Results from the PHENIX-I trial support skipping pelvic lymphadenectomy in women with early cervical cancer who have a negative sentinel lymph node biopsy.

Omitting pelvic lymphadenectomy in these patients “did not compromise disease-free survival and potentially [led to] improved overall survival,” reported lead investigator Jihong Liu, MD, gynecologic oncologist, Sun Yat-sen University Cancer Center, Guangzhou, China.

Forgoing the additional procedure also decreased the incidence of retroperitoneal lymph node recurrence and adverse events and demonstrated superior surgical outcomes including shorter operative duration, reduced blood loss, and a lower morbidity.

Liu reported the PHENIX-I results at this year’s Society of Gynecologic Oncology Annual Meeting on Women’s Cancers (SGO) 2025.

Pelvic lymphadenectomy has been part of standard care for early-stage cervical cancer for over a century, even though the incidence of lymph node metastasis in early-stage cervical cancer is relatively low. Overtreatment and increased morbidity have been notable drawbacks of the procedure.

It may be possible to forgo pelvic lymphadenectomy in early-stage cervical cancer when sentinel lymph node biopsy findings are negative, but evidence from randomized controlled trials are lacking, Liu explained.

The PHENIX-I trial prospectively assessed survival outcomes among patients who received pelvic lymphadenectomy and those who did not. More specifically, all patients underwent sentinel lymph node biopsy and patients with negative lymph nodes were then intraoperatively randomized (1:1) to undergo pelvic lymphadenectomy (417 patients) or not (416 patients).

The multicenter, randomized controlled trial involved patients undergoing radical hysterectomy for stage IA1 (lymphovascular invasion), IA2, IB1, IB2 or IIA1 cervical cancer with tumor size not exceeding 3 cm.

“The only difference between the two groups was that patients in the experimental arm did not have pelvic lymphadenectomy,” Liu said.

Liu and colleagues reported that 23 patients (2.8%) had a positive lymph node on postoperative pathology examination. The rate of false-negative sentinel lymph node biopsy was < 1%. About half the patients in both groups received postoperative adjuvant therapy, and there was no significant between-group difference in the rates and time to initiate adjuvant therapy.

Overall, about 3.85% of patients (n = 16) in the biopsy-only group had a recurrence compared with 6.24% (n = 26) in the pelvic lymphadenectomy group at a median follow-up of 50 months.

But no patients in the biopsy-only group had a recurrence in the retroperitoneal lymph nodes compared with 9 patients in the pelvic lymphadenectomy group.

The 3-year disease-free survival (primary endpoint) rates were similar between the two groups — 96.8% in the biopsy-only group and 94.5% in the lymphadenectomy group (hazard ratio [HR], 0.61; P = .12). However, the 3-year overall survival was significantly higher in biopsy-only group — 100% vs 97.8% in the lymphadenectomy group (HR, 0.21; P = .007). Overall, three patients (19%) in the biopsy-only group died from cervical cancer vs 14 (54%) in the lymphadenectomy group.

As for surgical complications, pelvic lymphadenectomy was associated with a higher incidence of pain (5.8% vs 1.7%), lymphocyst (22.1% vs 8.4%), and lymphedema (10.1% vs 2.4%), as well as longer operating time and more blood loss.

Offering perspective on PHENIX-I, discussant Premal Thaker, MD, noted that this is the first randomized trial to report on the use of sentinel lymph node biopsy alone vs biopsy plus pelvic lymphadenectomy after radical hysterectomy.

Key takeaways are the “equivalent” 3-year disease-free outcomes but “lower” overall survival in the pelvic lymphadenectomy group as well as more adverse events, said Thaker, gynecologic oncologist and surgeon, Siteman Cancer Center, Washington University, St Louis.

Although quality of life data was not presented in the trial, patients who skipped pelvic lymphadenectomy had fewer adverse events, “which is very important for our patients,” Thaker added.

This study had no commercial funding. Liu and Thaker had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Results from the PHENIX-I trial support skipping pelvic lymphadenectomy in women with early cervical cancer who have a negative sentinel lymph node biopsy.

Omitting pelvic lymphadenectomy in these patients “did not compromise disease-free survival and potentially [led to] improved overall survival,” reported lead investigator Jihong Liu, MD, gynecologic oncologist, Sun Yat-sen University Cancer Center, Guangzhou, China.

Forgoing the additional procedure also decreased the incidence of retroperitoneal lymph node recurrence and adverse events and demonstrated superior surgical outcomes including shorter operative duration, reduced blood loss, and a lower morbidity.

Liu reported the PHENIX-I results at this year’s Society of Gynecologic Oncology Annual Meeting on Women’s Cancers (SGO) 2025.

Pelvic lymphadenectomy has been part of standard care for early-stage cervical cancer for over a century, even though the incidence of lymph node metastasis in early-stage cervical cancer is relatively low. Overtreatment and increased morbidity have been notable drawbacks of the procedure.

It may be possible to forgo pelvic lymphadenectomy in early-stage cervical cancer when sentinel lymph node biopsy findings are negative, but evidence from randomized controlled trials are lacking, Liu explained.

The PHENIX-I trial prospectively assessed survival outcomes among patients who received pelvic lymphadenectomy and those who did not. More specifically, all patients underwent sentinel lymph node biopsy and patients with negative lymph nodes were then intraoperatively randomized (1:1) to undergo pelvic lymphadenectomy (417 patients) or not (416 patients).

The multicenter, randomized controlled trial involved patients undergoing radical hysterectomy for stage IA1 (lymphovascular invasion), IA2, IB1, IB2 or IIA1 cervical cancer with tumor size not exceeding 3 cm.

“The only difference between the two groups was that patients in the experimental arm did not have pelvic lymphadenectomy,” Liu said.

Liu and colleagues reported that 23 patients (2.8%) had a positive lymph node on postoperative pathology examination. The rate of false-negative sentinel lymph node biopsy was < 1%. About half the patients in both groups received postoperative adjuvant therapy, and there was no significant between-group difference in the rates and time to initiate adjuvant therapy.

Overall, about 3.85% of patients (n = 16) in the biopsy-only group had a recurrence compared with 6.24% (n = 26) in the pelvic lymphadenectomy group at a median follow-up of 50 months.

But no patients in the biopsy-only group had a recurrence in the retroperitoneal lymph nodes compared with 9 patients in the pelvic lymphadenectomy group.

The 3-year disease-free survival (primary endpoint) rates were similar between the two groups — 96.8% in the biopsy-only group and 94.5% in the lymphadenectomy group (hazard ratio [HR], 0.61; P = .12). However, the 3-year overall survival was significantly higher in biopsy-only group — 100% vs 97.8% in the lymphadenectomy group (HR, 0.21; P = .007). Overall, three patients (19%) in the biopsy-only group died from cervical cancer vs 14 (54%) in the lymphadenectomy group.

As for surgical complications, pelvic lymphadenectomy was associated with a higher incidence of pain (5.8% vs 1.7%), lymphocyst (22.1% vs 8.4%), and lymphedema (10.1% vs 2.4%), as well as longer operating time and more blood loss.

Offering perspective on PHENIX-I, discussant Premal Thaker, MD, noted that this is the first randomized trial to report on the use of sentinel lymph node biopsy alone vs biopsy plus pelvic lymphadenectomy after radical hysterectomy.

Key takeaways are the “equivalent” 3-year disease-free outcomes but “lower” overall survival in the pelvic lymphadenectomy group as well as more adverse events, said Thaker, gynecologic oncologist and surgeon, Siteman Cancer Center, Washington University, St Louis.

Although quality of life data was not presented in the trial, patients who skipped pelvic lymphadenectomy had fewer adverse events, “which is very important for our patients,” Thaker added.

This study had no commercial funding. Liu and Thaker had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Results from the PHENIX-I trial support skipping pelvic lymphadenectomy in women with early cervical cancer who have a negative sentinel lymph node biopsy.

Omitting pelvic lymphadenectomy in these patients “did not compromise disease-free survival and potentially [led to] improved overall survival,” reported lead investigator Jihong Liu, MD, gynecologic oncologist, Sun Yat-sen University Cancer Center, Guangzhou, China.

Forgoing the additional procedure also decreased the incidence of retroperitoneal lymph node recurrence and adverse events and demonstrated superior surgical outcomes including shorter operative duration, reduced blood loss, and a lower morbidity.

Liu reported the PHENIX-I results at this year’s Society of Gynecologic Oncology Annual Meeting on Women’s Cancers (SGO) 2025.

Pelvic lymphadenectomy has been part of standard care for early-stage cervical cancer for over a century, even though the incidence of lymph node metastasis in early-stage cervical cancer is relatively low. Overtreatment and increased morbidity have been notable drawbacks of the procedure.

It may be possible to forgo pelvic lymphadenectomy in early-stage cervical cancer when sentinel lymph node biopsy findings are negative, but evidence from randomized controlled trials are lacking, Liu explained.

The PHENIX-I trial prospectively assessed survival outcomes among patients who received pelvic lymphadenectomy and those who did not. More specifically, all patients underwent sentinel lymph node biopsy and patients with negative lymph nodes were then intraoperatively randomized (1:1) to undergo pelvic lymphadenectomy (417 patients) or not (416 patients).

The multicenter, randomized controlled trial involved patients undergoing radical hysterectomy for stage IA1 (lymphovascular invasion), IA2, IB1, IB2 or IIA1 cervical cancer with tumor size not exceeding 3 cm.

“The only difference between the two groups was that patients in the experimental arm did not have pelvic lymphadenectomy,” Liu said.

Liu and colleagues reported that 23 patients (2.8%) had a positive lymph node on postoperative pathology examination. The rate of false-negative sentinel lymph node biopsy was < 1%. About half the patients in both groups received postoperative adjuvant therapy, and there was no significant between-group difference in the rates and time to initiate adjuvant therapy.

Overall, about 3.85% of patients (n = 16) in the biopsy-only group had a recurrence compared with 6.24% (n = 26) in the pelvic lymphadenectomy group at a median follow-up of 50 months.

But no patients in the biopsy-only group had a recurrence in the retroperitoneal lymph nodes compared with 9 patients in the pelvic lymphadenectomy group.

The 3-year disease-free survival (primary endpoint) rates were similar between the two groups — 96.8% in the biopsy-only group and 94.5% in the lymphadenectomy group (hazard ratio [HR], 0.61; P = .12). However, the 3-year overall survival was significantly higher in biopsy-only group — 100% vs 97.8% in the lymphadenectomy group (HR, 0.21; P = .007). Overall, three patients (19%) in the biopsy-only group died from cervical cancer vs 14 (54%) in the lymphadenectomy group.

As for surgical complications, pelvic lymphadenectomy was associated with a higher incidence of pain (5.8% vs 1.7%), lymphocyst (22.1% vs 8.4%), and lymphedema (10.1% vs 2.4%), as well as longer operating time and more blood loss.

Offering perspective on PHENIX-I, discussant Premal Thaker, MD, noted that this is the first randomized trial to report on the use of sentinel lymph node biopsy alone vs biopsy plus pelvic lymphadenectomy after radical hysterectomy.

Key takeaways are the “equivalent” 3-year disease-free outcomes but “lower” overall survival in the pelvic lymphadenectomy group as well as more adverse events, said Thaker, gynecologic oncologist and surgeon, Siteman Cancer Center, Washington University, St Louis.

Although quality of life data was not presented in the trial, patients who skipped pelvic lymphadenectomy had fewer adverse events, “which is very important for our patients,” Thaker added.

This study had no commercial funding. Liu and Thaker had no relevant disclosures.

A version of this article first appeared on Medscape.com.

ORLANDO, Fla. — A study of automated three-dimensional total-body photography (3D TBP) found that it improved “hit” rates of positive malignant biopsies and reduced unnecessary biopsies of skin lesions but left unanswered questions about the practicality of its widespread use and cost-effectiveness.

“We did observe improved biopsy practices and outcomes,” said Jordan Phillipps, MD, a dermatology resident at Mayo Clinic in Jacksonville, Florida, who reported the results of the study during a late-breaker session at the American Academy of Dermatology (AAD) 2025 Annual Meeting.

“We observed reduced unnecessary biopsies, which was driven by benign and premalignant, particularly actinic keratosis, lesions,” Phillipps said. “We observed improved malignancy detection, which was profoundly driven by nonmelanoma skin cancers.”

Study Design and Results

The retrospective study included 410 adult patients who had at least two sessions with the Vectra WB360 3D TBP imaging system at a dedicated 3D imaging clinic at Mayo Clinic in Rochester, Minnesota Patient eligibility for the 3D clinic requires a previous melanoma diagnosis. All study participants also underwent dermoscopy, Phillipps said. Their average age was 51.6 years, and 53% were women.

The study accounted for 5981 total patient encounters, including 1150 dedicated Vectra imaging sessions, Phillipps said. In this group, 3006 biopsies were performed, of which 56% were benign, 32% were malignant, and 12% were premalignant. The study also separately evaluated lesion type, focusing on keratinocytic and pigmented lesions.

Most of the keratinocytic lesions were nonmelanoma skin cancers, he said, whereas the pigmented lesions were mostly benign.

“The intervention did significantly reduce biopsies per encounter by 35%, and this was driven by benign lesions and premalignant lesions, particularly actinic keratosis lesions,” Phillipps said.

Previous studies of automated TBP have been hampered by small study populations, he said, and this is one of the largest studies of the Vectra WB360 device. “Nonmelanoma skin cancers are underreported,” Phillipps said, noting that most studies focus on melanoma and pigmented lesions. “Our aim was to assess the effect of Vectra implementation on biopsy practice and outcomes,” he explained.

For malignant lesions, the investigators observed an improvement in malignancy detection, a modest 1.6% increase in hit rates of positive malignant biopsies, and a modest 1.3% decrease in the number needed to biopsy, he said.

A subgroup analysis of pigmented and keratinocytic lesions demonstrated that improved malignancy detection is “profoundly driven by nonmelanoma skin cancers” of 71% per biopsy, Phillipps said, along with “sizable” increases in the hit rate (+17%) and a reduction in the number of biopsies (–14%).

Melanoma detection decreased by 62% per biopsy. Phillipps said the reduction was probably because of the study methodology, specifically the eligibility requirement of having had a previous melanoma diagnosis. “These patients typically develop only one primary melanoma,” Phillipps said. To test this, the investigators compared melanoma hit rates with a matched, unexposed cohort that did not have Vectra imaging. They found that the hit rates were similar. “So this was reassuring that we weren’t missing any melanomas,” Phillipps said.

The results also showed improved efficacy for detecting severely dysplastic nevi, for which the hit rate increased by 16% and the number needed to biopsy decreased by 13%. “Actinic keratoses lesions were biopsied less,” he said, noting a 50% decrease. Both benign keratinocytic lesions, predominantly seborrheic keratosis and benign lichenoid keratosis, and benign pigmented (benign nevi) lesions were biopsied less.

 

Limitations and Questions

The highly selective nature of the patient population was a limitation of the study, Phillipps noted, along with financial and logistical challenges that impede the generalizability of the findings. Overall, he said, the study emphasized that 3D TBP is effective in skin cancer screening and diagnosis, notably beyond pigmented lesions.

Kristina Callis Duffin, MD, MS, chair of dermatology at The University of Utah, Salt Lake City, Utah, called the findings “exciting” but noted that the study did not compare results to the gold standard of clinician-performed skin screenings. “That absolutely would be the important way to do it, through a randomized trial,” she said, “but that’s a hard study to do.”

The cost-effectiveness of total-body imaging also needs to be evaluated, Duffin said. “You really have to look at a number of factors in terms of protection compared to a human gold standard, the rates of biopsies,” she said. “There are a lot of things to unpack; that cost-effectiveness has to be balanced with a more accurate diagnosis and reduction of morbidity with multiple biopsies.” 

Phillipps reported no relevant financial relationships. Duffin disclosed financial relationships with AbbVie, Alumis, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, FIDE, Janssen Pharmaceuticals, Novartis, and Pfizer.

A version of this article first appeared on Medscape.com.

ORLANDO, Fla. — A study of automated three-dimensional total-body photography (3D TBP) found that it improved “hit” rates of positive malignant biopsies and reduced unnecessary biopsies of skin lesions but left unanswered questions about the practicality of its widespread use and cost-effectiveness.

“We did observe improved biopsy practices and outcomes,” said Jordan Phillipps, MD, a dermatology resident at Mayo Clinic in Jacksonville, Florida, who reported the results of the study during a late-breaker session at the American Academy of Dermatology (AAD) 2025 Annual Meeting.

“We observed reduced unnecessary biopsies, which was driven by benign and premalignant, particularly actinic keratosis, lesions,” Phillipps said. “We observed improved malignancy detection, which was profoundly driven by nonmelanoma skin cancers.”

Study Design and Results

The retrospective study included 410 adult patients who had at least two sessions with the Vectra WB360 3D TBP imaging system at a dedicated 3D imaging clinic at Mayo Clinic in Rochester, Minnesota Patient eligibility for the 3D clinic requires a previous melanoma diagnosis. All study participants also underwent dermoscopy, Phillipps said. Their average age was 51.6 years, and 53% were women.

The study accounted for 5981 total patient encounters, including 1150 dedicated Vectra imaging sessions, Phillipps said. In this group, 3006 biopsies were performed, of which 56% were benign, 32% were malignant, and 12% were premalignant. The study also separately evaluated lesion type, focusing on keratinocytic and pigmented lesions.

Most of the keratinocytic lesions were nonmelanoma skin cancers, he said, whereas the pigmented lesions were mostly benign.

“The intervention did significantly reduce biopsies per encounter by 35%, and this was driven by benign lesions and premalignant lesions, particularly actinic keratosis lesions,” Phillipps said.

Previous studies of automated TBP have been hampered by small study populations, he said, and this is one of the largest studies of the Vectra WB360 device. “Nonmelanoma skin cancers are underreported,” Phillipps said, noting that most studies focus on melanoma and pigmented lesions. “Our aim was to assess the effect of Vectra implementation on biopsy practice and outcomes,” he explained.

For malignant lesions, the investigators observed an improvement in malignancy detection, a modest 1.6% increase in hit rates of positive malignant biopsies, and a modest 1.3% decrease in the number needed to biopsy, he said.

A subgroup analysis of pigmented and keratinocytic lesions demonstrated that improved malignancy detection is “profoundly driven by nonmelanoma skin cancers” of 71% per biopsy, Phillipps said, along with “sizable” increases in the hit rate (+17%) and a reduction in the number of biopsies (–14%).

Melanoma detection decreased by 62% per biopsy. Phillipps said the reduction was probably because of the study methodology, specifically the eligibility requirement of having had a previous melanoma diagnosis. “These patients typically develop only one primary melanoma,” Phillipps said. To test this, the investigators compared melanoma hit rates with a matched, unexposed cohort that did not have Vectra imaging. They found that the hit rates were similar. “So this was reassuring that we weren’t missing any melanomas,” Phillipps said.

The results also showed improved efficacy for detecting severely dysplastic nevi, for which the hit rate increased by 16% and the number needed to biopsy decreased by 13%. “Actinic keratoses lesions were biopsied less,” he said, noting a 50% decrease. Both benign keratinocytic lesions, predominantly seborrheic keratosis and benign lichenoid keratosis, and benign pigmented (benign nevi) lesions were biopsied less.

 

Limitations and Questions

The highly selective nature of the patient population was a limitation of the study, Phillipps noted, along with financial and logistical challenges that impede the generalizability of the findings. Overall, he said, the study emphasized that 3D TBP is effective in skin cancer screening and diagnosis, notably beyond pigmented lesions.

Kristina Callis Duffin, MD, MS, chair of dermatology at The University of Utah, Salt Lake City, Utah, called the findings “exciting” but noted that the study did not compare results to the gold standard of clinician-performed skin screenings. “That absolutely would be the important way to do it, through a randomized trial,” she said, “but that’s a hard study to do.”

The cost-effectiveness of total-body imaging also needs to be evaluated, Duffin said. “You really have to look at a number of factors in terms of protection compared to a human gold standard, the rates of biopsies,” she said. “There are a lot of things to unpack; that cost-effectiveness has to be balanced with a more accurate diagnosis and reduction of morbidity with multiple biopsies.” 

Phillipps reported no relevant financial relationships. Duffin disclosed financial relationships with AbbVie, Alumis, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, FIDE, Janssen Pharmaceuticals, Novartis, and Pfizer.

A version of this article first appeared on Medscape.com.

ORLANDO, Fla. — A study of automated three-dimensional total-body photography (3D TBP) found that it improved “hit” rates of positive malignant biopsies and reduced unnecessary biopsies of skin lesions but left unanswered questions about the practicality of its widespread use and cost-effectiveness.

“We did observe improved biopsy practices and outcomes,” said Jordan Phillipps, MD, a dermatology resident at Mayo Clinic in Jacksonville, Florida, who reported the results of the study during a late-breaker session at the American Academy of Dermatology (AAD) 2025 Annual Meeting.

“We observed reduced unnecessary biopsies, which was driven by benign and premalignant, particularly actinic keratosis, lesions,” Phillipps said. “We observed improved malignancy detection, which was profoundly driven by nonmelanoma skin cancers.”

Study Design and Results

The retrospective study included 410 adult patients who had at least two sessions with the Vectra WB360 3D TBP imaging system at a dedicated 3D imaging clinic at Mayo Clinic in Rochester, Minnesota Patient eligibility for the 3D clinic requires a previous melanoma diagnosis. All study participants also underwent dermoscopy, Phillipps said. Their average age was 51.6 years, and 53% were women.

The study accounted for 5981 total patient encounters, including 1150 dedicated Vectra imaging sessions, Phillipps said. In this group, 3006 biopsies were performed, of which 56% were benign, 32% were malignant, and 12% were premalignant. The study also separately evaluated lesion type, focusing on keratinocytic and pigmented lesions.

Most of the keratinocytic lesions were nonmelanoma skin cancers, he said, whereas the pigmented lesions were mostly benign.

“The intervention did significantly reduce biopsies per encounter by 35%, and this was driven by benign lesions and premalignant lesions, particularly actinic keratosis lesions,” Phillipps said.

Previous studies of automated TBP have been hampered by small study populations, he said, and this is one of the largest studies of the Vectra WB360 device. “Nonmelanoma skin cancers are underreported,” Phillipps said, noting that most studies focus on melanoma and pigmented lesions. “Our aim was to assess the effect of Vectra implementation on biopsy practice and outcomes,” he explained.

For malignant lesions, the investigators observed an improvement in malignancy detection, a modest 1.6% increase in hit rates of positive malignant biopsies, and a modest 1.3% decrease in the number needed to biopsy, he said.

A subgroup analysis of pigmented and keratinocytic lesions demonstrated that improved malignancy detection is “profoundly driven by nonmelanoma skin cancers” of 71% per biopsy, Phillipps said, along with “sizable” increases in the hit rate (+17%) and a reduction in the number of biopsies (–14%).

Melanoma detection decreased by 62% per biopsy. Phillipps said the reduction was probably because of the study methodology, specifically the eligibility requirement of having had a previous melanoma diagnosis. “These patients typically develop only one primary melanoma,” Phillipps said. To test this, the investigators compared melanoma hit rates with a matched, unexposed cohort that did not have Vectra imaging. They found that the hit rates were similar. “So this was reassuring that we weren’t missing any melanomas,” Phillipps said.

The results also showed improved efficacy for detecting severely dysplastic nevi, for which the hit rate increased by 16% and the number needed to biopsy decreased by 13%. “Actinic keratoses lesions were biopsied less,” he said, noting a 50% decrease. Both benign keratinocytic lesions, predominantly seborrheic keratosis and benign lichenoid keratosis, and benign pigmented (benign nevi) lesions were biopsied less.

 

Limitations and Questions

The highly selective nature of the patient population was a limitation of the study, Phillipps noted, along with financial and logistical challenges that impede the generalizability of the findings. Overall, he said, the study emphasized that 3D TBP is effective in skin cancer screening and diagnosis, notably beyond pigmented lesions.

Kristina Callis Duffin, MD, MS, chair of dermatology at The University of Utah, Salt Lake City, Utah, called the findings “exciting” but noted that the study did not compare results to the gold standard of clinician-performed skin screenings. “That absolutely would be the important way to do it, through a randomized trial,” she said, “but that’s a hard study to do.”

The cost-effectiveness of total-body imaging also needs to be evaluated, Duffin said. “You really have to look at a number of factors in terms of protection compared to a human gold standard, the rates of biopsies,” she said. “There are a lot of things to unpack; that cost-effectiveness has to be balanced with a more accurate diagnosis and reduction of morbidity with multiple biopsies.” 

Phillipps reported no relevant financial relationships. Duffin disclosed financial relationships with AbbVie, Alumis, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, FIDE, Janssen Pharmaceuticals, Novartis, and Pfizer.

A version of this article first appeared on Medscape.com.

The American College of Gastroenterology (ACG) has issued its first clinical practice guideline on the diagnosis and management of gastric premalignant conditions (GPMCs) including atrophic gastritis, gastric intestinal metaplasia, dysplasia, and certain gastric epithelial polyps, all of which have an increased risk of progressing to gastric cancer.

The guideline was published online in The American Journal of Gastroenterology.

GPMCs are “common in gastroenterology practices, but in the US, at least, we’ve not had concrete guidance,” first author Douglas Morgan, MD, MPH, AGAF, Division of Gastroenterology, The University of Alabama at Birmingham, noted in an interview.

With these guidelines, we hope there “will be a paradigm shift to finally establish surveillance in the stomach, much like we’ve been doing for decades in the colon and the esophagus,” Morgan said.

Gastric cancer is a common cancer in the United States with disproportionately higher incidence rates in immigrants from countries with a high incidence of gastric cancer and certain non-White populations.

In addition, the 5-year survival rate in the United States for gastric cancer is 36%, which falls short of global standards and is driven by the fact that only a small percentage of these cancers are diagnosed in the early, curable stage.

These guidelines will help address this marked disparity and the burden on minority and marginalized populations, the guideline authors wrote. “The overarching goals are to reduce [gastric cancer] incidence in the United States, increase the detection of early-stage disease (early gastric cancer), and to significantly increase the 5-year survival rates in the near term.”

 

Key Recommendations

The guideline includes recommendations on endoscopic surveillance for high-risk patients, the performance of high-quality endoscopy and image-enhanced endoscopy (IEE) for diagnosis and surveillance, GPMC histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and the management of autoimmune gastritis and gastric epithelial polyps.

In terms of screening, the guidelines recommend against routine upper endoscopy screening for gastric cancer and GPMC in the general US population (low quality of evidence; conditional recommendation).

They also noted that there is “insufficient” direct US evidence to make a recommendation on opportunistic endoscopy screening for gastric cancer and GPMC in patients deemed at high risk based on race/ethnicity and family history. In addition, they recommend against the use of noninvasive biomarkers for screening or surveillance of GPMC or gastric cancer.

In terms of endoscopic and histologic diagnosis of GPMC, high-quality endoscopic evaluation is crucial to detect premalignant conditions or gastric cancer, the authors said. This includes adequate mucosal cleansing and insufflation, and photodocumentation of anatomic landmarks, as well as use of high-definition white light endoscopy (HDWLE) and IEE.

Systematic gastric biopsies should follow the updated Sydney protocol, with at least two separate containers for antrum/incisura and corpus biopsies. Histology should document the subtype of gastric intestinal metaplasia — incomplete, complete, or mixed — and severity and extent of atrophic gastritis and metaplasia.

Morgan emphasized the importance of coordination between the gastroenterologist and pathologist. “Several of these measures are not routinely reported, so we need to be in conversations with our collaborating pathologists,” he told this news organization.

In terms of GPMC surveillance, the authors suggest surveillance endoscopy every 3 years in high-risk patients with gastric intestinal metaplasia who meet one of the following criteria: High-risk histology (incomplete vs complete subtype, extending into the corpus); family history of gastric cancer in a first-degree relative; foreign-born individuals from high-gastric cancer incidence nations; or high-risk race/ethnicity (East Asian, Latino/a, Black, American Indian, or Alaska Native).

Individuals with multiple risk factors for gastric cancer may be considered for shorter than 3-year intervals.

Low-risk gastric intestinal metaplasia (limited to antrum, mild atrophy, and complete gastric intestinal metaplasia subtype) does not require routine endoscopic surveillance.

In terms of endoscopic management of dysplastic GPMC, endoscopic resection is suggested for dysplasia with visible margins. If dysplasia is not visible, repeat endoscopy with HDWLE and IEE by an experienced endoscopist is advised.

In patients appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection, referral to a high-volume center with appropriate expertise in the diagnosis and therapeutic resection of gastric neoplasia is strongly recommended.

In patients with confirmed complete resection of dysplasia, endoscopic surveillance is also strongly recommended. Surveillance examinations should be performed by an experienced endoscopist using HDWLE and IEE, with biopsies according to the systematic biopsy protocol in addition to targeted biopsies.

In terms of nonendoscopic GPMC management, testing for H pylori (and eradication treatment if possible) is strongly recommended for patients with GPMC and those with a history of resected early gastric cancer.

Aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, or antioxidants are not recommended for patients with GPMC for the purpose of preventing gastric cancer.

In patients with autoimmune gastritis, testing for H pylori with a nonserological test, eradication treatment if positive, and posttreatment testing to confirm eradication is advised.

There is not enough evidence to make a formal recommendation on endoscopic surveillance in those with autoimmune gastritis; surveillance should be individualized, considering the risk for neuroendocrine tumors and possibly gastric cancer.

In terms of gastric epithelial polyps, endoscopic resection of all gastric adenomas is recommended, regardless of size, to exclude or prevent dysplasia and early gastric cancer. Adenomas that are not amenable to endoscopic resection should be referred for surgical resection, if clinically appropriate.

Morgan noted that the ACG GPMC guideline aligns with the updated ACG/American Society for Gastrointestinal Endoscopy upper endoscopy quality indicators released earlier this year.

Implementation of the ACG GPMC guideline and “change in clinical practice will require concrete targets and include training and quality initiatives,” the authors said.

This research received no commercial support. Morgan disclosed research support from Panbela Therapeutics, Thorne, and American Molecular Laboratories.

A version of this article first appeared on Medscape.com.

The American College of Gastroenterology (ACG) has issued its first clinical practice guideline on the diagnosis and management of gastric premalignant conditions (GPMCs) including atrophic gastritis, gastric intestinal metaplasia, dysplasia, and certain gastric epithelial polyps, all of which have an increased risk of progressing to gastric cancer.

The guideline was published online in The American Journal of Gastroenterology.

GPMCs are “common in gastroenterology practices, but in the US, at least, we’ve not had concrete guidance,” first author Douglas Morgan, MD, MPH, AGAF, Division of Gastroenterology, The University of Alabama at Birmingham, noted in an interview.

With these guidelines, we hope there “will be a paradigm shift to finally establish surveillance in the stomach, much like we’ve been doing for decades in the colon and the esophagus,” Morgan said.

Gastric cancer is a common cancer in the United States with disproportionately higher incidence rates in immigrants from countries with a high incidence of gastric cancer and certain non-White populations.

In addition, the 5-year survival rate in the United States for gastric cancer is 36%, which falls short of global standards and is driven by the fact that only a small percentage of these cancers are diagnosed in the early, curable stage.

These guidelines will help address this marked disparity and the burden on minority and marginalized populations, the guideline authors wrote. “The overarching goals are to reduce [gastric cancer] incidence in the United States, increase the detection of early-stage disease (early gastric cancer), and to significantly increase the 5-year survival rates in the near term.”

 

Key Recommendations

The guideline includes recommendations on endoscopic surveillance for high-risk patients, the performance of high-quality endoscopy and image-enhanced endoscopy (IEE) for diagnosis and surveillance, GPMC histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and the management of autoimmune gastritis and gastric epithelial polyps.

In terms of screening, the guidelines recommend against routine upper endoscopy screening for gastric cancer and GPMC in the general US population (low quality of evidence; conditional recommendation).

They also noted that there is “insufficient” direct US evidence to make a recommendation on opportunistic endoscopy screening for gastric cancer and GPMC in patients deemed at high risk based on race/ethnicity and family history. In addition, they recommend against the use of noninvasive biomarkers for screening or surveillance of GPMC or gastric cancer.

In terms of endoscopic and histologic diagnosis of GPMC, high-quality endoscopic evaluation is crucial to detect premalignant conditions or gastric cancer, the authors said. This includes adequate mucosal cleansing and insufflation, and photodocumentation of anatomic landmarks, as well as use of high-definition white light endoscopy (HDWLE) and IEE.

Systematic gastric biopsies should follow the updated Sydney protocol, with at least two separate containers for antrum/incisura and corpus biopsies. Histology should document the subtype of gastric intestinal metaplasia — incomplete, complete, or mixed — and severity and extent of atrophic gastritis and metaplasia.

Morgan emphasized the importance of coordination between the gastroenterologist and pathologist. “Several of these measures are not routinely reported, so we need to be in conversations with our collaborating pathologists,” he told this news organization.

In terms of GPMC surveillance, the authors suggest surveillance endoscopy every 3 years in high-risk patients with gastric intestinal metaplasia who meet one of the following criteria: High-risk histology (incomplete vs complete subtype, extending into the corpus); family history of gastric cancer in a first-degree relative; foreign-born individuals from high-gastric cancer incidence nations; or high-risk race/ethnicity (East Asian, Latino/a, Black, American Indian, or Alaska Native).

Individuals with multiple risk factors for gastric cancer may be considered for shorter than 3-year intervals.

Low-risk gastric intestinal metaplasia (limited to antrum, mild atrophy, and complete gastric intestinal metaplasia subtype) does not require routine endoscopic surveillance.

In terms of endoscopic management of dysplastic GPMC, endoscopic resection is suggested for dysplasia with visible margins. If dysplasia is not visible, repeat endoscopy with HDWLE and IEE by an experienced endoscopist is advised.

In patients appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection, referral to a high-volume center with appropriate expertise in the diagnosis and therapeutic resection of gastric neoplasia is strongly recommended.

In patients with confirmed complete resection of dysplasia, endoscopic surveillance is also strongly recommended. Surveillance examinations should be performed by an experienced endoscopist using HDWLE and IEE, with biopsies according to the systematic biopsy protocol in addition to targeted biopsies.

In terms of nonendoscopic GPMC management, testing for H pylori (and eradication treatment if possible) is strongly recommended for patients with GPMC and those with a history of resected early gastric cancer.

Aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, or antioxidants are not recommended for patients with GPMC for the purpose of preventing gastric cancer.

In patients with autoimmune gastritis, testing for H pylori with a nonserological test, eradication treatment if positive, and posttreatment testing to confirm eradication is advised.

There is not enough evidence to make a formal recommendation on endoscopic surveillance in those with autoimmune gastritis; surveillance should be individualized, considering the risk for neuroendocrine tumors and possibly gastric cancer.

In terms of gastric epithelial polyps, endoscopic resection of all gastric adenomas is recommended, regardless of size, to exclude or prevent dysplasia and early gastric cancer. Adenomas that are not amenable to endoscopic resection should be referred for surgical resection, if clinically appropriate.

Morgan noted that the ACG GPMC guideline aligns with the updated ACG/American Society for Gastrointestinal Endoscopy upper endoscopy quality indicators released earlier this year.

Implementation of the ACG GPMC guideline and “change in clinical practice will require concrete targets and include training and quality initiatives,” the authors said.

This research received no commercial support. Morgan disclosed research support from Panbela Therapeutics, Thorne, and American Molecular Laboratories.

A version of this article first appeared on Medscape.com.

The American College of Gastroenterology (ACG) has issued its first clinical practice guideline on the diagnosis and management of gastric premalignant conditions (GPMCs) including atrophic gastritis, gastric intestinal metaplasia, dysplasia, and certain gastric epithelial polyps, all of which have an increased risk of progressing to gastric cancer.

The guideline was published online in The American Journal of Gastroenterology.

GPMCs are “common in gastroenterology practices, but in the US, at least, we’ve not had concrete guidance,” first author Douglas Morgan, MD, MPH, AGAF, Division of Gastroenterology, The University of Alabama at Birmingham, noted in an interview.

With these guidelines, we hope there “will be a paradigm shift to finally establish surveillance in the stomach, much like we’ve been doing for decades in the colon and the esophagus,” Morgan said.

Gastric cancer is a common cancer in the United States with disproportionately higher incidence rates in immigrants from countries with a high incidence of gastric cancer and certain non-White populations.

In addition, the 5-year survival rate in the United States for gastric cancer is 36%, which falls short of global standards and is driven by the fact that only a small percentage of these cancers are diagnosed in the early, curable stage.

These guidelines will help address this marked disparity and the burden on minority and marginalized populations, the guideline authors wrote. “The overarching goals are to reduce [gastric cancer] incidence in the United States, increase the detection of early-stage disease (early gastric cancer), and to significantly increase the 5-year survival rates in the near term.”

 

Key Recommendations

The guideline includes recommendations on endoscopic surveillance for high-risk patients, the performance of high-quality endoscopy and image-enhanced endoscopy (IEE) for diagnosis and surveillance, GPMC histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and the management of autoimmune gastritis and gastric epithelial polyps.

In terms of screening, the guidelines recommend against routine upper endoscopy screening for gastric cancer and GPMC in the general US population (low quality of evidence; conditional recommendation).

They also noted that there is “insufficient” direct US evidence to make a recommendation on opportunistic endoscopy screening for gastric cancer and GPMC in patients deemed at high risk based on race/ethnicity and family history. In addition, they recommend against the use of noninvasive biomarkers for screening or surveillance of GPMC or gastric cancer.

In terms of endoscopic and histologic diagnosis of GPMC, high-quality endoscopic evaluation is crucial to detect premalignant conditions or gastric cancer, the authors said. This includes adequate mucosal cleansing and insufflation, and photodocumentation of anatomic landmarks, as well as use of high-definition white light endoscopy (HDWLE) and IEE.

Systematic gastric biopsies should follow the updated Sydney protocol, with at least two separate containers for antrum/incisura and corpus biopsies. Histology should document the subtype of gastric intestinal metaplasia — incomplete, complete, or mixed — and severity and extent of atrophic gastritis and metaplasia.

Morgan emphasized the importance of coordination between the gastroenterologist and pathologist. “Several of these measures are not routinely reported, so we need to be in conversations with our collaborating pathologists,” he told this news organization.

In terms of GPMC surveillance, the authors suggest surveillance endoscopy every 3 years in high-risk patients with gastric intestinal metaplasia who meet one of the following criteria: High-risk histology (incomplete vs complete subtype, extending into the corpus); family history of gastric cancer in a first-degree relative; foreign-born individuals from high-gastric cancer incidence nations; or high-risk race/ethnicity (East Asian, Latino/a, Black, American Indian, or Alaska Native).

Individuals with multiple risk factors for gastric cancer may be considered for shorter than 3-year intervals.

Low-risk gastric intestinal metaplasia (limited to antrum, mild atrophy, and complete gastric intestinal metaplasia subtype) does not require routine endoscopic surveillance.

In terms of endoscopic management of dysplastic GPMC, endoscopic resection is suggested for dysplasia with visible margins. If dysplasia is not visible, repeat endoscopy with HDWLE and IEE by an experienced endoscopist is advised.

In patients appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection, referral to a high-volume center with appropriate expertise in the diagnosis and therapeutic resection of gastric neoplasia is strongly recommended.

In patients with confirmed complete resection of dysplasia, endoscopic surveillance is also strongly recommended. Surveillance examinations should be performed by an experienced endoscopist using HDWLE and IEE, with biopsies according to the systematic biopsy protocol in addition to targeted biopsies.

In terms of nonendoscopic GPMC management, testing for H pylori (and eradication treatment if possible) is strongly recommended for patients with GPMC and those with a history of resected early gastric cancer.

Aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, or antioxidants are not recommended for patients with GPMC for the purpose of preventing gastric cancer.

In patients with autoimmune gastritis, testing for H pylori with a nonserological test, eradication treatment if positive, and posttreatment testing to confirm eradication is advised.

There is not enough evidence to make a formal recommendation on endoscopic surveillance in those with autoimmune gastritis; surveillance should be individualized, considering the risk for neuroendocrine tumors and possibly gastric cancer.

In terms of gastric epithelial polyps, endoscopic resection of all gastric adenomas is recommended, regardless of size, to exclude or prevent dysplasia and early gastric cancer. Adenomas that are not amenable to endoscopic resection should be referred for surgical resection, if clinically appropriate.

Morgan noted that the ACG GPMC guideline aligns with the updated ACG/American Society for Gastrointestinal Endoscopy upper endoscopy quality indicators released earlier this year.

Implementation of the ACG GPMC guideline and “change in clinical practice will require concrete targets and include training and quality initiatives,” the authors said.

This research received no commercial support. Morgan disclosed research support from Panbela Therapeutics, Thorne, and American Molecular Laboratories.

A version of this article first appeared on Medscape.com.

New research highlights the promise of artificial intelligence (AI) for opportunistic screening of chronic liver disease (CLD) through routine echocardiography. 

An AI algorithm called EchoNet-Liver demonstrated strong performance for detecting cirrhosis and steatotic liver disease (SLD) from routinely acquired transthoracic echocardiography studies containing subcostal images of the liver, the developers reported in NEJM AI.

“We hope that this algorithm enables physicians to opportunistically screen for chronic liver disease to identify asymptomatic and undiagnosed patients, thus enabling us to treat comorbidities relevant to the patient’s cardiovascular and noncardiovascular health,” Alan C. Kwan, MD, assistant professor, Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, California, told this news organization.

 

Harnessing Echo to Reveal Liver Trouble 

CLD affects over 1.5 billion people globally, with many cases remaining undiagnosed due to the asymptomatic nature of early disease and a lack of routine screening. Traditional diagnostic methods such as liver function tests, ultrasonography, and MRI are often limited by cost, availability, and patient access.

Echocardiography is a commonly performed imaging study that incidentally captures images of the liver but is not utilized for liver disease assessment.

EchoNet-Liver is an AI algorithm that can identify high-quality subcostal images from full echocardiography studies and detect the presence of cirrhosis and SLD. 

Kwan and colleagues trained it using nearly 1.6 million echocardiogram videos from 66,922 studies and 24,276 adult patients at Cedars-Sinai Medical Center (CSMC). The model predictions were compared with diagnoses from clinical evaluations of paired abdominal ultrasound or MRI studies. External validation studies were conducted using similar data from Stanford Health Care. 

In the “held-out” CSMC ultrasound dataset, EchoNet-Liver detected cirrhosis with an area under the receiver operating characteristic curve (AUROC) of 0.837 (95% CI, 0.828-0.848) and SLD with an AUROC of 0.799 (95% CI, 0.788-0.811).

The algorithm showed a sensitivity of 69.6% and a specificity of 84.6% for detecting cirrhosis, and a sensitivity of 74.1% and a specificity of 72.0% for detecting SLD. 

In the Stanford Health Care external-validation test ultrasound cohort, the model detected cirrhosis with an AUROC of 0.830 (95% CI, 0.799-0.859) and SLD with an AUROC of 0.769 (95% CI, 0.733-0.813), with sensitivity and specificity of 80.0% and 70.9%, respectively, for cirrhosis and 66.7% and 78.0%, respectively, for SLD. 

In the CSMC MRI-paired cohort, EchoNet-Liver detected cirrhosis with an AUROC of 0.704 (95% CI, 0.699-0.708) and SLD with an AUROC of 0.725 (95% CI, 0.707-0.762).

 

Identifying Subclinical Liver Disease to Improve Outcomes

“Across diverse populations and disease definitions, deep-learning-enhanced echocardiography enabled high-throughput, automated detection of CLD, which could enable opportunistic screening for asymptomatic liver disease,” the authors wrote. 

“By improving the diagnosis of subclinical CLD, we may be able to limit or reverse disease progression and improve care by triaging patients toward appropriate clinical and diagnostic management,” they said. 

By way of limitations, the researchers noted that the tool was developed using a cohort of patients who had both abdominal ultrasound and echocardiography within 30 days, and thus probably had a higher prevalence of liver disease compared with the general population receiving echocardiography. The true clinical utility of EchoNet-Liver will depend on whether its application to a general echocardiography population can efficiently detect undiagnosed CLD, they cautioned. 

“While we developed this algorithm based on clinical data, the application within the clinic would typically require FDA approval, which we have not yet applied for,” Kwan told this news organization.

“We plan to prospectively validate this algorithm at multiple sites to ensure that application of this algorithm improves patient care without causing excess diagnostic testing, thus providing value to patients and the healthcare system as a whole,” Kwan said.

Funding was provided in part by KAKENHI (Japan Society for the Promotion of Science). Kwan reported receiving consulting fees from InVision.

A version of this article first appeared on Medscape.com.

New research highlights the promise of artificial intelligence (AI) for opportunistic screening of chronic liver disease (CLD) through routine echocardiography. 

An AI algorithm called EchoNet-Liver demonstrated strong performance for detecting cirrhosis and steatotic liver disease (SLD) from routinely acquired transthoracic echocardiography studies containing subcostal images of the liver, the developers reported in NEJM AI.

“We hope that this algorithm enables physicians to opportunistically screen for chronic liver disease to identify asymptomatic and undiagnosed patients, thus enabling us to treat comorbidities relevant to the patient’s cardiovascular and noncardiovascular health,” Alan C. Kwan, MD, assistant professor, Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, California, told this news organization.

 

Harnessing Echo to Reveal Liver Trouble 

CLD affects over 1.5 billion people globally, with many cases remaining undiagnosed due to the asymptomatic nature of early disease and a lack of routine screening. Traditional diagnostic methods such as liver function tests, ultrasonography, and MRI are often limited by cost, availability, and patient access.

Echocardiography is a commonly performed imaging study that incidentally captures images of the liver but is not utilized for liver disease assessment.

EchoNet-Liver is an AI algorithm that can identify high-quality subcostal images from full echocardiography studies and detect the presence of cirrhosis and SLD. 

Kwan and colleagues trained it using nearly 1.6 million echocardiogram videos from 66,922 studies and 24,276 adult patients at Cedars-Sinai Medical Center (CSMC). The model predictions were compared with diagnoses from clinical evaluations of paired abdominal ultrasound or MRI studies. External validation studies were conducted using similar data from Stanford Health Care. 

In the “held-out” CSMC ultrasound dataset, EchoNet-Liver detected cirrhosis with an area under the receiver operating characteristic curve (AUROC) of 0.837 (95% CI, 0.828-0.848) and SLD with an AUROC of 0.799 (95% CI, 0.788-0.811).

The algorithm showed a sensitivity of 69.6% and a specificity of 84.6% for detecting cirrhosis, and a sensitivity of 74.1% and a specificity of 72.0% for detecting SLD. 

In the Stanford Health Care external-validation test ultrasound cohort, the model detected cirrhosis with an AUROC of 0.830 (95% CI, 0.799-0.859) and SLD with an AUROC of 0.769 (95% CI, 0.733-0.813), with sensitivity and specificity of 80.0% and 70.9%, respectively, for cirrhosis and 66.7% and 78.0%, respectively, for SLD. 

In the CSMC MRI-paired cohort, EchoNet-Liver detected cirrhosis with an AUROC of 0.704 (95% CI, 0.699-0.708) and SLD with an AUROC of 0.725 (95% CI, 0.707-0.762).

 

Identifying Subclinical Liver Disease to Improve Outcomes

“Across diverse populations and disease definitions, deep-learning-enhanced echocardiography enabled high-throughput, automated detection of CLD, which could enable opportunistic screening for asymptomatic liver disease,” the authors wrote. 

“By improving the diagnosis of subclinical CLD, we may be able to limit or reverse disease progression and improve care by triaging patients toward appropriate clinical and diagnostic management,” they said. 

By way of limitations, the researchers noted that the tool was developed using a cohort of patients who had both abdominal ultrasound and echocardiography within 30 days, and thus probably had a higher prevalence of liver disease compared with the general population receiving echocardiography. The true clinical utility of EchoNet-Liver will depend on whether its application to a general echocardiography population can efficiently detect undiagnosed CLD, they cautioned. 

“While we developed this algorithm based on clinical data, the application within the clinic would typically require FDA approval, which we have not yet applied for,” Kwan told this news organization.

“We plan to prospectively validate this algorithm at multiple sites to ensure that application of this algorithm improves patient care without causing excess diagnostic testing, thus providing value to patients and the healthcare system as a whole,” Kwan said.

Funding was provided in part by KAKENHI (Japan Society for the Promotion of Science). Kwan reported receiving consulting fees from InVision.

A version of this article first appeared on Medscape.com.

New research highlights the promise of artificial intelligence (AI) for opportunistic screening of chronic liver disease (CLD) through routine echocardiography. 

An AI algorithm called EchoNet-Liver demonstrated strong performance for detecting cirrhosis and steatotic liver disease (SLD) from routinely acquired transthoracic echocardiography studies containing subcostal images of the liver, the developers reported in NEJM AI.

“We hope that this algorithm enables physicians to opportunistically screen for chronic liver disease to identify asymptomatic and undiagnosed patients, thus enabling us to treat comorbidities relevant to the patient’s cardiovascular and noncardiovascular health,” Alan C. Kwan, MD, assistant professor, Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, California, told this news organization.

 

Harnessing Echo to Reveal Liver Trouble 

CLD affects over 1.5 billion people globally, with many cases remaining undiagnosed due to the asymptomatic nature of early disease and a lack of routine screening. Traditional diagnostic methods such as liver function tests, ultrasonography, and MRI are often limited by cost, availability, and patient access.

Echocardiography is a commonly performed imaging study that incidentally captures images of the liver but is not utilized for liver disease assessment.

EchoNet-Liver is an AI algorithm that can identify high-quality subcostal images from full echocardiography studies and detect the presence of cirrhosis and SLD. 

Kwan and colleagues trained it using nearly 1.6 million echocardiogram videos from 66,922 studies and 24,276 adult patients at Cedars-Sinai Medical Center (CSMC). The model predictions were compared with diagnoses from clinical evaluations of paired abdominal ultrasound or MRI studies. External validation studies were conducted using similar data from Stanford Health Care. 

In the “held-out” CSMC ultrasound dataset, EchoNet-Liver detected cirrhosis with an area under the receiver operating characteristic curve (AUROC) of 0.837 (95% CI, 0.828-0.848) and SLD with an AUROC of 0.799 (95% CI, 0.788-0.811).

The algorithm showed a sensitivity of 69.6% and a specificity of 84.6% for detecting cirrhosis, and a sensitivity of 74.1% and a specificity of 72.0% for detecting SLD. 

In the Stanford Health Care external-validation test ultrasound cohort, the model detected cirrhosis with an AUROC of 0.830 (95% CI, 0.799-0.859) and SLD with an AUROC of 0.769 (95% CI, 0.733-0.813), with sensitivity and specificity of 80.0% and 70.9%, respectively, for cirrhosis and 66.7% and 78.0%, respectively, for SLD. 

In the CSMC MRI-paired cohort, EchoNet-Liver detected cirrhosis with an AUROC of 0.704 (95% CI, 0.699-0.708) and SLD with an AUROC of 0.725 (95% CI, 0.707-0.762).

 

Identifying Subclinical Liver Disease to Improve Outcomes

“Across diverse populations and disease definitions, deep-learning-enhanced echocardiography enabled high-throughput, automated detection of CLD, which could enable opportunistic screening for asymptomatic liver disease,” the authors wrote. 

“By improving the diagnosis of subclinical CLD, we may be able to limit or reverse disease progression and improve care by triaging patients toward appropriate clinical and diagnostic management,” they said. 

By way of limitations, the researchers noted that the tool was developed using a cohort of patients who had both abdominal ultrasound and echocardiography within 30 days, and thus probably had a higher prevalence of liver disease compared with the general population receiving echocardiography. The true clinical utility of EchoNet-Liver will depend on whether its application to a general echocardiography population can efficiently detect undiagnosed CLD, they cautioned. 

“While we developed this algorithm based on clinical data, the application within the clinic would typically require FDA approval, which we have not yet applied for,” Kwan told this news organization.

“We plan to prospectively validate this algorithm at multiple sites to ensure that application of this algorithm improves patient care without causing excess diagnostic testing, thus providing value to patients and the healthcare system as a whole,” Kwan said.

Funding was provided in part by KAKENHI (Japan Society for the Promotion of Science). Kwan reported receiving consulting fees from InVision.

A version of this article first appeared on Medscape.com.

Diets in wealthier countries often include processed foods that contain additives, particularly emulsifiers. These additives are increasingly associated with the development of various diseases, including inflammatory bowel disease (IBD).

A research team led by Benoit Chassaing, PhD, research director at the French National Institute of Health and Medical Research (Inserm), focused on one such emulsifier — carboxymethylcellulose (CMC) — which is commonly found in processed baked goods, such as brioche and sandwich bread, and ice cream.

The study, published in the journal Gut, describes how the team developed a new method that uses a simple stool sample to predict an individual’s sensitivity to CMC.

 

Sensitivity Detection

In a previous clinical trial conducted on healthy volunteers, Chassaing and colleagues found that CMC consumption altered the gut microbiota and fecal metabolome in some healthy individuals. In mice, transplanting fecal microbiota from CMC-sensitive animals made other animals susceptible. This has led researchers to investigate the characteristics of sensitive microbiota.

To explore this, the researchers developed an in vitro microbiota model capable of replicating multiple healthy human microbiota. CMC sensitivity was tested using this model, and the findings were validated in vivo by transplanting microbiota classified as sensitive or resistant to mice. Only mice that received microbiota predicted to be CMC-sensitive developed severe colitis after consuming CMC.

 

Predictive Signature

Next, the team analyzed the stool metagenomes of individuals with microbiotas classified as sensitive or resistant to CMC. They identified a specific microbial signature that could predict whether a given microbiota would react negatively to emulsifiers. Using molecular analyses, this signature allows researchers to predict whether an individual’s microbiota is susceptible or resistant to CMC exposure.

For the research team, these findings open the possibility of determining whether an individual is sensitive to a particular emulsifier, allowing for personalized dietary recommendations. This is particularly relevant for patients with chronic IBD and may also help prevent these conditions in those not previously affected.

These findings could pave the way for personalized dietary recommendations, particularly for patients with chronic IBD. By identifying individuals sensitive to specific emulsifiers, clinicians can tailor diets to reduce inflammation and potentially prevent disease onset in those at risk.

To further validate these insights, the team is launching a cohort study in patients with Crohn’s to explore why some individuals are more susceptible to food additives than others.

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

Diets in wealthier countries often include processed foods that contain additives, particularly emulsifiers. These additives are increasingly associated with the development of various diseases, including inflammatory bowel disease (IBD).

A research team led by Benoit Chassaing, PhD, research director at the French National Institute of Health and Medical Research (Inserm), focused on one such emulsifier — carboxymethylcellulose (CMC) — which is commonly found in processed baked goods, such as brioche and sandwich bread, and ice cream.

The study, published in the journal Gut, describes how the team developed a new method that uses a simple stool sample to predict an individual’s sensitivity to CMC.

 

Sensitivity Detection

In a previous clinical trial conducted on healthy volunteers, Chassaing and colleagues found that CMC consumption altered the gut microbiota and fecal metabolome in some healthy individuals. In mice, transplanting fecal microbiota from CMC-sensitive animals made other animals susceptible. This has led researchers to investigate the characteristics of sensitive microbiota.

To explore this, the researchers developed an in vitro microbiota model capable of replicating multiple healthy human microbiota. CMC sensitivity was tested using this model, and the findings were validated in vivo by transplanting microbiota classified as sensitive or resistant to mice. Only mice that received microbiota predicted to be CMC-sensitive developed severe colitis after consuming CMC.

 

Predictive Signature

Next, the team analyzed the stool metagenomes of individuals with microbiotas classified as sensitive or resistant to CMC. They identified a specific microbial signature that could predict whether a given microbiota would react negatively to emulsifiers. Using molecular analyses, this signature allows researchers to predict whether an individual’s microbiota is susceptible or resistant to CMC exposure.

For the research team, these findings open the possibility of determining whether an individual is sensitive to a particular emulsifier, allowing for personalized dietary recommendations. This is particularly relevant for patients with chronic IBD and may also help prevent these conditions in those not previously affected.

These findings could pave the way for personalized dietary recommendations, particularly for patients with chronic IBD. By identifying individuals sensitive to specific emulsifiers, clinicians can tailor diets to reduce inflammation and potentially prevent disease onset in those at risk.

To further validate these insights, the team is launching a cohort study in patients with Crohn’s to explore why some individuals are more susceptible to food additives than others.

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

Diets in wealthier countries often include processed foods that contain additives, particularly emulsifiers. These additives are increasingly associated with the development of various diseases, including inflammatory bowel disease (IBD).

A research team led by Benoit Chassaing, PhD, research director at the French National Institute of Health and Medical Research (Inserm), focused on one such emulsifier — carboxymethylcellulose (CMC) — which is commonly found in processed baked goods, such as brioche and sandwich bread, and ice cream.

The study, published in the journal Gut, describes how the team developed a new method that uses a simple stool sample to predict an individual’s sensitivity to CMC.

 

Sensitivity Detection

In a previous clinical trial conducted on healthy volunteers, Chassaing and colleagues found that CMC consumption altered the gut microbiota and fecal metabolome in some healthy individuals. In mice, transplanting fecal microbiota from CMC-sensitive animals made other animals susceptible. This has led researchers to investigate the characteristics of sensitive microbiota.

To explore this, the researchers developed an in vitro microbiota model capable of replicating multiple healthy human microbiota. CMC sensitivity was tested using this model, and the findings were validated in vivo by transplanting microbiota classified as sensitive or resistant to mice. Only mice that received microbiota predicted to be CMC-sensitive developed severe colitis after consuming CMC.

 

Predictive Signature

Next, the team analyzed the stool metagenomes of individuals with microbiotas classified as sensitive or resistant to CMC. They identified a specific microbial signature that could predict whether a given microbiota would react negatively to emulsifiers. Using molecular analyses, this signature allows researchers to predict whether an individual’s microbiota is susceptible or resistant to CMC exposure.

For the research team, these findings open the possibility of determining whether an individual is sensitive to a particular emulsifier, allowing for personalized dietary recommendations. This is particularly relevant for patients with chronic IBD and may also help prevent these conditions in those not previously affected.

These findings could pave the way for personalized dietary recommendations, particularly for patients with chronic IBD. By identifying individuals sensitive to specific emulsifiers, clinicians can tailor diets to reduce inflammation and potentially prevent disease onset in those at risk.

To further validate these insights, the team is launching a cohort study in patients with Crohn’s to explore why some individuals are more susceptible to food additives than others.

This story was translated from Univadis France using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

The United States multi-society task force on colorectal cancer (CRC) has updated its 2014 guidance for optimizing the adequacy of bowel preparation for colonoscopy.

The latest consensus recommendations emphasize the importance of verbal and written patient education, refine diet restrictions, update optimal purgative regimens, and advise tracking bowel prep adequacy rates at both the individual endoscopist and unit levels.

“Colorectal cancer remains the second most common cause of cancer death in the United States, and colonoscopy is considered the gold standard for evaluating the colon, including assessing causes of colon-related signs or symptoms and the detection of precancerous lesions. It is well recognized that the adequacy of bowel preparation is essential for optimal colonoscopy performance,” the task force wrote.

 

Choice of Prep, Dosing and Timing, and Dietary Restrictions 

When choosing bowel preparation regimens, the task force recommends considering the individual’s medical history, medications, and, when available, the adequacy of bowel preparation reported from prior colonoscopies. Other considerations include patient preference, associated additional costs to the patient, and ease in obtaining and consuming any purgatives or adjuncts.

In terms of timing and dose, the task force now “suggests that lower-volume bowel preparation regimens, such as those that rely on only 2 liters of fluid compared to the traditional 4L, are acceptable options for individuals considered unlikely to have an inadequate bowel preparation. This assumes that the purgative is taken in a split-dose fashion (half the evening prior to colonoscopy and half the morning of the colonoscopy),” co–lead author Brian C. Jacobson, MD, MPH, AGAF, with Massachusetts General Hospital and Harvard Medical School, both in Boston, said in an interview.

The task force also states that a same-day bowel preparation regimen for afternoon, but not morning, colonoscopy is a “reasonable alternative to the now-common split-dose regimen,” Jacobson said.

The group did not find one bowel preparation purgative to be better than others, although table 7 in the document details characteristics of commonly used prep regimens including their side effects and contraindications.

Recommendations regarding dietary modifications depend upon the patient’s risk for inadequate bowel prep. For patients at low risk for inadequate bowel prep, the task force recommends limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. Table 5 in the document provides a list of low-residue foods and sample meals.

The task force also suggests the adjunctive use of oral simethicone (≥ 320 mg) to bowel prep as a way to potentially improve visualization, although they acknowledge that further research is needed.

How might these updated consensus recommendations change current clinical practice? 

Jacobson said: “Some physicians may try to identify individuals who will do just as well with a more patient-friendly, easily tolerated bowel preparation regimen, including less stringent dietary restrictions leading up to colonoscopy.” 

He noted that the task force prefers the term “guidance” to “guidelines.”

 

New Quality Benchmark 

The task force recommends documenting bowel prep quality in the endoscopy report after all washing and suctioning have been completed using reliably understood descriptors that communicate the adequacy of the preparation.

They recommend the term “adequate bowel preparation” be used to indicate that standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy.

Additionally, the task force recommends that endoscopy units and individual endoscopists track and aim for ≥ 90% adequacy rates in bowel preparation — up from the 85% benchmark contained in the prior recommendations.

Jacobson told this news organization it’s “currently unknown” how many individual endoscopists and endoscopy units track and meet the 90% benchmark at present.

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, who wasn’t on the task force, said endoscopy units and providers “need to be accountable and should be tracking this quality metric.”

Johnson noted that bowel prep inadequacy has “intrinsic costs,” impacting lesion detection, CRC incidence, and patient outcomes. Inadequate prep leads to “increased risk for morbidity, mortality, longer appointment and wait times for rescheduling, and negative connotations that may deter patients from returning.”

 

Brian Sullivan, MD, MHS, assistant professor of medicine, division of gastroenterology, Duke University School of Medicine, Durham, North Carolina, who wasn’t on the task force, said the recommendation to target a 90% or higher bowel preparation adequacy rate is “appreciated.”

“This benchmark encourages practices to standardize measurement, tracking, and reporting of preparation quality at both the individual and unit levels. Specifically, it should motivate providers to critically evaluate their interpretation of preparation quality and ensure adequate cleansing before making determinations,” Sullivan said in an interview.

“At the unit level, this metric can identify whether there are opportunities for quality improvement, such as by implementing evidence-based initiatives (provided in the guidance) to enhance outpatient preparation processes,” Sullivan noted.

The task force emphasized that the majority of consensus recommendations focus on individuals at average risk for inadequate bowel prep. Patients at high risk for inadequate bowel prep (eg, diabetes, constipation, opioid use) should receive tailored instructions, including a more extended dietary prep and high-volume purgatives.

 

‘Timely and Important’ Updates

Sullivan said the updated consensus recommendations on optimizing bowel preparation quality for colonoscopy are both “timely and important.” 

“Clear guidance facilitates dissemination and adoption, promoting flexible yet evidence-based approaches that enhance patient and provider satisfaction while potentially improving CRC prevention outcomes. For instance, surveys reveal that some practices still do not utilize split-dose bowel preparation, which is proven to improve preparation quality, particularly for the right-side of the colon. This gap underscores the need for standardized guidance to ensure high-quality colonoscopy and effective CRC screening,” Sullivan said.

He also noted that the inclusion of lower-volume bowel prep regimens and less intensive dietary modifications for selected patients is a “welcome update.”

“These options can improve patient adherence and satisfaction, which are critical not only for the quality of the index exam but also for ensuring patients return for future screenings, thereby supporting long-term CRC prevention efforts,” Sullivan said.

The task force includes representatives from the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy.

The consensus document was published online in the three societies’ respective scientific journals — Gastroenterology, the American Journal of Gastroenterology, and Gastrointestinal Endsocopy.

This research had no financial support. Jacobson is a consultant for Curis and Guardant Health. Sullivan had no disclosures. Johnson is an adviser to ISOThrive and a past president of the American College of Gastroenterology.

A version of this article first appeared on Medscape.com.

The United States multi-society task force on colorectal cancer (CRC) has updated its 2014 guidance for optimizing the adequacy of bowel preparation for colonoscopy.

The latest consensus recommendations emphasize the importance of verbal and written patient education, refine diet restrictions, update optimal purgative regimens, and advise tracking bowel prep adequacy rates at both the individual endoscopist and unit levels.

“Colorectal cancer remains the second most common cause of cancer death in the United States, and colonoscopy is considered the gold standard for evaluating the colon, including assessing causes of colon-related signs or symptoms and the detection of precancerous lesions. It is well recognized that the adequacy of bowel preparation is essential for optimal colonoscopy performance,” the task force wrote.

 

Choice of Prep, Dosing and Timing, and Dietary Restrictions 

When choosing bowel preparation regimens, the task force recommends considering the individual’s medical history, medications, and, when available, the adequacy of bowel preparation reported from prior colonoscopies. Other considerations include patient preference, associated additional costs to the patient, and ease in obtaining and consuming any purgatives or adjuncts.

In terms of timing and dose, the task force now “suggests that lower-volume bowel preparation regimens, such as those that rely on only 2 liters of fluid compared to the traditional 4L, are acceptable options for individuals considered unlikely to have an inadequate bowel preparation. This assumes that the purgative is taken in a split-dose fashion (half the evening prior to colonoscopy and half the morning of the colonoscopy),” co–lead author Brian C. Jacobson, MD, MPH, AGAF, with Massachusetts General Hospital and Harvard Medical School, both in Boston, said in an interview.

The task force also states that a same-day bowel preparation regimen for afternoon, but not morning, colonoscopy is a “reasonable alternative to the now-common split-dose regimen,” Jacobson said.

The group did not find one bowel preparation purgative to be better than others, although table 7 in the document details characteristics of commonly used prep regimens including their side effects and contraindications.

Recommendations regarding dietary modifications depend upon the patient’s risk for inadequate bowel prep. For patients at low risk for inadequate bowel prep, the task force recommends limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. Table 5 in the document provides a list of low-residue foods and sample meals.

The task force also suggests the adjunctive use of oral simethicone (≥ 320 mg) to bowel prep as a way to potentially improve visualization, although they acknowledge that further research is needed.

How might these updated consensus recommendations change current clinical practice? 

Jacobson said: “Some physicians may try to identify individuals who will do just as well with a more patient-friendly, easily tolerated bowel preparation regimen, including less stringent dietary restrictions leading up to colonoscopy.” 

He noted that the task force prefers the term “guidance” to “guidelines.”

 

New Quality Benchmark 

The task force recommends documenting bowel prep quality in the endoscopy report after all washing and suctioning have been completed using reliably understood descriptors that communicate the adequacy of the preparation.

They recommend the term “adequate bowel preparation” be used to indicate that standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy.

Additionally, the task force recommends that endoscopy units and individual endoscopists track and aim for ≥ 90% adequacy rates in bowel preparation — up from the 85% benchmark contained in the prior recommendations.

Jacobson told this news organization it’s “currently unknown” how many individual endoscopists and endoscopy units track and meet the 90% benchmark at present.

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, who wasn’t on the task force, said endoscopy units and providers “need to be accountable and should be tracking this quality metric.”

Johnson noted that bowel prep inadequacy has “intrinsic costs,” impacting lesion detection, CRC incidence, and patient outcomes. Inadequate prep leads to “increased risk for morbidity, mortality, longer appointment and wait times for rescheduling, and negative connotations that may deter patients from returning.”

 

Brian Sullivan, MD, MHS, assistant professor of medicine, division of gastroenterology, Duke University School of Medicine, Durham, North Carolina, who wasn’t on the task force, said the recommendation to target a 90% or higher bowel preparation adequacy rate is “appreciated.”

“This benchmark encourages practices to standardize measurement, tracking, and reporting of preparation quality at both the individual and unit levels. Specifically, it should motivate providers to critically evaluate their interpretation of preparation quality and ensure adequate cleansing before making determinations,” Sullivan said in an interview.

“At the unit level, this metric can identify whether there are opportunities for quality improvement, such as by implementing evidence-based initiatives (provided in the guidance) to enhance outpatient preparation processes,” Sullivan noted.

The task force emphasized that the majority of consensus recommendations focus on individuals at average risk for inadequate bowel prep. Patients at high risk for inadequate bowel prep (eg, diabetes, constipation, opioid use) should receive tailored instructions, including a more extended dietary prep and high-volume purgatives.

 

‘Timely and Important’ Updates

Sullivan said the updated consensus recommendations on optimizing bowel preparation quality for colonoscopy are both “timely and important.” 

“Clear guidance facilitates dissemination and adoption, promoting flexible yet evidence-based approaches that enhance patient and provider satisfaction while potentially improving CRC prevention outcomes. For instance, surveys reveal that some practices still do not utilize split-dose bowel preparation, which is proven to improve preparation quality, particularly for the right-side of the colon. This gap underscores the need for standardized guidance to ensure high-quality colonoscopy and effective CRC screening,” Sullivan said.

He also noted that the inclusion of lower-volume bowel prep regimens and less intensive dietary modifications for selected patients is a “welcome update.”

“These options can improve patient adherence and satisfaction, which are critical not only for the quality of the index exam but also for ensuring patients return for future screenings, thereby supporting long-term CRC prevention efforts,” Sullivan said.

The task force includes representatives from the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy.

The consensus document was published online in the three societies’ respective scientific journals — Gastroenterology, the American Journal of Gastroenterology, and Gastrointestinal Endsocopy.

This research had no financial support. Jacobson is a consultant for Curis and Guardant Health. Sullivan had no disclosures. Johnson is an adviser to ISOThrive and a past president of the American College of Gastroenterology.

A version of this article first appeared on Medscape.com.

The United States multi-society task force on colorectal cancer (CRC) has updated its 2014 guidance for optimizing the adequacy of bowel preparation for colonoscopy.

The latest consensus recommendations emphasize the importance of verbal and written patient education, refine diet restrictions, update optimal purgative regimens, and advise tracking bowel prep adequacy rates at both the individual endoscopist and unit levels.

“Colorectal cancer remains the second most common cause of cancer death in the United States, and colonoscopy is considered the gold standard for evaluating the colon, including assessing causes of colon-related signs or symptoms and the detection of precancerous lesions. It is well recognized that the adequacy of bowel preparation is essential for optimal colonoscopy performance,” the task force wrote.

 

Choice of Prep, Dosing and Timing, and Dietary Restrictions 

When choosing bowel preparation regimens, the task force recommends considering the individual’s medical history, medications, and, when available, the adequacy of bowel preparation reported from prior colonoscopies. Other considerations include patient preference, associated additional costs to the patient, and ease in obtaining and consuming any purgatives or adjuncts.

In terms of timing and dose, the task force now “suggests that lower-volume bowel preparation regimens, such as those that rely on only 2 liters of fluid compared to the traditional 4L, are acceptable options for individuals considered unlikely to have an inadequate bowel preparation. This assumes that the purgative is taken in a split-dose fashion (half the evening prior to colonoscopy and half the morning of the colonoscopy),” co–lead author Brian C. Jacobson, MD, MPH, AGAF, with Massachusetts General Hospital and Harvard Medical School, both in Boston, said in an interview.

The task force also states that a same-day bowel preparation regimen for afternoon, but not morning, colonoscopy is a “reasonable alternative to the now-common split-dose regimen,” Jacobson said.

The group did not find one bowel preparation purgative to be better than others, although table 7 in the document details characteristics of commonly used prep regimens including their side effects and contraindications.

Recommendations regarding dietary modifications depend upon the patient’s risk for inadequate bowel prep. For patients at low risk for inadequate bowel prep, the task force recommends limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. Table 5 in the document provides a list of low-residue foods and sample meals.

The task force also suggests the adjunctive use of oral simethicone (≥ 320 mg) to bowel prep as a way to potentially improve visualization, although they acknowledge that further research is needed.

How might these updated consensus recommendations change current clinical practice? 

Jacobson said: “Some physicians may try to identify individuals who will do just as well with a more patient-friendly, easily tolerated bowel preparation regimen, including less stringent dietary restrictions leading up to colonoscopy.” 

He noted that the task force prefers the term “guidance” to “guidelines.”

 

New Quality Benchmark 

The task force recommends documenting bowel prep quality in the endoscopy report after all washing and suctioning have been completed using reliably understood descriptors that communicate the adequacy of the preparation.

They recommend the term “adequate bowel preparation” be used to indicate that standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy.

Additionally, the task force recommends that endoscopy units and individual endoscopists track and aim for ≥ 90% adequacy rates in bowel preparation — up from the 85% benchmark contained in the prior recommendations.

Jacobson told this news organization it’s “currently unknown” how many individual endoscopists and endoscopy units track and meet the 90% benchmark at present.

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, who wasn’t on the task force, said endoscopy units and providers “need to be accountable and should be tracking this quality metric.”

Johnson noted that bowel prep inadequacy has “intrinsic costs,” impacting lesion detection, CRC incidence, and patient outcomes. Inadequate prep leads to “increased risk for morbidity, mortality, longer appointment and wait times for rescheduling, and negative connotations that may deter patients from returning.”

 

Brian Sullivan, MD, MHS, assistant professor of medicine, division of gastroenterology, Duke University School of Medicine, Durham, North Carolina, who wasn’t on the task force, said the recommendation to target a 90% or higher bowel preparation adequacy rate is “appreciated.”

“This benchmark encourages practices to standardize measurement, tracking, and reporting of preparation quality at both the individual and unit levels. Specifically, it should motivate providers to critically evaluate their interpretation of preparation quality and ensure adequate cleansing before making determinations,” Sullivan said in an interview.

“At the unit level, this metric can identify whether there are opportunities for quality improvement, such as by implementing evidence-based initiatives (provided in the guidance) to enhance outpatient preparation processes,” Sullivan noted.

The task force emphasized that the majority of consensus recommendations focus on individuals at average risk for inadequate bowel prep. Patients at high risk for inadequate bowel prep (eg, diabetes, constipation, opioid use) should receive tailored instructions, including a more extended dietary prep and high-volume purgatives.

 

‘Timely and Important’ Updates

Sullivan said the updated consensus recommendations on optimizing bowel preparation quality for colonoscopy are both “timely and important.” 

“Clear guidance facilitates dissemination and adoption, promoting flexible yet evidence-based approaches that enhance patient and provider satisfaction while potentially improving CRC prevention outcomes. For instance, surveys reveal that some practices still do not utilize split-dose bowel preparation, which is proven to improve preparation quality, particularly for the right-side of the colon. This gap underscores the need for standardized guidance to ensure high-quality colonoscopy and effective CRC screening,” Sullivan said.

He also noted that the inclusion of lower-volume bowel prep regimens and less intensive dietary modifications for selected patients is a “welcome update.”

“These options can improve patient adherence and satisfaction, which are critical not only for the quality of the index exam but also for ensuring patients return for future screenings, thereby supporting long-term CRC prevention efforts,” Sullivan said.

The task force includes representatives from the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy.

The consensus document was published online in the three societies’ respective scientific journals — Gastroenterology, the American Journal of Gastroenterology, and Gastrointestinal Endsocopy.

This research had no financial support. Jacobson is a consultant for Curis and Guardant Health. Sullivan had no disclosures. Johnson is an adviser to ISOThrive and a past president of the American College of Gastroenterology.

A version of this article first appeared on Medscape.com.

The most common pathology affecting the pancreas is excess intra-pancreatic fat deposition (IPFD), often called fatty pancreas disease (FPD) — a disorder experienced by roughly one fifth of the world’s population. Although it is more common than type 2 diabetes, pancreatitis, and pancreatic cancer combined, it has remained relatively obscure.

By contrast, fatty liver — once called nonalcoholic fatty liver disease and recently renamed metabolic dysfunction–associated steatotic liver disease (MASLD) — is well-known.

“When it comes to diseases of the liver and pancreas, the liver is the big brother that has gotten all the attention, while the pancreas is the neglected little stepbrother that’s not sufficiently profiled in most medical textbooks and gets very little attention,” Max Petrov, MD, MPH, PhD, professor of pancreatology, University of Auckland, New Zealand, said in an interview. “The phenomenon of fatty pancreas has been observed for decades, but it is underappreciated and underrecognized.”

 

As early as 1926, fat depositions were identified during autopsies, but the condition remained relatively unknown, Mohammad Bilal, MD, associate professor of medicine-gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Fortunately, FPD has recently been receiving more focus.”

Generally, healthy individuals have small amounts of fat in their pancreas. IPFD is defined as “the diffuse presence of fat in the pancreas, measured on a continuous scale,” and FPD refers to IPFD above the upper limit of normal. While there is no clear consensus as to what the normal range is, studies suggest it’s a pancreatic fat content ranging from 1.8% to 10.4%.

FPD’s “most important implication is that it can be a precursor for more challenging and burdensome diseases of the pancreas,” Petrov said.

Fatty changes in the pancreas affect both its endocrine and exocrine systems. FPD is associated with type 2 diabetes, the most common disease of the endocrine pancreas, as well as pancreatitis and pancreatic cancer, the most common diseases of the exocrine pancreas. It’s also implicated in the development of carotid atherosclerosis, pancreatic fistula following surgery, and exocrine pancreatic insufficiency (EPI).

 

A ‘Pandora’s Box’

Up to half of people with fatty pancreas are lean. The condition isn’t merely caused by an overflow of fat from the liver into the pancreas in people who consume more calories than they burn, Petrov said. Neither robust postmortem nor biopsy studies have found a statistically significant association between fatty deposition in the pancreas and liver fat.

Compared with the way people accumulate liver fat, the development of FPD is more complex, Petrov said.

“Hepatic fat is a relatively simple process: Lipid droplets accumulate in the hepatocytes; but, in the pancreas, there are several ways by which fat may accumulate,” he said.

One relates to the location of the pancreas within visceral, retroperitoneal fat, Petrov said. That fat can migrate and build up between pancreatic lobules.

Fat also can accumulate inside the lobes. This process can involve a buildup of fat droplets in acinar and stellate cells on the exocrine side and in the islets of Langerhans on the endocrine side. Additionally, when functional pancreatic cells die, particularly acinar cells, adult stem cells may replace them with adipocytes. Transformation of acinar cells into fat cells — a process called acinar-to-adipocyte transdifferentiation — also may be a way fat accumulates inside the lobes, Petrov said.

The accumulation of fat is a response to a wide array of insults to the pancreas over time. For example, obesity and metabolic syndrome lead to the accumulation of adipocytes and fat infiltration, whereas alcohol abuse and viral infections may lead to the death of acinar cells, which produce digestive enzymes.

Ultimately, the negative changes produced by excess fat in the pancreas are the origin of all common noninherited pancreatic diseases, bringing them under one umbrella, Petrov maintained. He dubbed this hypothesis PANcreatic Diseases Originating from intRapancreatic fAt (PANDORA).

The type of cells involved has implications for which disease may arise. For example, fat infiltration in stellate cells may promote pancreatic cancer, whereas its accumulation in the islets of Langerhans, which produce insulin and glucagon, is associated with type 2 diabetes.

The PANDORA hypothesis has eight foundational principles:

• Fatty pancreas is a key driver of pancreatic diseases in most people.
• Inflammation within the pancreatic microenvironment results from overwhelming lipotoxicity fueled by fatty pancreas.
• Aberrant communication between acinar cells involving lipid droplets drives acute pancreatitis.
• The pancreas responds to lipotoxicity with fibrosis and calcification — the hallmarks of chronic pancreatitis.
• Fat deposition affects signaling between stellate cells and other components of the microenvironment in ways that raise the risk for pancreatic cancer.
• The development of diabetes of the exocrine pancreas and EPI is affected by the presence of fatty pancreas.
• The higher risk for pancreatic disease in older adults is influenced by fatty pancreas.
• The multipronged nature of intrapancreatic fat deposition accounts for the common development of one pancreatic disease after another.

The idea that all common pancreatic diseases are the result of pathways emanating from FPD could “explain the bidirectional relationship between diabetes and pancreatitis or pancreatic cancer,” Petrov said.

 

Risk Factors, Symptoms, and Diagnosis

A variety of risk factors are involved in the accumulation of fat that may lead to pancreatic diseases, including aging, cholelithiasis, dyslipidemia, drugs/toxins (eg, steroids), genetic predisposition, iron overload, diet (eg, fatty foods, ultraprocessed foods), heavy alcohol use, overweight/obesity, pancreatic duct obstruction, tobacco use, viral infection (eg, hepatitis B, COVID-19), severe malnutrition, prediabetes, and dysglycemia.

Petrov described FPD as a “silent disease” that’s often asymptomatic, with its presence emerging as an incidental finding during abdominal ultrasonography for other reasons. However, patients may sometimes experience stomach pain or nausea if they have concurrent diseases of the pancreas, he said.

There are no currently available lab tests that can definitively detect the presence of FPD. Rather, the gold standard for a noninvasive diagnosis of FPD is MRI, with CT as the second-best choice, Petrov said.

In countries where advanced imaging is not available, a low-cost alternative might be a simple abdominal ultrasound, but it is not definitive, he said. “It’s operator-dependent and can be subjective.”

Some risk factors, such as derangements of glucose and lipid metabolism, especially in the presence of heavy alcohol use and a high-fat diet, can “be detected on lab tests,” Petrov said. “This, in combination with the abdominal ultrasound, might suggest the patients will benefit from deeper investigation, including MRI.”

Because the exocrine pancreas helps with digestion of fatty food, intralobular fatty deposits or replacement of pancreatic exocrine cells with adipose cells can lead to steatorrhea, Bilal said.

“Fat within the stool or oily diarrhea is a clue to the presence of FPD,” Bilal said.

Although this symptom isn’t unique to FPD and is found in other types of pancreatic conditions, its presence suggests that further investigation for FPD is warranted, he added.

 

Common-Sense Treatment Approaches

At present, there are no US Food and Drug Administration–approved treatments for FPD, Petrov said.

“What might be recommended is something along the lines of treatment of MASLD — appropriate diet and physical activity,” he said. Petrov hopes that as the disease entity garners more research attention, more clinical drug trials will be initiated, and new medications are found and approved.

Petrov suggested that there could be a “theoretical rationale” for the use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as a treatment, given their effectiveness in multiple conditions, including MASLD, but no human trials have robustly shown specific benefits of these drugs for FPD.

Petrov added that, to date, 12 classes of drugs have been investigated for reducing IPFD: biguanides, sulfonylureas, GLP-1 RAs, thiazolidinediones, dipeptidyl peptidase–4 (DPP-4) inhibitors, sodium-glucose cotransporter 2 inhibitors, statins, fibrates, pancreatic lipase inhibitors, angiotensin II receptor blockers, somatostatin receptor agonists, and antioxidants.

Of these, most have shown promise in preclinical animal models. But only thiazolidinediones, GLP-1 RAs, DPP-4 inhibitors, and somatostatin receptor agonists have been investigated in randomized controlled trials in humans. The findings have been inconsistent, with the active treatment often not achieving statistically significant improvements.

“At this stage of our knowledge, we can’t recommend a specific pharmacotherapy,” Petrov said. But we can suggest dietary changes, such as saturated fat reduction, alcohol reduction, smoking cessation, reduction in consumption of ultraprocessed food, physical exercise, and addressing obesity and other drivers of metabolic disease.

Bilal, who is also a spokesperson for AGA, suggested that pancreatic enzyme replacement therapy, often used to treat pancreatic EPI, may treat some symptoms of FPD such as diarrhea.

Bariatric surgery has shown promise for FPD, in that it can decrease the patient’s body mass and potentially reduce the fat in the pancreas as well as it can improve metabolic diseases and hyperlipidemia. One study showed that it significantly decreased IPFD, fatty acid uptake, and blood flow, and these improvements were associated with more favorable glucose homeostasis and beta-cell function.

However, bariatric surgery is only appropriate for certain patients; is associated with potentially adverse sequelae including malnutrition, anemia, and digestive tract stenosis; and is currently not indicated for FPD.

Bilal advises clinicians to “keep an eye on FPD” if it’s detected incidentally and to screen patients more carefully for MASLD, metabolic disease, and diabetes.

“Although there are no consensus guidelines and recommendations for managing FPD at present, these common-sense approaches will benefit the patient’s overall health and hopefully will have a beneficial impact on pancreatic health as well,” he said.

Petrov reported no relevant financial relationships. Bilal reported being a consultant for Boston Scientific, Steris Endoscopy, and Cook Medical.

A version of this article first appeared on Medscape.com.

The most common pathology affecting the pancreas is excess intra-pancreatic fat deposition (IPFD), often called fatty pancreas disease (FPD) — a disorder experienced by roughly one fifth of the world’s population. Although it is more common than type 2 diabetes, pancreatitis, and pancreatic cancer combined, it has remained relatively obscure.

By contrast, fatty liver — once called nonalcoholic fatty liver disease and recently renamed metabolic dysfunction–associated steatotic liver disease (MASLD) — is well-known.

“When it comes to diseases of the liver and pancreas, the liver is the big brother that has gotten all the attention, while the pancreas is the neglected little stepbrother that’s not sufficiently profiled in most medical textbooks and gets very little attention,” Max Petrov, MD, MPH, PhD, professor of pancreatology, University of Auckland, New Zealand, said in an interview. “The phenomenon of fatty pancreas has been observed for decades, but it is underappreciated and underrecognized.”

 

As early as 1926, fat depositions were identified during autopsies, but the condition remained relatively unknown, Mohammad Bilal, MD, associate professor of medicine-gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Fortunately, FPD has recently been receiving more focus.”

Generally, healthy individuals have small amounts of fat in their pancreas. IPFD is defined as “the diffuse presence of fat in the pancreas, measured on a continuous scale,” and FPD refers to IPFD above the upper limit of normal. While there is no clear consensus as to what the normal range is, studies suggest it’s a pancreatic fat content ranging from 1.8% to 10.4%.

FPD’s “most important implication is that it can be a precursor for more challenging and burdensome diseases of the pancreas,” Petrov said.

Fatty changes in the pancreas affect both its endocrine and exocrine systems. FPD is associated with type 2 diabetes, the most common disease of the endocrine pancreas, as well as pancreatitis and pancreatic cancer, the most common diseases of the exocrine pancreas. It’s also implicated in the development of carotid atherosclerosis, pancreatic fistula following surgery, and exocrine pancreatic insufficiency (EPI).

 

A ‘Pandora’s Box’

Up to half of people with fatty pancreas are lean. The condition isn’t merely caused by an overflow of fat from the liver into the pancreas in people who consume more calories than they burn, Petrov said. Neither robust postmortem nor biopsy studies have found a statistically significant association between fatty deposition in the pancreas and liver fat.

Compared with the way people accumulate liver fat, the development of FPD is more complex, Petrov said.

“Hepatic fat is a relatively simple process: Lipid droplets accumulate in the hepatocytes; but, in the pancreas, there are several ways by which fat may accumulate,” he said.

One relates to the location of the pancreas within visceral, retroperitoneal fat, Petrov said. That fat can migrate and build up between pancreatic lobules.

Fat also can accumulate inside the lobes. This process can involve a buildup of fat droplets in acinar and stellate cells on the exocrine side and in the islets of Langerhans on the endocrine side. Additionally, when functional pancreatic cells die, particularly acinar cells, adult stem cells may replace them with adipocytes. Transformation of acinar cells into fat cells — a process called acinar-to-adipocyte transdifferentiation — also may be a way fat accumulates inside the lobes, Petrov said.

The accumulation of fat is a response to a wide array of insults to the pancreas over time. For example, obesity and metabolic syndrome lead to the accumulation of adipocytes and fat infiltration, whereas alcohol abuse and viral infections may lead to the death of acinar cells, which produce digestive enzymes.

Ultimately, the negative changes produced by excess fat in the pancreas are the origin of all common noninherited pancreatic diseases, bringing them under one umbrella, Petrov maintained. He dubbed this hypothesis PANcreatic Diseases Originating from intRapancreatic fAt (PANDORA).

The type of cells involved has implications for which disease may arise. For example, fat infiltration in stellate cells may promote pancreatic cancer, whereas its accumulation in the islets of Langerhans, which produce insulin and glucagon, is associated with type 2 diabetes.

The PANDORA hypothesis has eight foundational principles:

• Fatty pancreas is a key driver of pancreatic diseases in most people.
• Inflammation within the pancreatic microenvironment results from overwhelming lipotoxicity fueled by fatty pancreas.
• Aberrant communication between acinar cells involving lipid droplets drives acute pancreatitis.
• The pancreas responds to lipotoxicity with fibrosis and calcification — the hallmarks of chronic pancreatitis.
• Fat deposition affects signaling between stellate cells and other components of the microenvironment in ways that raise the risk for pancreatic cancer.
• The development of diabetes of the exocrine pancreas and EPI is affected by the presence of fatty pancreas.
• The higher risk for pancreatic disease in older adults is influenced by fatty pancreas.
• The multipronged nature of intrapancreatic fat deposition accounts for the common development of one pancreatic disease after another.

The idea that all common pancreatic diseases are the result of pathways emanating from FPD could “explain the bidirectional relationship between diabetes and pancreatitis or pancreatic cancer,” Petrov said.

 

Risk Factors, Symptoms, and Diagnosis

A variety of risk factors are involved in the accumulation of fat that may lead to pancreatic diseases, including aging, cholelithiasis, dyslipidemia, drugs/toxins (eg, steroids), genetic predisposition, iron overload, diet (eg, fatty foods, ultraprocessed foods), heavy alcohol use, overweight/obesity, pancreatic duct obstruction, tobacco use, viral infection (eg, hepatitis B, COVID-19), severe malnutrition, prediabetes, and dysglycemia.

Petrov described FPD as a “silent disease” that’s often asymptomatic, with its presence emerging as an incidental finding during abdominal ultrasonography for other reasons. However, patients may sometimes experience stomach pain or nausea if they have concurrent diseases of the pancreas, he said.

There are no currently available lab tests that can definitively detect the presence of FPD. Rather, the gold standard for a noninvasive diagnosis of FPD is MRI, with CT as the second-best choice, Petrov said.

In countries where advanced imaging is not available, a low-cost alternative might be a simple abdominal ultrasound, but it is not definitive, he said. “It’s operator-dependent and can be subjective.”

Some risk factors, such as derangements of glucose and lipid metabolism, especially in the presence of heavy alcohol use and a high-fat diet, can “be detected on lab tests,” Petrov said. “This, in combination with the abdominal ultrasound, might suggest the patients will benefit from deeper investigation, including MRI.”

Because the exocrine pancreas helps with digestion of fatty food, intralobular fatty deposits or replacement of pancreatic exocrine cells with adipose cells can lead to steatorrhea, Bilal said.

“Fat within the stool or oily diarrhea is a clue to the presence of FPD,” Bilal said.

Although this symptom isn’t unique to FPD and is found in other types of pancreatic conditions, its presence suggests that further investigation for FPD is warranted, he added.

 

Common-Sense Treatment Approaches

At present, there are no US Food and Drug Administration–approved treatments for FPD, Petrov said.

“What might be recommended is something along the lines of treatment of MASLD — appropriate diet and physical activity,” he said. Petrov hopes that as the disease entity garners more research attention, more clinical drug trials will be initiated, and new medications are found and approved.

Petrov suggested that there could be a “theoretical rationale” for the use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as a treatment, given their effectiveness in multiple conditions, including MASLD, but no human trials have robustly shown specific benefits of these drugs for FPD.

Petrov added that, to date, 12 classes of drugs have been investigated for reducing IPFD: biguanides, sulfonylureas, GLP-1 RAs, thiazolidinediones, dipeptidyl peptidase–4 (DPP-4) inhibitors, sodium-glucose cotransporter 2 inhibitors, statins, fibrates, pancreatic lipase inhibitors, angiotensin II receptor blockers, somatostatin receptor agonists, and antioxidants.

Of these, most have shown promise in preclinical animal models. But only thiazolidinediones, GLP-1 RAs, DPP-4 inhibitors, and somatostatin receptor agonists have been investigated in randomized controlled trials in humans. The findings have been inconsistent, with the active treatment often not achieving statistically significant improvements.

“At this stage of our knowledge, we can’t recommend a specific pharmacotherapy,” Petrov said. But we can suggest dietary changes, such as saturated fat reduction, alcohol reduction, smoking cessation, reduction in consumption of ultraprocessed food, physical exercise, and addressing obesity and other drivers of metabolic disease.

Bilal, who is also a spokesperson for AGA, suggested that pancreatic enzyme replacement therapy, often used to treat pancreatic EPI, may treat some symptoms of FPD such as diarrhea.

Bariatric surgery has shown promise for FPD, in that it can decrease the patient’s body mass and potentially reduce the fat in the pancreas as well as it can improve metabolic diseases and hyperlipidemia. One study showed that it significantly decreased IPFD, fatty acid uptake, and blood flow, and these improvements were associated with more favorable glucose homeostasis and beta-cell function.

However, bariatric surgery is only appropriate for certain patients; is associated with potentially adverse sequelae including malnutrition, anemia, and digestive tract stenosis; and is currently not indicated for FPD.

Bilal advises clinicians to “keep an eye on FPD” if it’s detected incidentally and to screen patients more carefully for MASLD, metabolic disease, and diabetes.

“Although there are no consensus guidelines and recommendations for managing FPD at present, these common-sense approaches will benefit the patient’s overall health and hopefully will have a beneficial impact on pancreatic health as well,” he said.

Petrov reported no relevant financial relationships. Bilal reported being a consultant for Boston Scientific, Steris Endoscopy, and Cook Medical.

A version of this article first appeared on Medscape.com.

The most common pathology affecting the pancreas is excess intra-pancreatic fat deposition (IPFD), often called fatty pancreas disease (FPD) — a disorder experienced by roughly one fifth of the world’s population. Although it is more common than type 2 diabetes, pancreatitis, and pancreatic cancer combined, it has remained relatively obscure.

By contrast, fatty liver — once called nonalcoholic fatty liver disease and recently renamed metabolic dysfunction–associated steatotic liver disease (MASLD) — is well-known.

“When it comes to diseases of the liver and pancreas, the liver is the big brother that has gotten all the attention, while the pancreas is the neglected little stepbrother that’s not sufficiently profiled in most medical textbooks and gets very little attention,” Max Petrov, MD, MPH, PhD, professor of pancreatology, University of Auckland, New Zealand, said in an interview. “The phenomenon of fatty pancreas has been observed for decades, but it is underappreciated and underrecognized.”

 

As early as 1926, fat depositions were identified during autopsies, but the condition remained relatively unknown, Mohammad Bilal, MD, associate professor of medicine-gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Fortunately, FPD has recently been receiving more focus.”

Generally, healthy individuals have small amounts of fat in their pancreas. IPFD is defined as “the diffuse presence of fat in the pancreas, measured on a continuous scale,” and FPD refers to IPFD above the upper limit of normal. While there is no clear consensus as to what the normal range is, studies suggest it’s a pancreatic fat content ranging from 1.8% to 10.4%.

FPD’s “most important implication is that it can be a precursor for more challenging and burdensome diseases of the pancreas,” Petrov said.

Fatty changes in the pancreas affect both its endocrine and exocrine systems. FPD is associated with type 2 diabetes, the most common disease of the endocrine pancreas, as well as pancreatitis and pancreatic cancer, the most common diseases of the exocrine pancreas. It’s also implicated in the development of carotid atherosclerosis, pancreatic fistula following surgery, and exocrine pancreatic insufficiency (EPI).

 

A ‘Pandora’s Box’

Up to half of people with fatty pancreas are lean. The condition isn’t merely caused by an overflow of fat from the liver into the pancreas in people who consume more calories than they burn, Petrov said. Neither robust postmortem nor biopsy studies have found a statistically significant association between fatty deposition in the pancreas and liver fat.

Compared with the way people accumulate liver fat, the development of FPD is more complex, Petrov said.

“Hepatic fat is a relatively simple process: Lipid droplets accumulate in the hepatocytes; but, in the pancreas, there are several ways by which fat may accumulate,” he said.

One relates to the location of the pancreas within visceral, retroperitoneal fat, Petrov said. That fat can migrate and build up between pancreatic lobules.

Fat also can accumulate inside the lobes. This process can involve a buildup of fat droplets in acinar and stellate cells on the exocrine side and in the islets of Langerhans on the endocrine side. Additionally, when functional pancreatic cells die, particularly acinar cells, adult stem cells may replace them with adipocytes. Transformation of acinar cells into fat cells — a process called acinar-to-adipocyte transdifferentiation — also may be a way fat accumulates inside the lobes, Petrov said.

The accumulation of fat is a response to a wide array of insults to the pancreas over time. For example, obesity and metabolic syndrome lead to the accumulation of adipocytes and fat infiltration, whereas alcohol abuse and viral infections may lead to the death of acinar cells, which produce digestive enzymes.

Ultimately, the negative changes produced by excess fat in the pancreas are the origin of all common noninherited pancreatic diseases, bringing them under one umbrella, Petrov maintained. He dubbed this hypothesis PANcreatic Diseases Originating from intRapancreatic fAt (PANDORA).

The type of cells involved has implications for which disease may arise. For example, fat infiltration in stellate cells may promote pancreatic cancer, whereas its accumulation in the islets of Langerhans, which produce insulin and glucagon, is associated with type 2 diabetes.

The PANDORA hypothesis has eight foundational principles:

• Fatty pancreas is a key driver of pancreatic diseases in most people.
• Inflammation within the pancreatic microenvironment results from overwhelming lipotoxicity fueled by fatty pancreas.
• Aberrant communication between acinar cells involving lipid droplets drives acute pancreatitis.
• The pancreas responds to lipotoxicity with fibrosis and calcification — the hallmarks of chronic pancreatitis.
• Fat deposition affects signaling between stellate cells and other components of the microenvironment in ways that raise the risk for pancreatic cancer.
• The development of diabetes of the exocrine pancreas and EPI is affected by the presence of fatty pancreas.
• The higher risk for pancreatic disease in older adults is influenced by fatty pancreas.
• The multipronged nature of intrapancreatic fat deposition accounts for the common development of one pancreatic disease after another.

The idea that all common pancreatic diseases are the result of pathways emanating from FPD could “explain the bidirectional relationship between diabetes and pancreatitis or pancreatic cancer,” Petrov said.

 

Risk Factors, Symptoms, and Diagnosis

A variety of risk factors are involved in the accumulation of fat that may lead to pancreatic diseases, including aging, cholelithiasis, dyslipidemia, drugs/toxins (eg, steroids), genetic predisposition, iron overload, diet (eg, fatty foods, ultraprocessed foods), heavy alcohol use, overweight/obesity, pancreatic duct obstruction, tobacco use, viral infection (eg, hepatitis B, COVID-19), severe malnutrition, prediabetes, and dysglycemia.

Petrov described FPD as a “silent disease” that’s often asymptomatic, with its presence emerging as an incidental finding during abdominal ultrasonography for other reasons. However, patients may sometimes experience stomach pain or nausea if they have concurrent diseases of the pancreas, he said.

There are no currently available lab tests that can definitively detect the presence of FPD. Rather, the gold standard for a noninvasive diagnosis of FPD is MRI, with CT as the second-best choice, Petrov said.

In countries where advanced imaging is not available, a low-cost alternative might be a simple abdominal ultrasound, but it is not definitive, he said. “It’s operator-dependent and can be subjective.”

Some risk factors, such as derangements of glucose and lipid metabolism, especially in the presence of heavy alcohol use and a high-fat diet, can “be detected on lab tests,” Petrov said. “This, in combination with the abdominal ultrasound, might suggest the patients will benefit from deeper investigation, including MRI.”

Because the exocrine pancreas helps with digestion of fatty food, intralobular fatty deposits or replacement of pancreatic exocrine cells with adipose cells can lead to steatorrhea, Bilal said.

“Fat within the stool or oily diarrhea is a clue to the presence of FPD,” Bilal said.

Although this symptom isn’t unique to FPD and is found in other types of pancreatic conditions, its presence suggests that further investigation for FPD is warranted, he added.

 

Common-Sense Treatment Approaches

At present, there are no US Food and Drug Administration–approved treatments for FPD, Petrov said.

“What might be recommended is something along the lines of treatment of MASLD — appropriate diet and physical activity,” he said. Petrov hopes that as the disease entity garners more research attention, more clinical drug trials will be initiated, and new medications are found and approved.

Petrov suggested that there could be a “theoretical rationale” for the use of glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as a treatment, given their effectiveness in multiple conditions, including MASLD, but no human trials have robustly shown specific benefits of these drugs for FPD.

Petrov added that, to date, 12 classes of drugs have been investigated for reducing IPFD: biguanides, sulfonylureas, GLP-1 RAs, thiazolidinediones, dipeptidyl peptidase–4 (DPP-4) inhibitors, sodium-glucose cotransporter 2 inhibitors, statins, fibrates, pancreatic lipase inhibitors, angiotensin II receptor blockers, somatostatin receptor agonists, and antioxidants.

Of these, most have shown promise in preclinical animal models. But only thiazolidinediones, GLP-1 RAs, DPP-4 inhibitors, and somatostatin receptor agonists have been investigated in randomized controlled trials in humans. The findings have been inconsistent, with the active treatment often not achieving statistically significant improvements.

“At this stage of our knowledge, we can’t recommend a specific pharmacotherapy,” Petrov said. But we can suggest dietary changes, such as saturated fat reduction, alcohol reduction, smoking cessation, reduction in consumption of ultraprocessed food, physical exercise, and addressing obesity and other drivers of metabolic disease.

Bilal, who is also a spokesperson for AGA, suggested that pancreatic enzyme replacement therapy, often used to treat pancreatic EPI, may treat some symptoms of FPD such as diarrhea.

Bariatric surgery has shown promise for FPD, in that it can decrease the patient’s body mass and potentially reduce the fat in the pancreas as well as it can improve metabolic diseases and hyperlipidemia. One study showed that it significantly decreased IPFD, fatty acid uptake, and blood flow, and these improvements were associated with more favorable glucose homeostasis and beta-cell function.

However, bariatric surgery is only appropriate for certain patients; is associated with potentially adverse sequelae including malnutrition, anemia, and digestive tract stenosis; and is currently not indicated for FPD.

Bilal advises clinicians to “keep an eye on FPD” if it’s detected incidentally and to screen patients more carefully for MASLD, metabolic disease, and diabetes.

“Although there are no consensus guidelines and recommendations for managing FPD at present, these common-sense approaches will benefit the patient’s overall health and hopefully will have a beneficial impact on pancreatic health as well,” he said.

Petrov reported no relevant financial relationships. Bilal reported being a consultant for Boston Scientific, Steris Endoscopy, and Cook Medical.

A version of this article first appeared on Medscape.com.

Despite universal hepatitis C virus (HCV) screening recommendations issued in 2020, HCV screening rates remain suboptimal among US women, a new analysis showed. 

“We found that screening rates were higher and rose more steeply in pregnant individuals compared to nonpregnant reproductive age females after this guidance.” However overall, HCV screening in women still remained low by the end of 2022, authors Roshni Singh, MD, and Rachel Epstein, MD, MSc, with the section of infectious diseases, Boston Medical Center, noted in an email to this news organization.

The study was published online in JAMA.

The researchers leveraged TriNetX LIVE electronic health record data to compare HCV screening rates from 68 US healthcare organizations covering more than 115 million patients.

Using a multiple-group interrupted time series analysis, they compared HCV screening rates for pregnant and nonpregnant women for each 6-month period before (January 2014 to December 2019) and after (July 2020 to December 2022) the 2020 guidelines. January to June 2020 was considered a washout period to account for the COVID-19 pandemic peak and guideline dissemination.

For the entire 9-year study period (2014-2022), a total of 79,231 incident HCV tests occurred among pregnant women and 678,951 occurred among nonpregnant women. 

In the 6 months before the guidance, HCV screening per 1000 person-years increased from 52 to 117 tests among pregnant women and 16 to 24 tests among nonpregnant women.

In the 6 months after the guidance, screening per 1000 person-years increased from 141 to 253 among pregnant women and from 29 to 37 among nonpregnant women.

Yet by the end of 2022, only 38.7% of women with a pregnancy and 8.7% of nonpregnant women were ever tested for the HCV.

 

How to Boost HCV Screening

These results suggest that “innovative strategies are needed to improve HCV diagnosis and treatment,” the authors wrote. 

“Several interventions have been demonstrated to be effective in increasing screening in general, including electronic medical record alerts for opt-out testing, routine test offer by nonclinician office staff, offering testing in nontraditional spaces, including substance use treatment programs, harm reduction centers, STI clinics, and mobile health units,” Singh and Epstein told this news organization.

“A key step is educating primary care providers in addition to addiction medicine and emergency medicine clinicians about the updated guidelines as they interface with a large number of at-risk individuals,” they said. And the most important measure is creating clear work flows that respond to positive results to link people to treatment and cure. 

“Clinicians need to feel empowered that their work screening a patient can make a meaningful difference in both the patient’s life and in helping end this epidemic,” the two researchers explained. 

Aaron Glatt, MD, a spokesperson for the Infectious Diseases Society of America, who wasn’t involved in the study, told this news organization that the low HCV screening rates are not surprising. 

“We tend not to do well with screening. It’s not necessarily anybody’s fault, but patients don’t necessarily want to be screened. Sometimes physicians are very busy. Sometimes screening is not the most important thing for them to do. Sometimes there are processes in place that fall through,” said Glatt, chief of infectious diseases and hospital epidemiologist at Mount Sinai South Nassau, Oceanside, New York. 

“We tend to do a better job of screening in pregnant than nonpregnant women because pregnancy is a focus and there is 9 months that you can be following-up, so there is more opportunity. A healthy nonpregnant woman may not see her doctor for another year,” Glatt noted. 

“I think that many physicians are very good at screening for hepatitis C in patients that are clearly at risk,” he added. “We’re not so good at screening for people” that don’t have a clear risk but do “have risk factors.”

The study had no commercial funding. Singh, Epstein, and Glatt had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Despite universal hepatitis C virus (HCV) screening recommendations issued in 2020, HCV screening rates remain suboptimal among US women, a new analysis showed. 

“We found that screening rates were higher and rose more steeply in pregnant individuals compared to nonpregnant reproductive age females after this guidance.” However overall, HCV screening in women still remained low by the end of 2022, authors Roshni Singh, MD, and Rachel Epstein, MD, MSc, with the section of infectious diseases, Boston Medical Center, noted in an email to this news organization.

The study was published online in JAMA.

The researchers leveraged TriNetX LIVE electronic health record data to compare HCV screening rates from 68 US healthcare organizations covering more than 115 million patients.

Using a multiple-group interrupted time series analysis, they compared HCV screening rates for pregnant and nonpregnant women for each 6-month period before (January 2014 to December 2019) and after (July 2020 to December 2022) the 2020 guidelines. January to June 2020 was considered a washout period to account for the COVID-19 pandemic peak and guideline dissemination.

For the entire 9-year study period (2014-2022), a total of 79,231 incident HCV tests occurred among pregnant women and 678,951 occurred among nonpregnant women. 

In the 6 months before the guidance, HCV screening per 1000 person-years increased from 52 to 117 tests among pregnant women and 16 to 24 tests among nonpregnant women.

In the 6 months after the guidance, screening per 1000 person-years increased from 141 to 253 among pregnant women and from 29 to 37 among nonpregnant women.

Yet by the end of 2022, only 38.7% of women with a pregnancy and 8.7% of nonpregnant women were ever tested for the HCV.

 

How to Boost HCV Screening

These results suggest that “innovative strategies are needed to improve HCV diagnosis and treatment,” the authors wrote. 

“Several interventions have been demonstrated to be effective in increasing screening in general, including electronic medical record alerts for opt-out testing, routine test offer by nonclinician office staff, offering testing in nontraditional spaces, including substance use treatment programs, harm reduction centers, STI clinics, and mobile health units,” Singh and Epstein told this news organization.

“A key step is educating primary care providers in addition to addiction medicine and emergency medicine clinicians about the updated guidelines as they interface with a large number of at-risk individuals,” they said. And the most important measure is creating clear work flows that respond to positive results to link people to treatment and cure. 

“Clinicians need to feel empowered that their work screening a patient can make a meaningful difference in both the patient’s life and in helping end this epidemic,” the two researchers explained. 

Aaron Glatt, MD, a spokesperson for the Infectious Diseases Society of America, who wasn’t involved in the study, told this news organization that the low HCV screening rates are not surprising. 

“We tend not to do well with screening. It’s not necessarily anybody’s fault, but patients don’t necessarily want to be screened. Sometimes physicians are very busy. Sometimes screening is not the most important thing for them to do. Sometimes there are processes in place that fall through,” said Glatt, chief of infectious diseases and hospital epidemiologist at Mount Sinai South Nassau, Oceanside, New York. 

“We tend to do a better job of screening in pregnant than nonpregnant women because pregnancy is a focus and there is 9 months that you can be following-up, so there is more opportunity. A healthy nonpregnant woman may not see her doctor for another year,” Glatt noted. 

“I think that many physicians are very good at screening for hepatitis C in patients that are clearly at risk,” he added. “We’re not so good at screening for people” that don’t have a clear risk but do “have risk factors.”

The study had no commercial funding. Singh, Epstein, and Glatt had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Despite universal hepatitis C virus (HCV) screening recommendations issued in 2020, HCV screening rates remain suboptimal among US women, a new analysis showed. 

“We found that screening rates were higher and rose more steeply in pregnant individuals compared to nonpregnant reproductive age females after this guidance.” However overall, HCV screening in women still remained low by the end of 2022, authors Roshni Singh, MD, and Rachel Epstein, MD, MSc, with the section of infectious diseases, Boston Medical Center, noted in an email to this news organization.

The study was published online in JAMA.

The researchers leveraged TriNetX LIVE electronic health record data to compare HCV screening rates from 68 US healthcare organizations covering more than 115 million patients.

Using a multiple-group interrupted time series analysis, they compared HCV screening rates for pregnant and nonpregnant women for each 6-month period before (January 2014 to December 2019) and after (July 2020 to December 2022) the 2020 guidelines. January to June 2020 was considered a washout period to account for the COVID-19 pandemic peak and guideline dissemination.

For the entire 9-year study period (2014-2022), a total of 79,231 incident HCV tests occurred among pregnant women and 678,951 occurred among nonpregnant women. 

In the 6 months before the guidance, HCV screening per 1000 person-years increased from 52 to 117 tests among pregnant women and 16 to 24 tests among nonpregnant women.

In the 6 months after the guidance, screening per 1000 person-years increased from 141 to 253 among pregnant women and from 29 to 37 among nonpregnant women.

Yet by the end of 2022, only 38.7% of women with a pregnancy and 8.7% of nonpregnant women were ever tested for the HCV.

 

How to Boost HCV Screening

These results suggest that “innovative strategies are needed to improve HCV diagnosis and treatment,” the authors wrote. 

“Several interventions have been demonstrated to be effective in increasing screening in general, including electronic medical record alerts for opt-out testing, routine test offer by nonclinician office staff, offering testing in nontraditional spaces, including substance use treatment programs, harm reduction centers, STI clinics, and mobile health units,” Singh and Epstein told this news organization.

“A key step is educating primary care providers in addition to addiction medicine and emergency medicine clinicians about the updated guidelines as they interface with a large number of at-risk individuals,” they said. And the most important measure is creating clear work flows that respond to positive results to link people to treatment and cure. 

“Clinicians need to feel empowered that their work screening a patient can make a meaningful difference in both the patient’s life and in helping end this epidemic,” the two researchers explained. 

Aaron Glatt, MD, a spokesperson for the Infectious Diseases Society of America, who wasn’t involved in the study, told this news organization that the low HCV screening rates are not surprising. 

“We tend not to do well with screening. It’s not necessarily anybody’s fault, but patients don’t necessarily want to be screened. Sometimes physicians are very busy. Sometimes screening is not the most important thing for them to do. Sometimes there are processes in place that fall through,” said Glatt, chief of infectious diseases and hospital epidemiologist at Mount Sinai South Nassau, Oceanside, New York. 

“We tend to do a better job of screening in pregnant than nonpregnant women because pregnancy is a focus and there is 9 months that you can be following-up, so there is more opportunity. A healthy nonpregnant woman may not see her doctor for another year,” Glatt noted. 

“I think that many physicians are very good at screening for hepatitis C in patients that are clearly at risk,” he added. “We’re not so good at screening for people” that don’t have a clear risk but do “have risk factors.”

The study had no commercial funding. Singh, Epstein, and Glatt had no relevant disclosures.

A version of this article first appeared on Medscape.com.

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with retained gastric contents and aborted procedures among patients undergoing upper endoscopy, according to a meta-analysis of more than 80,000 patients.

Safety profiles, however, were comparable across groups, suggesting that prolonged fasting may be a sufficient management strategy, instead of withholding GLP-1RAs, lead author Antonio Facciorusso, MD, PhD, of the University of Foggia, Italy, and colleagues reported.

“The impact of GLP-1RAs on slowing gastric motility has raised concerns in patients undergoing endoscopic procedures, particularly upper endoscopies,” the investigators wrote in Clinical Gastroenterology and Hepatology. “This is due to the perceived risk of aspiration of retained gastric contents in sedated patients and the decreased visibility of the gastric mucosa, which can reduce the diagnostic yield of the examination.”

The American Society of Anesthesiologists (ASA) recommends withholding GLP-1RAs before procedures or surgery, whereas AGA suggests an individualized approach, citing limited supporting data. 

A previous meta-analysis reported that GLP-1RAs mildly delayed gastric emptying, but clinical relevance remained unclear. 

The present meta-analysis aimed to clarify this uncertainty by analyzing 13 retrospective studies that involved 84,065 patients undergoing upper endoscopy. Outcomes were compared among GLP-1RA users vs non-users, including rates of retained gastric contents, aborted procedures, and adverse events. 

Patients on GLP-1RAs had significantly higher rates of retained gastric contents than non-users (odds ratio [OR], 5.56), a finding that held steady (OR, 4.20) after adjusting for age, sex, diabetes, body mass index, and other therapies. 

GLP-1RAs were also associated with an increased likelihood of aborted procedures (OR, 5.13; 1% vs. 0.3%) and a higher need for repeat endoscopies (OR, 2.19; 1% vs 2%); however, Facciorusso and colleagues noted that these events, in absolute terms, were relatively uncommon.

“The rate of aborted and repeat procedures in the included studies was low,” the investigators wrote. “This meant that only for every 110 patients undergoing upper endoscopy while in GLP-1RA therapy would we observe an aborted procedure and only for every 120 patients would we need to repeat the procedure.”

The overall safety profile of GLP-1RAs in the context of upper endoscopy remained largely reassuring, they added. Specifically, rates of bronchial aspiration were not significantly different between users and non-users. What’s more, no single study reported a statistically significant increase in major complications, including pulmonary adverse events, among GLP-1RA users. 

According to Facciorusso and colleagues, these findings suggest that retained gastric contents do not appear to substantially heighten the risk of serious harm, though further prospective studies are needed.

“Our comprehensive analysis indicates that, while the use of GLP-1RA results in higher rates of [retained gastric contents], the actual clinical impact appears to be limited,” they wrote. “Therefore, there is no strong evidence to support the routine discontinuation of the drug before upper endoscopy procedures.”

Instead, they supported the AGA task force’s recommendation for an individualized approach, and not withholding GLP-1RAs unnecessarily, calling this “the best compromise.”

“Prolonging the duration of fasting for solids could represent the optimal approach in these patients, although this strategy requires further evaluation,” the investigators concluded.

The investigators disclosed no conflicts of interest.







 

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with retained gastric contents and aborted procedures among patients undergoing upper endoscopy, according to a meta-analysis of more than 80,000 patients.

Safety profiles, however, were comparable across groups, suggesting that prolonged fasting may be a sufficient management strategy, instead of withholding GLP-1RAs, lead author Antonio Facciorusso, MD, PhD, of the University of Foggia, Italy, and colleagues reported.

“The impact of GLP-1RAs on slowing gastric motility has raised concerns in patients undergoing endoscopic procedures, particularly upper endoscopies,” the investigators wrote in Clinical Gastroenterology and Hepatology. “This is due to the perceived risk of aspiration of retained gastric contents in sedated patients and the decreased visibility of the gastric mucosa, which can reduce the diagnostic yield of the examination.”

The American Society of Anesthesiologists (ASA) recommends withholding GLP-1RAs before procedures or surgery, whereas AGA suggests an individualized approach, citing limited supporting data. 

A previous meta-analysis reported that GLP-1RAs mildly delayed gastric emptying, but clinical relevance remained unclear. 

The present meta-analysis aimed to clarify this uncertainty by analyzing 13 retrospective studies that involved 84,065 patients undergoing upper endoscopy. Outcomes were compared among GLP-1RA users vs non-users, including rates of retained gastric contents, aborted procedures, and adverse events. 

Patients on GLP-1RAs had significantly higher rates of retained gastric contents than non-users (odds ratio [OR], 5.56), a finding that held steady (OR, 4.20) after adjusting for age, sex, diabetes, body mass index, and other therapies. 

GLP-1RAs were also associated with an increased likelihood of aborted procedures (OR, 5.13; 1% vs. 0.3%) and a higher need for repeat endoscopies (OR, 2.19; 1% vs 2%); however, Facciorusso and colleagues noted that these events, in absolute terms, were relatively uncommon.

“The rate of aborted and repeat procedures in the included studies was low,” the investigators wrote. “This meant that only for every 110 patients undergoing upper endoscopy while in GLP-1RA therapy would we observe an aborted procedure and only for every 120 patients would we need to repeat the procedure.”

The overall safety profile of GLP-1RAs in the context of upper endoscopy remained largely reassuring, they added. Specifically, rates of bronchial aspiration were not significantly different between users and non-users. What’s more, no single study reported a statistically significant increase in major complications, including pulmonary adverse events, among GLP-1RA users. 

According to Facciorusso and colleagues, these findings suggest that retained gastric contents do not appear to substantially heighten the risk of serious harm, though further prospective studies are needed.

“Our comprehensive analysis indicates that, while the use of GLP-1RA results in higher rates of [retained gastric contents], the actual clinical impact appears to be limited,” they wrote. “Therefore, there is no strong evidence to support the routine discontinuation of the drug before upper endoscopy procedures.”

Instead, they supported the AGA task force’s recommendation for an individualized approach, and not withholding GLP-1RAs unnecessarily, calling this “the best compromise.”

“Prolonging the duration of fasting for solids could represent the optimal approach in these patients, although this strategy requires further evaluation,” the investigators concluded.

The investigators disclosed no conflicts of interest.







 

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are associated with retained gastric contents and aborted procedures among patients undergoing upper endoscopy, according to a meta-analysis of more than 80,000 patients.

Safety profiles, however, were comparable across groups, suggesting that prolonged fasting may be a sufficient management strategy, instead of withholding GLP-1RAs, lead author Antonio Facciorusso, MD, PhD, of the University of Foggia, Italy, and colleagues reported.

“The impact of GLP-1RAs on slowing gastric motility has raised concerns in patients undergoing endoscopic procedures, particularly upper endoscopies,” the investigators wrote in Clinical Gastroenterology and Hepatology. “This is due to the perceived risk of aspiration of retained gastric contents in sedated patients and the decreased visibility of the gastric mucosa, which can reduce the diagnostic yield of the examination.”

The American Society of Anesthesiologists (ASA) recommends withholding GLP-1RAs before procedures or surgery, whereas AGA suggests an individualized approach, citing limited supporting data. 

A previous meta-analysis reported that GLP-1RAs mildly delayed gastric emptying, but clinical relevance remained unclear. 

The present meta-analysis aimed to clarify this uncertainty by analyzing 13 retrospective studies that involved 84,065 patients undergoing upper endoscopy. Outcomes were compared among GLP-1RA users vs non-users, including rates of retained gastric contents, aborted procedures, and adverse events. 

Patients on GLP-1RAs had significantly higher rates of retained gastric contents than non-users (odds ratio [OR], 5.56), a finding that held steady (OR, 4.20) after adjusting for age, sex, diabetes, body mass index, and other therapies. 

GLP-1RAs were also associated with an increased likelihood of aborted procedures (OR, 5.13; 1% vs. 0.3%) and a higher need for repeat endoscopies (OR, 2.19; 1% vs 2%); however, Facciorusso and colleagues noted that these events, in absolute terms, were relatively uncommon.

“The rate of aborted and repeat procedures in the included studies was low,” the investigators wrote. “This meant that only for every 110 patients undergoing upper endoscopy while in GLP-1RA therapy would we observe an aborted procedure and only for every 120 patients would we need to repeat the procedure.”

The overall safety profile of GLP-1RAs in the context of upper endoscopy remained largely reassuring, they added. Specifically, rates of bronchial aspiration were not significantly different between users and non-users. What’s more, no single study reported a statistically significant increase in major complications, including pulmonary adverse events, among GLP-1RA users. 

According to Facciorusso and colleagues, these findings suggest that retained gastric contents do not appear to substantially heighten the risk of serious harm, though further prospective studies are needed.

“Our comprehensive analysis indicates that, while the use of GLP-1RA results in higher rates of [retained gastric contents], the actual clinical impact appears to be limited,” they wrote. “Therefore, there is no strong evidence to support the routine discontinuation of the drug before upper endoscopy procedures.”

Instead, they supported the AGA task force’s recommendation for an individualized approach, and not withholding GLP-1RAs unnecessarily, calling this “the best compromise.”

“Prolonging the duration of fasting for solids could represent the optimal approach in these patients, although this strategy requires further evaluation,” the investigators concluded.

The investigators disclosed no conflicts of interest.