ACG Postgraduate Course 10/26/2024

Peri-Procedural Management of Antithrombotic Agents: How to Minimize Unintended Bleeding and Clotting

Neena S. Abraham, MD, MSc (Epid), MACG – Mayo Clinic

-rule of 5 = life threatening GIB

-reversal of anticoagulants, can use PCC instead of more expensive (4 factor prothrombin complex concentrate), don’t use FFP

-for warfarin, don’t give vit K 

–don’t give plt for GI bleed

-don’t need to stop ASA (if it is for 2ndary prophylaxis; if for primary prophylaxis, ASA no longer recommended and can be stopped)

-warfarin resumption – resume w/i 4-7 days from drug discontinuation, same day if EGD diagnostic and you have hemostasis

-resume DOAC and antiplatelet agents the day after the procedure in most or w/i 48-72 hours

-delay nonurgent screening 90 days from CVA/TIA/PE/DES placement

-bridging of anticoagulants needed only in mechanical valves, • AF with CHA2DS2 score >5 • History of thromboembolism during temporary interruption of VKAs • Certain CV surgery (i.e., cardiac valve replacement, carotid endarterectomy, major vascular surgery)

-for PEG placement in pt on dual antiplt agents, no inc risk of bleeding on DAPT. If there is local bleeding, you can use silver nitrate sticks and make bumper more snug for 24-48 hrs. Need to hold warfarin 5 days and DOAC 2 days prior to PEG placement then resume next day

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Non-Variceal Upper GI Bleeding: Inject, Cauterize, Clip, or Spray?

Loren A. Laine, MD, FACG – Yale School of Medicine

-erythromycin 250 mg IV prior to egd reduces need for 2nd EGD and hospital stay; metoclopramide not helpful

-bipolar probe – apply for 8-10 sec at setting of 15W

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Small Bowel Bleeding: How to Locate, Treat, and Improve Quality of Care

Jonathan A. Leighton, MD, FACG – Mayo Clinic

-for capsule study, only need clear liquids and 12 hour fast, no need for any purgative bowel prep

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Lower GI Bleeding: Tips for Optimal Localization and Treatment

Neil Sengupta, MD, FACG – University of Chicago Medicine

-CT angiography can be good initial diagnostic test given no need for prep; needs to be performed w/i 4 hours of hematochezia

-if CTA positive, then refer to IR for transcatheter angiography (within 90 min) vs urgent colonoscopy

-preventing diverticular rebleeding: stop nonASA nsaids, avoid antiplatelet agents if possible, d/c ASA for primary card prevention but not for secondary

-for clipping diverticular bleed, try to clip vessel clot/vessel directly instead of “zippering” closed over mouth of diverticulum

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Making Sense of the Alphabet Soup: Updates in Non-Hepatitis C Viral Hepatidities

Paul Martin, MD, FACG (he/him/his) – University of Miami School of Medicine

-HBV is oncogenic and can cause HCC without cirrhosis

–Higher HCC incidence observed in males, >35 yr old, HBeAg+, HBV DNA >1000 IU/mL

-treat chronic HBV in patient >30 with HBV DNA >2000 and any ALT level or in patient <30 with HBV DNA >2000 and ALT >ULN

-Treat all patients with CHB with cirrhosis and detectable HBV DNA levels irrespective of ALT levels

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Managing Complications of Cirrhosis

Jasmohan S. Bajaj, MD, MS, FACG – Virginia Commonwealth University School of Medicine

-Ascites – 2g NA restriction plus diuretics (spirono with or without lasix)

-fluid restriction not needed in ascites w/o hypoNa

-risk score for SBP on admission https://silveys.shinyapps.io/app_cgh/

-SBP: Initiate albumin therapy (1.5 g/kg at day 1 and 1 g/kg at day;  Hold non-selective beta-blockers in MAP<65 mm Hg or AKI.

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Learning Luncheon 05: Management of an Ileal Pouch: From Symptoms to Cancer Surveillance

Maia Kayal, MD, MS – Icahn School of Medicine at Mount Sinai

-cuffitis won’t respond to abx but will respond to mesalamines

-if cuff present, surveillance every 3 years; yearly if dysplasia or chronic pouchitis

-probiotics for pouchitis not very helpful so can concentrate on diet/fiber

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Evaluation and Management of Chronic Abdominal Pain and Suspected IBS

Jill K. Deutsch, MD, MA – Yale University School of Medicine

-IBS-D – check celiac, CRP, calprotectin

-centrally mediated abd pain syndrome – treated with TCA, SSRI, or SNRI

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Constipation: Pharmacologic and Non-Pharmacologic Therapies

William D. Chey, MD, FACG – University of Michigan

-constipation – fiber, fiber/PEG, MgOx 500-2000mg, short term stimulant laxatives (4 weeks or less or prn), then Rx options

-electroacupunture can work well for CIC

-Soluble fiber best – psyllium, pectin, dextrin, etc

Functional Diarrhea: What’s in My Toolbox?

Speaker: Brian E. Lacy, MD, PhD, FACG (he/him/his) – Mayo Clinic

-if gluten free diet is helpful in nonceliac patient, it is likely due to cutting out the fructans in most patients

-no evidence for any probiotics

-antispasmodic taken prior to a meal may help some with postprandial urgency

-bile acid diarrhea prevelance is 10-30% in IBS pt; can check C4 testing (7-alpha-hydroxy-4-cholesten-3-one)

-Alosetron still option for IBS-D/functional diarrhea; odansetron is another 5-HT3 antagonist that may be helpful in IBS-D

-Amitriptyline has good evidence for IBS – 10-30 mg daily

-known SOD, prior CCK, h/o pancreatitis, big drinker – don’t use eluxadoline (Viberzi)

-iberogast, pepogest may be cheaper than IBGard

-avoid insoluble fiber with diarrhea, but soluble fiber good

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Management of Acute Pancreatitis: Updates From the Guidelines

Santhi Swaroop Vege, MD, MACG – Mayo Clinic

IV hydration in acute panc:

• Rate – Non-aggressive ( a.k.a.moderately aggressive) (1.5 ml/kg/hr)

• 10ml/kg bolus if hypovolemia present

• Type – Lactated Ringer

• Timing – Immediately at diagnosis 

• Monitoring – Clinical, Hct, BUN, Cr, urine output

• Duration : 36 – 48 hrs

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Chronic Pancreatitis: Managing Pain, Exocrine, and Endocrine Dysfunction

Jodie A. Barkin, MD, FACG – University of Miami Miller School of Medicine

-causes of chronic panc: TIGAR-O

Toxic‐metabolic: Alcohol, Smoking, HyperCa,  Hypertriglyceridemia, Medications, Toxins (CKD,  Chemo/XRT, Vascular), Metabolic (DM, obesity) 

Idiopathic 

Genetic: CFTR, PRSS1, SPINK, CTRC, among others 

Autoimmune Pancreatitis 

Recurrent Acute Pancreatitis 

Obstructive: Divisum, Ampullary stenosis, MPD  stones/strictures/calcifications, Neoplasm

-in woman, most common causes idiopathic, alcohol, genetic, then obstructive

-in men, most common causes alcohol, idiopathic, genetic, then obstructive

-for pain, consider gabapentin or amitriptyline; PERT used, but not for pain

– General combination: selenium, ascorbic acid, b‐carotene, methionine 

– Blueberries  ↑ insulin sensitivity and ↑ pancreatic β‐cell survival in murine models2

-order fecal elastase only for moderate to high suspicion of EPI and needs to be solid stool

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Pancreatic Cysts: Drain it, Surveil it, or Leave it Alone?

Anne Marie Lennon, MD, PhD, FACG (she/her/hers) – University of Pittsburgh

-Patients who are not medically fit for surgery should not undergo further evaluation of incidentally found pancreatic cysts, irrespective of cyst size

-EUS when:

SIGNS OR SYMPTOMS 

Jaundice 

Acute pancreatitis 

Diabetes Mellitus 

Elevated CA19-9 

or

IMAGING

 Mural nodule 

Main pancreatic duct >5mm 

Thickened/enhancing cyst wall 

Growth ≥ 3mm/year

Cyst size ≥ 2cm

-Cyst sampling (high CEA, low glucose – IPMN/MCN; low CEA, high glucose – serous cyst/pseudocyst)

-Molecular markers: 

TP53, SMAD4, CTNNB1 & mTOR genes* = HGD/Cancer→ Multidisciplinary Group 

KRAS, GNAS or BRAF = IPMN/MCN→ Surveillance 

VHL = Serous Cyst → Discharge 

-Consideration can be given to stopping surveillance of low risk cysts after 5 years

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NERD, GERD, and Everything in Between

Christine Y. Hachem, MD, FACG – St. Louis University

-After 8 week trial of PPI for GERD, if symptoms recur, then do EGD after being off PPI for 2-4 weeks

-pH testing on/off PPI:

• OFF PPI-> need objective evidence of GERD (Normal EGD) 

• ON PPI-> already have objective evidence of GERD and want to  assess for breakthrough acid or nonacid reflux

-can get handout on conservative measures for GERD/NERD from ACG website

• 2/3 with objective GERD may relapse (Grade C esophagitis)

-PCABS: • Longer half life and not limited to meal dosing as binds  active/inactive pumps • Non-inferior, ? Superior in NERD and Erosive Esophagitis

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Barrett’s Esophagus: Screening, Surveillance, Ablate or Resect?

Nicholas J. Shaheen, MD, MPH, MACG – University of North Carolina

-ACG 2023 guidelines for who to screen for BE: 3 risk factors, including male, non-Hispanic white, age >50 years, have a history of smoking, chronic gastroesophageal reflux disease, obesity, or a family history of BE or esophageal adenocarcinoma

-SSBE (<3 CM) surveillance q5yr; LSBE (>3cm) surveillance q3yr

-Ablation therapy for BE with IMC, HGD, and maybe LGD (shared choice) – changes surveillance interval after

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Esophageal Motility Disorders: Common Presentations, Testing Modalities, and Treatments

Jennifer Horsley-Silva, MD (she/her/hers) – Mayo Clinic

-Achalasia tx:

-PD, LHM and POEM are comparable effective therapies for type I or type II achalasia  Treatment based on shared decision-making  

-POEM is the preferred treatment for management of type III achalasia  

-Botulinum toxin injection is reserved for those who cannot undergo definitive therapy

-For EGJOO, treatment is not clear, if r/o other causes and tried conservative management, can consider achalasia-like tx

-Hypercontractile esophagus and Distal Esophageal Spasm  Treat GERD, smooth muscle relaxants, psychotropics

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Eosinophilic Esophagitis: Updates From the ACG Guidelines

Evan S. Dellon, MD, MPH, FACG – University of North Carolina at Chapel Hill

-Use EREFS to grade EoE

-PPI tx in EoE: Double the approved reflux dose per day (e.g. omeprazole 20mg twice daily or  40mg daily, or other PPI equivalent) recommended, but may be able to decrease to maintenance if they have response

-allergy testing directed food elimination not recommended

-empiric food elimination is recommended  – can try 1 or 2 FED – eliminate dairy 1st if doing 1FED, dairy and wheat if 2FED

-Dupixent – use in non-PPI responsive EoE

-If patients have good response to topical steroids, you can consider continued maintenance therapy if you can get insurance improval.

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Positioning IBD Therapies for UC: Where to Start and When to Switch

David T. Rubin, MD, FACG (he/him/his) – University of Chicago Medicine

-VARSITY trial: vedolizumab>adalimumab for UC

-adalimumab is weak for colitis; infliximab is better

-Non-response to anti-TNF, then you should not try another anti-TNF. Instead move to different mechanism of action.

-Chance of response to Skyrizi (IL23)  still good even if patient failed Stelara (IL12/23)

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Risks of Adverse Side Effects With New IBD Therapies: Selecting Treatment Based on Safety

Millie D. Long, MD, MPH, FACG – University of North Carolina

-JAK inhibitors Caution in those with a cardiac history including atherosclerotic disease, smoking, ?clotting history; Don’t use in pregnancy

-If use an anti-TNF with IMM, can consider stopping IMM after 6 months if in deep remission

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Colonic Dysplasia in IBD: Surveil or Resect?

Samir A. Shah, MD, FACG (he/him/his) – Alpert Medical School of Brown University

-for surveillance, can go out to 5 yrs if disease controlled and no h/o high risk findings and 2 consecutive normal exams

-Chromoendoscopy is much better at finding dysplasia than WLE

-0.1%FD&C#2 (similar to indigo carmine), mixed in 500 cc sterile H20 or can use methylene blue (1 ampule in 500 cc H20); don’t need to use a spray catheter

-Inflammatory polyps can cause elevated calprotectin even in patient under good control, so could explain someone in clinical remission who has elevated calprotectin.

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SIBO, Disaccharidase Deficiencies, Foods, and Functional – What Do I Do?

Brooks D. Cash, MD, FACG (he/him/his) – University of Texas Health Science Center at Houston

-Fructans (wheat, rye, onions, leeks, zucchini, etc) seem to be the biggest FODMAP responsible for symptoms 

-Secondary causes of sucrase deficiency: Celiac deficiency, bacterial overgrowth, IBD, allergic enteropathy, acute gastroenteritis, giardiasis, other (eg mucositis)

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Celiac Disease – What’s New and What’s on the Horizon

Amy S. Oxentenko, MD, FACG (she/her/hers) – Mayo Clinic

-recommend not ordering celiac panels, but only getting IgA TTG antibodies and total IgA level

-single bite biopsies have higher sensitivity than double bite biopsies

-other causes of intraepithelial lymphocytosis: NSAIDs, H. pylori, SIBO, gastroenteritis, IBD

-other causes of villous atrophy: Drugs (olmesartan, mycophenylate mofetil, checkpoint inhibitors, others), CVID, Autoimmune, tropical sprue, Whipple’s

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Optimizing Colonoscopy Performance: Tips and Tricks to Improve Quality

Douglas K. Rex, MD, MACG – Indiana University School of Medicine

-difficult sigmoid or redundant colon – stop using air and use water to fill colon

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Resecting Colon Polyps: Snare, EMR, or ESD?

Shivangi T. Kothari, MD, FACG – Center for Advanced Therapeutic Endoscopy, University of Rochester Medical Center

-when doing saline lift, inject proximal side 1st then distal side