming interfaces (APIs) that allow programmatic access to the PubMed database. We have used the publicly available PyMed Python package to query the PubMed API.

The following data were extracted for each entry: PubMed unique article ID (PMID), title, publishing journal, abstract text, keywords (if any), and authors’ affiliations. The search was performed on 7 March 2021. Duplicate records (PMID) were omitted.

2.2. Inclusion Criteria

The authors (senior gastroenterologists and AI specialists) decided on key terms ( Table 1 ) related to five research fields that comply with innovation: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy. The search was conducted in PubMed entries’ titles and abstracts. Entries were limited to publications between 1 January 2000 to 31 December 2021.

List of terms used to classify entries into five innovation research fields: artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy.

2.3. Data Processing

Data processing and result visualization were written in Python (Ver. 3.6.5, 64 bits). Each title, study abstract, and authors’ affiliations were lowercased.

A list of open-access journals was obtained from the Scimago Journal & Country Rank site ( https://www.scimagojr.com/ , accessed on 8 March 2022). The list was merged to the PubMed data using International Standard Serial Numbers (ISSN). Gastroenterology and hepatology journals were classified using the merged list.

Annual trends of innovation-related publications between 2000–2021 were plotted for the entire PubMed data set and the Gastroenterology and hepatology sub-group.

Overall, during 2000–2021, 327,460 PubMed records were innovation-related as defined by the study ( Figure 1 ). Of those, 15,520 (4.7%) records were published in gastroenterology and hepatology journals.

Publication trends of innovation research fields (artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy) in the medical field during 2000–2021.

For the entire PubMed literature, the 2 major innovation fields were the microbiome with 94,993 (29.0%) publications and AI with 82,788 (25.3%) publications ( Figure 1 ). However, AI surpassed microbiome publications during 2019 and showed a marked exponential curve. In gastroenterology and hepatology journals, the microbiome, with 6896 publications (44.4%), and advanced endoscopy, with 4117 publications (26.5%), were the leading innovation fields, while AI showed only a minor rise with 899 (5.8%) publications ( Figure 2 ).

Publication trends of innovation research fields (artificial intelligence (AI), virtual reality (VR), telemedicine, the microbiome, and advanced endoscopy) in the gastroenterology field during 2000–2021.

While microbiome- and advanced endoscopy-related publications started to rise in the gastroenterology and hepatology literature during 2000–2008, most digital technology innovation-related publications (AI, VR, telemedicine) were written in the last decade. Telemedicine literature started to rise only in the last two years.

4. Discussion

The subject of the microbiome shows a high volume of publications in the gastroenterology and hepatology field, which reflects the obvious connection to the GI tract physiology and pathophysiology. Recent research on the microbiome focuses on the effect of specific taxa on the development of various diseases, including inflammatory bowel disease (IBD) and gastrointestinal (GI) malignancies, with an interesting horizon of fecal microbiome transplantation (FMT) as an effective and specific therapy for IBD and a variety of malignant diseases (interestingly, not only GI-related malignancies [ 5 , 6 , 7 , 8 ].

The gastroenterology-specific advanced endoscopy field is the second most prevalent and correlates with the particular attention and importance attributed to technical endoscopic improvements. Various technical improvements were implemented in recent years, including high-resolution and high-magnification endoscopes that enable improved pathologic detection, high-resolution small diameter probes, high-resolution microendoscopes (HRME), narrow-band imaging etc. [ 9 , 10 , 11 , 12 ]. Improvements and research in this field is a common practice, and new technical improvements that enable better endoscopic views and improved endoscope function (including better bowel cleaning) are predicted in the upcoming years [ 13 , 14 ].

Focusing on these topics is almost obvious, as these research fields are largely the domain of gastroenterology, and innovations in these fields are predictable.

Similarly to general medicine, the number of AI publications in the gastroenterology literature has increased exponentially in the last couple of years. Currently, we use AI systems for data analysis [ 15 , 16 , 17 ], for prediction models of disease outcomes, prognosis, and treatment response [ 18 , 19 , 20 , 21 ], and for image analysis during live endoscopy [ 22 , 23 ] and post-endoscopy picture analysis [ 24 , 25 , 26 ]. Intensified collaboration with AI experts can improve the above models using big-data analysis. Thus, we can reach more solid conclusions on a specific case, enhance patient stratification, and provide personalized tailor-made medicine. Improving data analysis using advanced algorithms for free text mining will enable further progress. Furthermore, improved image analysis may offer higher levels of data processing. It might provide accurate pathology analysis in a real-time setting, facilitating decision making and even causing biopsies to become superfluous in selected cases [ 27 ].

However, telemedicine and VR are still relatively disregarded in our daily practice. The importance of telemedicine during regular patient care was specifically demonstrated during the COVID-19 pandemic, which emphasized the need for remote patient surveillance [ 28 , 29 ].

Telemedicine can widen our viewpoint on various outcome measures usually hidden from medical sight. Thus, telemedicine may indicate impaired daily activities and lifestyle malfunction. Furthermore, it can improve patients’ compliance and enable continuous and enhanced connection with the medical caregivers. This method was specifically useful in chronic patients requiring intensified monitoring [ 30 , 31 ]. Implementing telemedicine might require specific patients, caregiver education and innovations to overcome barriers preventing its frequent use, such as lack of exposure and fear from new technologies [ 32 , 33 ]. With improved data analysis, telemedicine implementation can improve patients’ care and decision making while maintaining regular medical surveillance facing the challenges imposed mainly (but not only) by the COVID-19 pandemic.

VR has been used for training purposes for decades. Flight simulators are the most known example, and VR is a cornerstone during pilots’ training. VR has been gaining popularity in medical training during the last two decades, as shown in Figure 1 . Most relevant data assess surgeon’s training.

Naturally, VR has major advantages when using a three-dimensional (3D) model for resident training [ 34 , 35 ]. Furthermore, 3D models can assist surgeons in planning and rehearsing future operations and help with patient’s education and understanding of the forthcoming procedure. Other research themes concern patients’ use of VR during rehabilitation due to various medical conditions. Specific interest was attributed to using VR as a distraction technique during pain and chronic pain treatment by inducing neurophysiological changes beyond simple distraction, as in spinal cord injuries and even phantom pains after amputation [ 36 , 37 , 38 , 39 ].

In the gastroenterology field, both models are applicable but rarely implemented. VR can be useful during endoscopy training and practicing [ 40 , 41 ], both for training residents and for planning advanced endoscopic procedures. Patients may also benefit from 3D models of upcoming procedures. Regarding patients’ rehabilitation, VR may probably be used for treating GI motility abnormalities, chronic pelvic pain symptoms, etc. Furthermore, implementing VR might reduce pain during endoscopic procedures and spare the need for enhanced sedation.

A new, interesting research question could relate to the issue of whether the adoption of AI and other novelty advancements has occurred more rapidly in other fields of medicine. Our study addressed the gastroenterology field; however, it is likely that other clinical specialties may also face this delay. This issue merits further research.

Our study has a few limitations. This analysis only provides a high-level look at the field. The sheer number of publications prohibits a manual analysis of the records. A list of terms was determined based on current data in the literature and consensus between the authors, who are senior gastroenterologists and AI specialists. However, different terms might have achieved different results. The data were extracted from MEDLINE/PubMed. Other options such as Google Scholar were not included and might have reached different results. The list of journals was extracted from the open-source Journal & Country Rank site database. Other journal databases may have yielded somewhat different results.

5. Conclusions

Gastroenterology journals published relatively large amounts of microbiota-themed research before the topic become investigated broadly in biomedical research. Nevertheless, the field of gastroenterology seems to lag almost a decade behind the biomedical sciences as a whole in the adoption of artificial intelligence as the subject or means of research. It appears vital to bridge this gap and also to identify the most novel modalities and topics that may be overlooked or difficult to adopt by gastroenterology researchers today, similar to how AI was overlooked or proved challenging a decade ago.

Author Contributions

E.K., study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript. A.L., study concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; study supervision. E.S., study concept and design; critical revision of the manuscript for important intellectual content. S.S., study concept and design; critical revision of the manuscript for important intellectual content. A.T., study concept and design; critical revision of the manuscript for important intellectual content. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

BMJ Open Gastroenterology

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BMJ Open Gastroenterology is an online-only, peer-reviewed, open access journal, dedicated to publishing high-quality papers in gastroenterology, hepatology, endoscopy, clinical nutrition, paediatric gastroenterology and basic science.  BMJ Open Gastroenterology  adheres to the highest industry standards concerning publication ethics (see our  policies ).

BMJ Open Gastroenterology  is the open access companion to  Gut   and  Frontline Gastroenterology  and is an official journal of the  British Society of Gastroenterology .

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Prevalence of hepatitis delta found to be high in hepatitis B surface antigen chronic carriers

by Elana Gotkine

The prevalence of hepatitis delta virus (HDV) is high in hepatitis B surface antigen (HBs Ag) chronic carriers detected through annual screenings, according to a study published online March 22 in United European Gastroenterology Journal .

Laura Weichselbaum, from CHU Saint-Pierre in Brussels, and colleagues examined the diagnostic impact of an annual screening for HDV serology in HBs Ag chronic carriers. All chronic HBs Ag-positive patients were tested annually between January 2014 and October 2021 for HDV antibody (HDV Ab).

Positive patients underwent repeated elastometry annually. Patients with detectable HDV RNA were compared to those with undetectable HDV RNA (groups 1 [27 patients] and 2 [30 patients], respectively). A total of 610 chronic HBs Ag-positive patients were identified; in 534 patients, repeated screening for HDV Ab was performed.

Overall, 60 patients (11 percent) were HDV Ab-positive at baseline and were considered coinfected. The researchers diagnosed seven cases of HDV superinfection through repeated screening. Cirrhosis was initially diagnosed in 12 of 60 coinfected patients, and during follow-up, it developed in six patients. The cumulative incidence of cirrhosis was 13.8 and 0 percent in groups 1 and 2, respectively, at seven years.

"A systematic screening for HDV in chronic HB Ag carriers revealed a high prevalence of HDV Ab," the authors write. "Repeated serological screening enables the diagnosis of superinfections in asymptomatic patients. Regular assessment of fibrosis using elastometry leads to the identification of incidental cirrhosis in patients with detectable HDV RNA."

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Mayo Clinic Minute: Tips to safely watch the total solar eclipse

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On April 8, North America will experience a total solar eclipse , stretching across parts of Mexico, the U.S. and Canada, with approximately 31.6 million people living in the path of totality. According to NASA, every contiguous state in the U.S., along with parts of Alaska and Hawaii, will witness at least a partial solar eclipse.

With all eyes toward the sky during an eclipse,  Dr. Dawn Davis , a dermatologist at Mayo Clinic, says it's important to protect your eyes and your skin from ultraviolet (UV) light damage. You'll need eye protection with special-purpose solar filters for viewing, and you should take precautions to safeguard your skin from the sun's rays during long periods outside.

And when it comes to protection, she says sunscreen is for the skin only – never for the eye itself.

Watch: The Mayo Clinic Minute

Journalists: Broadcast-quality video (1:02) is in the downloads at the end of this post. Please courtesy: "Mayo Clinic News Network." Read the  script .

A total solar eclipse is when the moon completely blocks the sun, temporarily darkening the sky. Looking directly at the sun can cause damage to the retina due to the strong amount of UV light.

"If you would like to see the solar eclipse, you will need to have special solar eclipse glasses," says Dr. Davis.

While it's crucial to protect your eyes with ISO-approved solar eclipse glasses, Dr. Davis cautions people never to put sunscreen directly on their eyes.

"You cannot put sunscreen on your eyeballs, sunscreen is only for the skin," she says.

Lotion applied to the eyes can cause chemical irritation and possibly damage.

"While we're spending time making sure that we protect our eyes during the solar eclipse, which is extremely important, it's important to remember that your skin is also vulnerable to the UV light," says Dr. Davis.

Along with the proper eyewear, consider wearing a broad-brimmed hat and using sunscreen with SPF 50. "I would reapply every two hours at minimum. And if you happen to sweat or get wet, I would reapply immediately," Dr. Davis says.

Tips for safely viewing the total solar eclipse

Along with wearing special glasses, there are additional ways to stay safe during a solar eclipse.

• Wear sunscreen with a high SPF and broad-spectrum protection. Reapply it every two hours, or more often if you sweat or get wet.
• Wear a hat that covers your head, face, ears and neck. A wide-brimmed hat is ideal, as it can also shield your eyes from the sun.
• Wear protective clothing that covers your arms and legs. Choose light-colored, loose-fitting and breathable fabrics that can keep you cool and comfortable.
• Seek shade whenever possible, especially during the peak hours of the sun’s intensity (between 10 a.m. and 4 p.m.).
• Drink plenty of water to stay hydrated, and avoid heat exhaustion or heatstroke

View the path of the total solar eclipse courtesy: NASA's Scientific Visualization Studio

Visit the  American Astronomical Society  for a listing of reputable vendors of approved safety eclipse glasses.

Learn about  pinhole and optical projection  for alternative safe viewing options.

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Out of the park: New research tallies total carbon impact of tourism at Yellowstone

People depend on natural ecosystems of trees, grasses and shrubs to capture carbon from the atmosphere and pull it underground to slow the decline toward climate-change disaster. Ironically, these same protected spaces also tend to be highly photogenic hot-spots for tourism.

New research from the Quinney College of Natural Resources and the Institute of Outdoor Recreation and Tourism makes a case study of one such place -- Yellowstone National Park -- to calculate surplus carbon visitors from across the world add to the atmosphere each year as a direct result of a park visit.

Emily Wilkins and Jordan Smith from the Department of Environment and Society and colleagues leveraged existing data to create a tally of carbon emissions generated by one year of tourist visits to Yellowstone National Park, a popular destination that can receive over 4 million visitors per year. They estimated that recreation visits to the park produce just over one megaton of carbon emissions per year, an average of 479 kilograms attributable to each visitor (about the weight of a grand piano).

The bulk of those emissions occur before a visitor even spies a geyser or a wandering wolf pack. Travel to and from the park entrance accounts for almost 90 percent of the total. Another 5 percent is produced as visitors move from place to place within park boundaries and four percent is sourced in overnight accommodations. Just 1 percent of the total comes from park operations such as visitor centers, museums, shops and restaurants.

Just over one-third of visits to Yellowstone involve someone taking a flight, but those particular trips accounted for a whopping 72 percent of the emissions for out-of-park transit.

"As the tourism industry explores strategies to reduce their carbon impact, this could be low-hanging fruit," said Wilkins, who now works with the U.S. Geological Survey. "Future campaigns to encourage a greater proportion of visitors from nearby locations rather than Europe or Asia, or encouraging driving over flying, have potential for big impacts on reducing these emission numbers."

But it seems that carbon accounting for Yellowstone National Park is still in the black.

"Interestingly, ecosystems within the park boundary pull around 1.5 megatons of carbon from the atmosphere each year," Smith said. "So, even accounting for the significant impact of tourism, there is a net benefit in the system as a carbon sink."

This is almost certainly not the case for smaller parks with high visitation numbers, he said.

This new method for calculating the carbon impact of tourism for national parks is designed to be adaptable for application to other parks and protected areas, Smith said, to help decision makers evaluate the effectiveness of potential emission reduction strategies.

Tourism is no lightweight player in the world's total carbon tally. By one account, tourism accounted for 8 percent of annual global carbon emissions, with the U.S. earning the dubious honor of the highest total tourism carbon footprint in the world. And that number is expected to grow.

It's important to note that this research was not a comprehensive policy analysis, according to the authors. Ecotourism has other costs and benefits that weren't under consideration in this particular research. For example, while tourism does contribute significantly to carbon emissions globally, positive experiences and education at parks like Yellowstone have potential to lead to indirect environmental benefits, such as encouraging pro-environmental behaviors back at home.

"We really need more research on both the effect of tourism on climate change, and the effect of climate change on tourism," Wilkins said. "These topics both have major economic and environmental repercussions. Managers and decision makers need a more complete perspective for how tourism to parks is contributing to a vulnerable global climate system."

• Global Warming
• Air Quality
• Travel and Recreation
• Environmental Policies
• World Development
• Ocean Policy
• Yellowstone Caldera
• Carbon dioxide sink
• Carbon cycle
• Mount Rainier
• Geology of the Capitol Reef area
• Carbon dioxide
• Air pollution

Story Source:

Materials provided by S.J. & Jessie E. Quinney College of Natural Resources, Utah State University . Original written by Lael Gilbert. Note: Content may be edited for style and length.

Journal Reference :

• Emily J. Wilkins, Dani T. Dagan, Jordan W. Smith. Quantifying and evaluating strategies to decrease carbon dioxide emissions generated from tourism to Yellowstone National Park . PLOS Climate , 2024; 3 (4): e0000391 DOI: 10.1371/journal.pclm.0000391

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MIT economics to launch new predoctoral fellowship program

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The MIT Department of Economics is launching a new program this year that will pair faculty with predoctoral fellows.

“MIT economics right now is historically strong,” says Jon Gruber, the Ford Professor of Economics and department head of MIT economics. “To remain in that position involves having the resources to stay on the cutting edge of the research frontier, and that requires the use of predocs.”

The nature of economic research has changed enormously, adds Gruber, due to factors like the use of large datasets, innovations in experiment design, and comprehensive data analysis, all of which require the support of predocs. This new research model empowers economists to address national and global challenges in profound and much more effective ways.

The new predoc program is made possible by an ongoing major fundraising initiative in the department. 

Gruber gave credit to Glenn Ellison, the Gregory K. Palm (1970) Professor of Economics and former department chair, for working closely with Roger Altman, MIT Corporation member and the former head and current member of the visiting committee, to craft a vision for the future of the department that will ultimately include up to 24 predocs that would work for economics faculty at MIT. 

“It’s a great vision. They put a lot of work into it,” Gruber says.

With significant support from the Altman Family Fund, Gruber explains, the predoc program will be able to ramp up, providing predocs to the department’s junior faculty. He expects six predocs to start in the department this fall.

“We’ll have a wide range of junior faculty who will be using these predocs for a bunch of really interesting and important questions that are very data- and research-intensive,” Gruber says.

Tobias Salz, the Castle Krob Career Development Associate Professor of Economics, is one of the faculty members already benefiting from a pilot of the new program. He’s working on a large project on the search engine market.

“I am working with a predoctoral research fellow who has been instrumental in many parts of the project, including the design of an experiment and data analysis,” says Salz. “Initially, I was only able to hire him for one year, but with the new funding I am able to extend his contract. The predoctoral program has therefore helped ensure continuity on this project, which has made a big difference.”

Nina Roussille, assistant professor of economics, says her work will greatly benefit from collaborating with a predoc. Several of her projects either require the analysis of large, administrative datasets or the implementation of large-scale experiments.

“This kind of work will be greatly enhanced and streamlined with the help of a predoc to construct, clean, and analyze the data, as well as to set up the experiments and study their effects. This will free up some of my time to participate in more projects and allow me to focus my efforts on high-yield tasks, such as data analysis and paper writing,” says Roussille.

Roussille adds that she’s excited about the opportunity to mentor a young economist on the path to a PhD.

“They’ll greatly benefit from the vibrant research environment of the MIT economics department,” she said.

Gruber sees the program as mutually beneficial for both the predocs and the faculty.

“The advantage for the predoc is they get research experience and they get to know a faculty member,” adds Gruber. “The advantage for the faculty is they get to work with someone who wants to excel and make an impression with the person they research for.”

Beyond establishing the predoc program, this current fundraising initiative prioritizes building resources for faculty research in the Department of Economics. In addition to the gift from the Altman Family Fund to establish the predoctoral fellowship program, this fundraising initiative has secured several other significant contributions, including:  

• the creation of the Daniel (1972) and Gail Rubinfeld Professorship Fund, through the support of Dan Rubinfeld, PhD ’72;
• the Thapanee Sirivadhanabhakdi Techajareonvikul (1999) Professorship Fund, established by economics undergraduate alumna and her husband, Aswin Techajareonvkul MBA ’02;
• another endowed professorship in the department, through the support of an anonymous donor;
• the creation of the Locher Economics Fund, which will provide discretionary resources to support faculty research for the department, through the support of Kurt ’88, SM ’89, and Anne Stark Locher; and
• a gift to create the Dr. James A. Berkovec (1977) Memorial Faculty Research Fund in Economics, established by Ben Golub, ’78, SM ’82, PhD ’84.

To date, almost $30 million has been secured for these purposes, and efforts are ongoing.

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Regions & Countries

Most americans favor legalizing marijuana for medical, recreational use, legalizing recreational marijuana viewed as good for local economies; mixed views of impact on drug use, community safety.

Pew Research Center conducted this study to understand the public’s views about the legalization of marijuana in the United States. For this analysis, we surveyed 5,140 adults from Jan. 16 to Jan. 21, 2024. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for the report and its methodology .

As more states pass laws legalizing marijuana for recreational use , Americans continue to favor legalization of both medical and recreational use of the drug.

An overwhelming share of U.S. adults (88%) say marijuana should be legal for medical or recreational use.

Nearly six-in-ten Americans (57%) say that marijuana should be legal for medical and recreational purposes, while roughly a third (32%) say that marijuana should be legal for medical use only.

Just 11% of Americans say that the drug should not be legal at all.

Opinions about marijuana legalization have changed little over the past five years, according to the Pew Research Center survey, conducted Jan. 16-21, 2024, among 5,14o adults.

The impact of legalizing marijuana for recreational use

While a majority of Americans continue to say marijuana should be legal , there are varying views about the impacts of recreational legalization.

About half of Americans (52%) say that legalizing the recreational use of marijuana is good for local economies; just 17% think it is bad and 29% say it has no impact.

More adults also say legalizing marijuana for recreational use makes the criminal justice system more fair (42%) than less fair (18%); 38% say it has no impact.

However, Americans have mixed views on the impact of legalizing marijuana for recreational use on:

• Use of other drugs: About as many say it increases (29%) as say it decreases (27%) the use of other drugs, like heroin, fentanyl and cocaine (42% say it has no impact).
• Community safety: More Americans say legalizing recreational marijuana makes communities less safe (34%) than say it makes them safer (21%); 44% say it has no impact.

Partisan differences on impact of recreational use of marijuana

There are deep partisan divisions regarding the impact of marijuana legalization for recreational use.

Majorities of Democrats and Democratic-leaning independents say legalizing recreational marijuana is good for local economies (64% say this) and makes the criminal justice system fairer (58%).

Fewer Republicans and Republican leaners say legalization for recreational use has a positive effect on local economies (41%) and the criminal justice system (27%).

Republicans are more likely than Democrats to cite downsides from legalizing recreational marijuana:

• 42% of Republicans say it increases the use of other drugs, like heroin, fentanyl and cocaine, compared with just 17% of Democrats.
• 48% of Republicans say it makes communities less safe, more than double the share of Democrats (21%) who say this.

Demographic, partisan differences in views of marijuana legalization

Sizable age and partisan differences persist on the issue of marijuana legalization though small shares of adults across demographic groups are completely opposed to it.

Older adults are far less likely than younger adults to favor marijuana legalization.

This is particularly the case among adults ages 75 and older: 31% say marijuana should be legal for both medical and recreational use.

By comparison, half of adults between the ages of 65 and 74 say marijuana should be legal for medical and recreational use, and larger shares in younger age groups say the same.

Republicans continue to be less supportive than Democrats of legalizing marijuana for both legal and recreational use: 42% of Republicans favor legalizing marijuana for both purposes, compared with 72% of Democrats.

There continue to be ideological differences within each party:

• 34% of conservative Republicans say marijuana should be legal for medical and recreational use, compared with a 57% majority of moderate and liberal Republicans.
• 62% of conservative and moderate Democrats say marijuana should be legal for medical and recreational use, while an overwhelming majority of liberal Democrats (84%) say this.

Views of marijuana legalization vary by age within both parties

Along with differences by party and age, there are also age differences within each party on the issue.

A 57% majority of Republicans ages 18 to 29 favor making marijuana legal for medical and recreational use, compared with 52% among those ages 30 to 49 and much smaller shares of older Republicans.

Still, wide majorities of Republicans in all age groups favor legalizing marijuana at least for medical use. Among those ages 65 and older, just 20% say marijuana should not be legal even for medical purposes.

While majorities of Democrats across all age groups support legalizing marijuana for medical and recreational use, older Democrats are less likely to say this.

About half of Democrats ages 75 and older (53%) say marijuana should be legal for both purposes, but much larger shares of younger Democrats say the same (including 81% of Democrats ages 18 to 29). Still, only 7% of Democrats ages 65 and older think marijuana should not be legalized even for medical use, similar to the share of all other Democrats who say this.

Views of the effects of legalizing recreational marijuana among racial and ethnic groups

Substantial shares of Americans across racial and ethnic groups say when marijuana is legal for recreational use, it has a more positive than negative impact on the economy and criminal justice system.

About half of White (52%), Black (53%) and Hispanic (51%) adults say legalizing recreational marijuana is good for local economies. A slightly smaller share of Asian adults (46%) say the same.

Criminal justice

Across racial and ethnic groups, about four-in-ten say that recreational marijuana being legal makes the criminal justice system fairer, with smaller shares saying it would make it less fair.

However, there are wider racial differences on questions regarding the impact of recreational marijuana on the use of other drugs and the safety of communities.

Use of other drugs

Nearly half of Black adults (48%) say recreational marijuana legalization doesn’t have an effect on the use of drugs like heroin, fentanyl and cocaine. Another 32% in this group say it decreases the use of these drugs and 18% say it increases their use.

In contrast, Hispanic adults are slightly more likely to say legal marijuana increases the use of these other drugs (39%) than to say it decreases this use (30%); 29% say it has no impact.

Among White adults, the balance of opinion is mixed: 28% say marijuana legalization increases the use of other drugs and 25% say it decreases their use (45% say it has no impact). Views among Asian adults are also mixed, though a smaller share (31%) say legalization has no impact on the use of other drugs.

Community safety

Hispanic and Asian adults also are more likely to say marijuana’s legalization makes communities less safe: 41% of Hispanic adults and 46% of Asian adults say this, compared with 34% of White adults and 24% of Black adults.

Wide age gap on views of impact of legalizing recreational marijuana

Young Americans view the legalization of marijuana for recreational use in more positive terms compared with their older counterparts.

Clear majorities of adults under 30 say it is good for local economies (71%) and that it makes the criminal justice system fairer (59%).

By comparison, a third of Americans ages 65 and older say legalizing the recreational use of marijuana is good for local economies; about as many (32%) say it makes the criminal justice system more fair.

There also are sizable differences in opinion by age about how legalizing recreational marijuana affects the use of other drugs and the safety of communities.

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Table of contents, most americans now live in a legal marijuana state – and most have at least one dispensary in their county, 7 facts about americans and marijuana, americans overwhelmingly say marijuana should be legal for medical or recreational use, clear majorities of black americans favor marijuana legalization, easing of criminal penalties, religious americans are less likely to endorse legal marijuana for recreational use, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .