This Week in Gastroenterology — May 21, 2026

Welcome to This Week in Gastroenterology. This week we're covering 10 notable papers spanning advances in IBD management, optimizing endoscopic interventions, new insights in hepatology, and colorectal cancer from prevention to practice. Let's dive in.

Advances in IBD Management

First, in inflammatory bowel disease, three papers explore new treatment strategies, monitoring techniques, and future nutritional approaches. In *Clinical Gastroenterology and Hepatology*, investigators from China tested a novel induction strategy for moderate-to-severe ulcerative colitis, aiming to break through the so-called "efficacy ceiling" of current therapies [1]. In a randomized trial, they compared an 8-week induction with combined upadacitinib and vedolizumab against standard vedolizumab monotherapy. The results were compelling: endoscopic remission at week 8 was achieved by 37.5% of patients in the combination group, more than double the 15.1% in the monotherapy group. Clinical remission was also significantly higher. Adverse event rates were similar. While the open-label design and early trial termination warrant some caution, this study provides the first randomized evidence supporting a short-term, intensive combination strategy of a small molecule and a biologic to achieve rapid remission in ulcerative colitis.

While we push for better remission rates, monitoring for disease recurrence remains a key challenge, particularly after surgery for Crohn's disease. A new international consensus statement in *The Lancet Gastroenterology & Hepatology* provides crucial guidance on using intestinal ultrasound for this purpose [6]. Using a formal consensus method, a panel of 16 international experts developed 67 recommendations to standardize the use of this non-invasive tool. Key takeaways include specific guidance on which anatomical areas to evaluate, such as the neoterminal ileum, and which sonographic features to assess, like bowel wall thickness and vascularity. The panel also recommends waiting at least 4 weeks after surgery to perform the ultrasound to avoid confounding by immediate postoperative changes. This provides a much-needed, expert-driven framework for implementing intestinal ultrasound in routine clinical practice for postoperative Crohn's surveillance.

Looking to the future of IBD care, a review in *Nature Reviews Gastroenterology & Hepatology* outlines a framework for precision nutrition [7]. The authors propose a stepwise approach, moving from general phenotype-based dietary advice to more sophisticated strategies informed by multiomics and other biological data. This highlights the field's move away from one-size-fits-all dietary recommendations and toward truly personalized nutritional strategies to prevent and manage IBD, leveraging advances in biomarker detection and artificial intelligence.

Optimizing Endoscopic Interventions

Next, we turn to interventional endoscopy, with three papers that challenge current practices and introduce new techniques. A key question in biliary disease is how urgently to perform ERCP for acute cholangitis. A randomized controlled trial in *Gut* provides a surprisingly clear answer for mild-to-moderate cases [5]. Investigators randomized over 300 patients to either urgent ERCP within 24 hours or early ERCP within 24 to 48 hours. The primary outcome, 30-day mortality, was not significantly different between the groups, at approximately 4% versus 6.6%. There were also no differences in organ failure or length of hospital stay. Critically, however, post-ERCP adverse events were significantly more frequent in the urgent group, at 17.1% versus 9.2%. The clinical takeaway is clear: for stable patients with mild-to-moderate cholangitis, waiting up to 48 hours for ERCP is not only safe but may actually be safer by reducing procedure-related complications.

Staying with interventions, a study in *Gastrointestinal Endoscopy* suggests a more efficient way to manage gastric varices using EUS-guided coil and glue embolization [9]. The authors compared the conventional strategy of targeting the submucosal variceal complex with a newer approach of targeting the feeder vessel directly, when it can be clearly seen on endoscopic ultrasound. In their comparative analysis of 135 patients, the feeder-vessel-first strategy was superior. It required significantly less coil and glue and, most importantly, led to a dramatically lower reintervention rate at 6 months—just 3.1% compared to 17.5% with the conventional method. This suggests that when a feeder vessel is discernible, targeting it should be the preferred strategy, as it is more efficient and may prove more cost-effective.

And for a look at future hemostasis technology, a preclinical paper in *Science Translational Medicine* introduces a novel topical agent derived from platelets, which the authors call high phosphatidylserine-exposed procoagulant platelets, or hPPL [4]. In murine and porcine models of liver and gastric ulcer bleeding, this agent demonstrated superior hemostatic efficacy compared to clinical thrombin and other commercial materials. Notably, it worked effectively even in the setting of antiplatelet therapy. While still in early development, this points toward a potential new tool for managing complex endoscopic bleeding, particularly in coagulopathic patients.

Hepatology Insights

In hepatology, we have two large-scale observational studies with important clinical implications. First, from *Clinical Gastroenterology and Hepatology*, an analysis of the PROMISE trial links hepatic steatosis directly to higher-risk coronary plaques [3]. Among more than 3,600 patients undergoing coronary CT angiography, those with hepatic steatosis had a higher rate of major adverse cardiovascular events. After adjusting for traditional risk factors, steatosis was associated with a nearly 70% increased risk of MACE. The study suggests a mechanism for this link: steatosis was associated with a greater burden of noncalcified plaque, the more vulnerable type that is prone to rupture. This reinforces that hepatic steatosis is not just a liver problem but a marker for systemic cardiovascular risk, and its detection should prompt a more integrated cardiometabolic risk assessment.

Next, a fascinating study from South Korea published in *Alimentary Pharmacology & Therapeutics* reports a temporal association between COVID-19 vaccination and functional cure of chronic hepatitis B [2]. Using an interrupted time series analysis of nearly 60,000 patients, researchers found that the rate of Hepatitis B surface antigen loss—a rare event signifying functional cure—significantly increased following the national COVID-19 vaccination rollout. The incidence rate ratio was 1.56, suggesting the rate increased by about 56% at the intervention point. This effect was transient, with rates declining again in the post-vaccination period. The finding was strengthened by a negative control analysis showing no change in hepatocellular carcinoma incidence. This suggests a population-level immunomodulatory effect of the vaccine that can influence hepatitis B dynamics, a powerful demonstration of how systemic immune activation can impact chronic viral infections.

Colorectal Cancer: From Prevention to Practice

Finally, in colorectal cancer, two papers address the spectrum from high-risk hereditary syndromes to management in older adults. A study in *Gut* provides new insight into why some individuals with Lynch syndrome develop cancer while others don't [8]. Using single-cell profiling of tumor-free colonic tissue, researchers compared Lynch syndrome carriers with and without a history of colorectal cancer to controls. They made a key discovery: Lynch syndrome carriers who did *not* have a history of cancer showed a striking enrichment of a specific immune cell type called mucosal-associated invariant T cells, or MAIT cells. This suggests that these MAIT cells may be providing effective immune surveillance, protecting against cancer development in these high-risk individuals. This finding could pave the way for new risk stratification tools and preventative strategies that harness this protective immune response.

And once colorectal cancer develops, a new expert panel recommendation in *The Lancet Gastroenterology & Hepatology* provides pragmatic guidance for managing the disease in older adults, defined as those aged 70 or older [10]. The authors highlight the paradox that this is the primary group affected by the disease, yet they are consistently under-represented in the clinical trials that shape treatment guidelines. The panel strongly advocates for the routine use of geriatric assessment to guide treatment decisions. This approach helps tailor therapy based on an individual’s functional status, comorbidities, and physiological reserves, rather than on chronological age alone. This is a call to action for clinicians to move beyond a one-size-fits-all approach and implement patient-centered, individualized care for this large and growing patient population.

If you only have time for one paper this week, make it the trial on ERCP timing in *Gut* [5]. It directly challenges the 'sooner is always better' reflex for mild-to-moderate cholangitis, showing that a more measured approach within 48 hours is just as effective for patient outcomes and is associated with fewer procedural harms. This is a simple, powerful finding that can immediately and safely change practice.

Here are the key takeaways from this week in Gastroenterology: First: For mild-to-moderate acute cholangitis, performing ERCP within 24 to 48 hours is as effective as urgent ERCP within 24 hours, and may be safer by reducing post-procedure adverse events [5]. Second: In moderate-to-severe ulcerative colitis, an 8-week induction with combined upadacitinib and vedolizumab was superior to vedolizumab monotherapy for achieving endoscopic remission, supporting the concept of short-term combination therapy [1]. Third: When performing EUS-guided embolization for gastric varices, targeting a discernible feeder vessel is superior to the conventional approach, requiring less coil and glue and significantly reducing reintervention rates [9]. Fourth: Hepatic steatosis is an independent risk factor for major adverse cardiovascular events, linked to a higher burden of vulnerable, noncalcified coronary plaque. Its presence on imaging should prompt a broader cardiometabolic risk assessment [3]. And Fifth: In managing older adults with colorectal cancer, chronological age is a poor guide. Incorporating geriatric assessment into clinical practice is crucial for making patient-centered treatment decisions [10].

That's your roundup for This Week in Gastroenterology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.