Here are the “Cliff Notes” to MUSC’s 2024 Gastroenterology & Hepatology Update! If you attended and have an addition or have any questions for those who did attend feel free to share them in the comment section below…

•  Hepcidin, a peptide hormone produced in the liver, plays a crucial role in iron homeostasis.

•  Both chronic liver disease & EtOH decrease hepcidin, leading to increased iron deposition in liver.

•  In hereditary hemochromatosis (HH), type 1 (“classical”) is the most common in the world.

•  Liver biopsy should not be performed in patients with clear diagnosis of hemochromatosis (based on blood tests) & no evidence or concern of cirrhosis

•  If the ferritin is > 1,000 can now do Fibroscan instead of liver biopsy.

•  If ferritin <1000, incidence of fibrosis is < 2%

•  If phlebotomy x 1-2 times reduces ferritin to normal, question the HH diagnosis

•  Typical HH pt needs weekly phlebotomies for 16 weeks (removes ~4g Fe from liver)

•  Start treatment in men: ferritin > 300 ng/ml & TS > 50%, 

                           in women: ferritin > 200 ng/ml & TS > 45%.

•  In HH, the target ferritin level is 50-100; do weekly phlebotomy to reach this goal.

•  Only hemochromatosis patients with cirrhosis need surveillance

•  AVMs account for 30-40% of small bowel bleeding, which only accounts for 5-10% of all GI bleeding

•  APC is preferable to BICAP for treatment of duodenal AVM’s.

•  Long-acting octreotide 40 mg q 4 wks is effective for recurrent SB AVM bleeding – consider sooner

•  Other agents: thalidomide, bevacizumab

•  AI might augment capsule endoscopy more in the future (shortens reading time).

•  5% of adult U.S. population has Barrett’s. We are under-screening for Barrett’s!

•  New ACG Recommendation: a swallowable, capsule sponge device (combined with a biomarker) is an acceptable non-endoscopic alternative for Barrett’s screening in chronic GERD & other risk factors

•  The “sponge on a string” cell collection method for Barrett’s screening might increase in use among PCPs in the future.

•  NBI is underused in Barrett’s screening and should probably be used in all cases to make endoscopic diagnosis.

•  If patient is 40-50 yrs old and has negative Barrett’s screen, they are unlikely to develop it in future, so no need to re-screen.

•  New acronyms: PEEN & PEEC in setting of nonydplastic Barrett’s (NDB)

•  PEEN = Post-Endoscopy Esophageal Neoplasia (PEEN): EAC or BE-HGD detected before next recommended surveillance

•  PEEC = Post-Endoscopy Esophageal adenoCarcinoma (PEEC): EAC detected before next recommended surveillance (accounts for 24% of esoph adenoca)

•  Hepatorenal syndrome is renamed “cirrhosis-AKI” = creat 1.3 or greater in presence of ascites not responding to holding diuretics and albumin infusion.

•  Terlipressin (avoid if creat >3) is superior to Levophed, which is superior to midodrine/octreotide for cirrhosis-AKI.

•  ½ of population has a GI motility disorder.

•  Pyloric Botox for gastroparesis is of little benefit; the jury is still out on G-POEM.

•  Probiotics can also be a cause of SIBO by overpopulating the SB with bacteria

•  An orally ingested vibrating capsule is FDA-approved for chronic idiopathic constipation.

•  60% of IBS-D is post-infectious.

•  11% of gastroenteritis cases will result in IBS.

•  IBS and SIBO are not exactly the same thing, but they are highly linked together.

•  Hydrogen sulfide is the cause of diarrhea, cramps, urgency, and bloating.

•  Methane is the cause of constipation and bloating.

•  SIBO breath test is predictive of response to Xifaxan.

•  IBS is now thought of more as a small bowel microbiome disease than a colon disease.

•  The main underlying pathophysiology in IBS is probably vinculin Ab affecting the interstitial cells of Cajal (ICC).

•  Liver bx not needed for PBC dx.

•  AlkP and bili predict long term outcomes in PBC.

•  Get Fibroscan to stage PBC.

•  Most PBC-AIH overlap is really just PBC (pathologist tend to exaggerate the autoimmune side on liver biopsy).

•  Only 40% of PBC responds to Urso.

•  New agents for PBC are PPAR agonists: Iqirvo (elafibrinor) and Livdelzi (seladelpar) – combo therapy likely the way of the future.

•  The # 1 cause of death in MASLD is cardiac disease, particularly CHF-associated cirrhotic cardiomyopathy, so be quicker to get echo in cirrhotics with fatigue.

•  Point of care intestinal US for IBD very useful for real time decision making but takes a lot of training.

Enumerate. Educate. Engage.