TBD Meeting (3042-18)

For the pancreatobiliary session, Michelle Ann Anderson, MD, of the University of Michigan, Ann Arbor, reminded us about appropriate patient selection given the risk of pancreatitis after endoscopic retrograde cholangiopancreatography pancreatitis, also known as post-ERCP pancreatitis. Strategies to prevent post-ERCP pancreatitis include using pancreatic duct stents and using wire rather than contrast for cannulation. She recommended rectal indomethacin for all patients. Because of encouraging data, she recommended 2-3 L of lactated Ringer’s solution during the procedure and recovery. 

Katie Morgan, MD, from the Medical University of South Carolina, Charleston, reviewed her group’s experience with 195 total pancreatectomies with islet autotransplants for chronic pancreatitis. Quality of life improved with major reductions in narcotic use, and 25% of patients were insulin free. 

Bret Petersen, MD, of Mayo Clinic, Rochester, Minn., discussed multidrug resistant infection in ERCP endoscopes. He reminded us of the risk of lapses in endoscope reprocessing steps and the need for monitoring. He commented on recent Food and Drug Administration’s culture guidance and new technologies in development. 

James Scheiman, MD, from the University of Virginia, Charlottesville, discussed pancreatic cysts. He reviewed the controversy between the more conservative American Gastroenterological Association guidelines and the more aggressive International Consensus guidelines. He advised considering patient preferences with a multidisciplinary approach.
For the liver session, Guadalupe García-Tsao, MD, of Yale University, New Haven, Conn., discussed the controversy regarding nonselective beta-blockers. She advised caution if refractory ascites are present because of risk for renal dysfunction, but she also highlighted the benefits including reduced first and recurrent variceal hemorrhage. 

Rohit Loomba, MD, from the University of California at San Diego addressed fibrosis assessments in fatty liver. In his algorithm, patients with low Nonalcoholic Fatty Liver Disease Fibrosis Score or Fibrosis-4 scores would have continued observation, while patients with medium or high scores would undergo transient elastography or magnetic resonance elastography. 

Patrick Northup, MD, from the University of Virginia discussed anticoagulation for portal vein thrombosis. He also discussed consideration of transjugular intrahepatic portosystemic shunt if there are high-risk varices. Duration of anticoagulation is controversial, but this strategy may prevent decompensation and affect transplant outcomes. 

Daryl Lau, MD, MSc, MPH, from Harvard Medical School, Boston, reviewed the hepatitis B virus therapy controversy for e-antigen–negative patients with prolonged viral suppression. She recommended caution in general and emphasized that stage 3-4 fibrosis patients should not discontinue therapy. 

The final talk was my review of hepatitis C virus treatment. I emphasized that pretreatment fibrosis assessments are critical given continued risk of hepatocellular carcinoma after cure. Challenges include identifying the remaining patients and supporting them through treatment. HCV therapies demonstrate what is possible when breakthroughs are translated to clinical care, and I was honored to participate in this course that highlighted many advances in our field.

Dr. Muir is a professor of medicine, director of gastroenterology & hepatology research at Duke Clinical Research Institute, and chief of the division of gastroenterology in the department of medicine at Duke University, all in Durham, N.C. He has received research grants from and served on the advisory boards for AbbVie, Gilead Sciences, Merck, and several other pharmaceutical companies. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

For the pancreatobiliary session, Michelle Ann Anderson, MD, of the University of Michigan, Ann Arbor, reminded us about appropriate patient selection given the risk of pancreatitis after endoscopic retrograde cholangiopancreatography pancreatitis, also known as post-ERCP pancreatitis. Strategies to prevent post-ERCP pancreatitis include using pancreatic duct stents and using wire rather than contrast for cannulation. She recommended rectal indomethacin for all patients. Because of encouraging data, she recommended 2-3 L of lactated Ringer’s solution during the procedure and recovery. 

Katie Morgan, MD, from the Medical University of South Carolina, Charleston, reviewed her group’s experience with 195 total pancreatectomies with islet autotransplants for chronic pancreatitis. Quality of life improved with major reductions in narcotic use, and 25% of patients were insulin free. 

Bret Petersen, MD, of Mayo Clinic, Rochester, Minn., discussed multidrug resistant infection in ERCP endoscopes. He reminded us of the risk of lapses in endoscope reprocessing steps and the need for monitoring. He commented on recent Food and Drug Administration’s culture guidance and new technologies in development. 

James Scheiman, MD, from the University of Virginia, Charlottesville, discussed pancreatic cysts. He reviewed the controversy between the more conservative American Gastroenterological Association guidelines and the more aggressive International Consensus guidelines. He advised considering patient preferences with a multidisciplinary approach.
For the liver session, Guadalupe García-Tsao, MD, of Yale University, New Haven, Conn., discussed the controversy regarding nonselective beta-blockers. She advised caution if refractory ascites are present because of risk for renal dysfunction, but she also highlighted the benefits including reduced first and recurrent variceal hemorrhage. 

Rohit Loomba, MD, from the University of California at San Diego addressed fibrosis assessments in fatty liver. In his algorithm, patients with low Nonalcoholic Fatty Liver Disease Fibrosis Score or Fibrosis-4 scores would have continued observation, while patients with medium or high scores would undergo transient elastography or magnetic resonance elastography. 

Patrick Northup, MD, from the University of Virginia discussed anticoagulation for portal vein thrombosis. He also discussed consideration of transjugular intrahepatic portosystemic shunt if there are high-risk varices. Duration of anticoagulation is controversial, but this strategy may prevent decompensation and affect transplant outcomes. 

Daryl Lau, MD, MSc, MPH, from Harvard Medical School, Boston, reviewed the hepatitis B virus therapy controversy for e-antigen–negative patients with prolonged viral suppression. She recommended caution in general and emphasized that stage 3-4 fibrosis patients should not discontinue therapy. 

The final talk was my review of hepatitis C virus treatment. I emphasized that pretreatment fibrosis assessments are critical given continued risk of hepatocellular carcinoma after cure. Challenges include identifying the remaining patients and supporting them through treatment. HCV therapies demonstrate what is possible when breakthroughs are translated to clinical care, and I was honored to participate in this course that highlighted many advances in our field.

Dr. Muir is a professor of medicine, director of gastroenterology & hepatology research at Duke Clinical Research Institute, and chief of the division of gastroenterology in the department of medicine at Duke University, all in Durham, N.C. He has received research grants from and served on the advisory boards for AbbVie, Gilead Sciences, Merck, and several other pharmaceutical companies. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

For the pancreatobiliary session, Michelle Ann Anderson, MD, of the University of Michigan, Ann Arbor, reminded us about appropriate patient selection given the risk of pancreatitis after endoscopic retrograde cholangiopancreatography pancreatitis, also known as post-ERCP pancreatitis. Strategies to prevent post-ERCP pancreatitis include using pancreatic duct stents and using wire rather than contrast for cannulation. She recommended rectal indomethacin for all patients. Because of encouraging data, she recommended 2-3 L of lactated Ringer’s solution during the procedure and recovery. 

Katie Morgan, MD, from the Medical University of South Carolina, Charleston, reviewed her group’s experience with 195 total pancreatectomies with islet autotransplants for chronic pancreatitis. Quality of life improved with major reductions in narcotic use, and 25% of patients were insulin free. 

Bret Petersen, MD, of Mayo Clinic, Rochester, Minn., discussed multidrug resistant infection in ERCP endoscopes. He reminded us of the risk of lapses in endoscope reprocessing steps and the need for monitoring. He commented on recent Food and Drug Administration’s culture guidance and new technologies in development. 

James Scheiman, MD, from the University of Virginia, Charlottesville, discussed pancreatic cysts. He reviewed the controversy between the more conservative American Gastroenterological Association guidelines and the more aggressive International Consensus guidelines. He advised considering patient preferences with a multidisciplinary approach.
For the liver session, Guadalupe García-Tsao, MD, of Yale University, New Haven, Conn., discussed the controversy regarding nonselective beta-blockers. She advised caution if refractory ascites are present because of risk for renal dysfunction, but she also highlighted the benefits including reduced first and recurrent variceal hemorrhage. 

Rohit Loomba, MD, from the University of California at San Diego addressed fibrosis assessments in fatty liver. In his algorithm, patients with low Nonalcoholic Fatty Liver Disease Fibrosis Score or Fibrosis-4 scores would have continued observation, while patients with medium or high scores would undergo transient elastography or magnetic resonance elastography. 

Patrick Northup, MD, from the University of Virginia discussed anticoagulation for portal vein thrombosis. He also discussed consideration of transjugular intrahepatic portosystemic shunt if there are high-risk varices. Duration of anticoagulation is controversial, but this strategy may prevent decompensation and affect transplant outcomes. 

Daryl Lau, MD, MSc, MPH, from Harvard Medical School, Boston, reviewed the hepatitis B virus therapy controversy for e-antigen–negative patients with prolonged viral suppression. She recommended caution in general and emphasized that stage 3-4 fibrosis patients should not discontinue therapy. 

The final talk was my review of hepatitis C virus treatment. I emphasized that pretreatment fibrosis assessments are critical given continued risk of hepatocellular carcinoma after cure. Challenges include identifying the remaining patients and supporting them through treatment. HCV therapies demonstrate what is possible when breakthroughs are translated to clinical care, and I was honored to participate in this course that highlighted many advances in our field.

Dr. Muir is a professor of medicine, director of gastroenterology & hepatology research at Duke Clinical Research Institute, and chief of the division of gastroenterology in the department of medicine at Duke University, all in Durham, N.C. He has received research grants from and served on the advisory boards for AbbVie, Gilead Sciences, Merck, and several other pharmaceutical companies. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.

Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.

Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

The inflammatory bowel disease (IBD) session covered optimal ways to initiate treatment for ulcerative colitis and Crohn’s disease, when and how to discontinue some of those treatments, and the use of biosimilars as substitutes for biologic therapies. Finally, suggestions were provided regarding the often-challenging identification of irritable bowel complaints in patients with IBD.

Dr. Weinberg is chairman of the department of medicine, Fox Chase Cancer Center, Philadelphia. This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2018.

A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.

Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017^®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.

Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.

Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.

Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
 

Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.

Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017^®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.

Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.

Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.

Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
 

Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.

Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017^®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.

Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.

Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.

Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
 

Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

K. Rajender Reddy, MD, discussed the management of hepatitis B virus reactivation (HBVr), which can occur in the setting of treatment with immunosuppressive or direct-acting antiviral agents, HIV, or organ transplant. He discussed the mechanisms by which HBVr occurs despite serologic evidence of viral clearance, and he reviewed the American Gastroenterological Association Institute’s 2015 Clinical Decision Support Tool on managing HBVr. In patients treated with anti-TNF therapy, HBVr was seen almost exclusively in HBsAg+ patients and not HBsAg–/anti-HBc+ patients. Data supports HBV screening prior to starting anti–tumor necrosis factor therapy and prophylactic antiviral therapy for HBsAg-positive patients, Dr. Reddy explained.

Allison R. Schulman, MD, MPH then discussed endoscopic bariatric therapy for obesity. When he spoke about gastric interventions, he said that, although space-occupying devices have been shown to reduce weight and resolve comorbidities, they are more likely to be removed early because of intolerance and can be associated with serious adverse events (in less than 0.1%). He also said that endoscopic sleeve gastroplasty has been associated with significant weight loss and a beneficial effect on comorbidities and aspiration therapy has been associated with a 20%-25% total body weight loss over 1-2 years. With regard to small-bowel interventions, Dr. Schulman discussed sleeves and liners, mucosal resurfacing therapy, anastomosis and enteral diversion, and flow-altering therapy, none of which are Food and Drug Administration–approved. Endoscopic bariatric therapy options of both types fill a gap between medications and surgery, Dr. Schulman concluded, and are reversible, repeatable, and cost-effective and can be used in combination.

Neil H. Stollman, MD, AGAF, reviewed the role of fecal microbial transplantation (FMT) in gastrointestinal disorders and the variety of ways in which FMT can be administered. One of its main uses is for recurrent Clostridium difficile infection (rCDI); this is the only indication for which the FDA will not require an investigational new drug permit. Dr. Stollman discussed current guidelines for FMT and said that systematic reviews have demonstrated that FMT has an overall cure rate of 85%-90% for rCDI with no or few adverse events. He recommended not resuming vancomycin after FMT and not retesting for rCDI unless the patient has suggestive symptoms. Currently, he noted, more than 180 clinical trials are studying the efficacy of FMT in other diseases, including inflammatory bowel disease, irritable bowel syndrome, and liver disease.

Fasiha Kanwal, MD, MSHS, AGAF, who is editor in chief of Clinical Gastroenterology and Hepatology, presented the top three clinical papers published in that journal or in the journal Gastroenterology. The first paper, titled “Chromoendoscopy for surveillance in ulcerative colitis and Crohn’s disease: A systematic review of randomized trials” (Clin Gastroenterol Hepatol. 2017 Nov;15[11]:1684-97), found that chromoendoscopy identifies more patients with dysplasia when compared with standard-definition, white-light endoscopy. There was no direct evidence, however, of an effect on all-cause or cancer-specific mortality.

The second paper, “Efficacy and safety of mycophenolate mofetil and tacrolimus as second-line therapy for patients with autoimmune hepatitis” (Clin Gastroenterol Hepatol. 2017 Dec;15[12]:1950-6), showed that both agents were generally well tolerated and that they were equally effective in patients who had responded completely to standard therapy but could not tolerate it. In nonresponders to standard therapy, tacrolimus was more effective.

Dr. Kanwal’s study entitled, “Risk of hepatocellular cancer in HCV patients treated with direct-acting antiviral agents” (Gastroenterology. 2017 Oct;153[4]:996-1005) was the third paper. This study found that sustained virologic response (SVR) resulted in a considerable reduction in the risk of HCC. However, the absolute risk of HCC was high in some patients who achieved sustained virologic response, including about 40% who had already progressed to cirrhosis, she said.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2018. Dr. Chang is the vice-chief of the Vatche and Tamar Manounkian division of digestive diseases, the program director of University of California, Los Angeles, GI fellowship program, the codirector of G. Oppenheimer Center for Neurobiology of Stress and Resilience, and a professor of medicine at UCLA. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

K. Rajender Reddy, MD, discussed the management of hepatitis B virus reactivation (HBVr), which can occur in the setting of treatment with immunosuppressive or direct-acting antiviral agents, HIV, or organ transplant. He discussed the mechanisms by which HBVr occurs despite serologic evidence of viral clearance, and he reviewed the American Gastroenterological Association Institute’s 2015 Clinical Decision Support Tool on managing HBVr. In patients treated with anti-TNF therapy, HBVr was seen almost exclusively in HBsAg+ patients and not HBsAg–/anti-HBc+ patients. Data supports HBV screening prior to starting anti–tumor necrosis factor therapy and prophylactic antiviral therapy for HBsAg-positive patients, Dr. Reddy explained.

Allison R. Schulman, MD, MPH then discussed endoscopic bariatric therapy for obesity. When he spoke about gastric interventions, he said that, although space-occupying devices have been shown to reduce weight and resolve comorbidities, they are more likely to be removed early because of intolerance and can be associated with serious adverse events (in less than 0.1%). He also said that endoscopic sleeve gastroplasty has been associated with significant weight loss and a beneficial effect on comorbidities and aspiration therapy has been associated with a 20%-25% total body weight loss over 1-2 years. With regard to small-bowel interventions, Dr. Schulman discussed sleeves and liners, mucosal resurfacing therapy, anastomosis and enteral diversion, and flow-altering therapy, none of which are Food and Drug Administration–approved. Endoscopic bariatric therapy options of both types fill a gap between medications and surgery, Dr. Schulman concluded, and are reversible, repeatable, and cost-effective and can be used in combination.

Neil H. Stollman, MD, AGAF, reviewed the role of fecal microbial transplantation (FMT) in gastrointestinal disorders and the variety of ways in which FMT can be administered. One of its main uses is for recurrent Clostridium difficile infection (rCDI); this is the only indication for which the FDA will not require an investigational new drug permit. Dr. Stollman discussed current guidelines for FMT and said that systematic reviews have demonstrated that FMT has an overall cure rate of 85%-90% for rCDI with no or few adverse events. He recommended not resuming vancomycin after FMT and not retesting for rCDI unless the patient has suggestive symptoms. Currently, he noted, more than 180 clinical trials are studying the efficacy of FMT in other diseases, including inflammatory bowel disease, irritable bowel syndrome, and liver disease.

Fasiha Kanwal, MD, MSHS, AGAF, who is editor in chief of Clinical Gastroenterology and Hepatology, presented the top three clinical papers published in that journal or in the journal Gastroenterology. The first paper, titled “Chromoendoscopy for surveillance in ulcerative colitis and Crohn’s disease: A systematic review of randomized trials” (Clin Gastroenterol Hepatol. 2017 Nov;15[11]:1684-97), found that chromoendoscopy identifies more patients with dysplasia when compared with standard-definition, white-light endoscopy. There was no direct evidence, however, of an effect on all-cause or cancer-specific mortality.

The second paper, “Efficacy and safety of mycophenolate mofetil and tacrolimus as second-line therapy for patients with autoimmune hepatitis” (Clin Gastroenterol Hepatol. 2017 Dec;15[12]:1950-6), showed that both agents were generally well tolerated and that they were equally effective in patients who had responded completely to standard therapy but could not tolerate it. In nonresponders to standard therapy, tacrolimus was more effective.

Dr. Kanwal’s study entitled, “Risk of hepatocellular cancer in HCV patients treated with direct-acting antiviral agents” (Gastroenterology. 2017 Oct;153[4]:996-1005) was the third paper. This study found that sustained virologic response (SVR) resulted in a considerable reduction in the risk of HCC. However, the absolute risk of HCC was high in some patients who achieved sustained virologic response, including about 40% who had already progressed to cirrhosis, she said.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2018. Dr. Chang is the vice-chief of the Vatche and Tamar Manounkian division of digestive diseases, the program director of University of California, Los Angeles, GI fellowship program, the codirector of G. Oppenheimer Center for Neurobiology of Stress and Resilience, and a professor of medicine at UCLA. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

K. Rajender Reddy, MD, discussed the management of hepatitis B virus reactivation (HBVr), which can occur in the setting of treatment with immunosuppressive or direct-acting antiviral agents, HIV, or organ transplant. He discussed the mechanisms by which HBVr occurs despite serologic evidence of viral clearance, and he reviewed the American Gastroenterological Association Institute’s 2015 Clinical Decision Support Tool on managing HBVr. In patients treated with anti-TNF therapy, HBVr was seen almost exclusively in HBsAg+ patients and not HBsAg–/anti-HBc+ patients. Data supports HBV screening prior to starting anti–tumor necrosis factor therapy and prophylactic antiviral therapy for HBsAg-positive patients, Dr. Reddy explained.

Allison R. Schulman, MD, MPH then discussed endoscopic bariatric therapy for obesity. When he spoke about gastric interventions, he said that, although space-occupying devices have been shown to reduce weight and resolve comorbidities, they are more likely to be removed early because of intolerance and can be associated with serious adverse events (in less than 0.1%). He also said that endoscopic sleeve gastroplasty has been associated with significant weight loss and a beneficial effect on comorbidities and aspiration therapy has been associated with a 20%-25% total body weight loss over 1-2 years. With regard to small-bowel interventions, Dr. Schulman discussed sleeves and liners, mucosal resurfacing therapy, anastomosis and enteral diversion, and flow-altering therapy, none of which are Food and Drug Administration–approved. Endoscopic bariatric therapy options of both types fill a gap between medications and surgery, Dr. Schulman concluded, and are reversible, repeatable, and cost-effective and can be used in combination.

Neil H. Stollman, MD, AGAF, reviewed the role of fecal microbial transplantation (FMT) in gastrointestinal disorders and the variety of ways in which FMT can be administered. One of its main uses is for recurrent Clostridium difficile infection (rCDI); this is the only indication for which the FDA will not require an investigational new drug permit. Dr. Stollman discussed current guidelines for FMT and said that systematic reviews have demonstrated that FMT has an overall cure rate of 85%-90% for rCDI with no or few adverse events. He recommended not resuming vancomycin after FMT and not retesting for rCDI unless the patient has suggestive symptoms. Currently, he noted, more than 180 clinical trials are studying the efficacy of FMT in other diseases, including inflammatory bowel disease, irritable bowel syndrome, and liver disease.

Fasiha Kanwal, MD, MSHS, AGAF, who is editor in chief of Clinical Gastroenterology and Hepatology, presented the top three clinical papers published in that journal or in the journal Gastroenterology. The first paper, titled “Chromoendoscopy for surveillance in ulcerative colitis and Crohn’s disease: A systematic review of randomized trials” (Clin Gastroenterol Hepatol. 2017 Nov;15[11]:1684-97), found that chromoendoscopy identifies more patients with dysplasia when compared with standard-definition, white-light endoscopy. There was no direct evidence, however, of an effect on all-cause or cancer-specific mortality.

The second paper, “Efficacy and safety of mycophenolate mofetil and tacrolimus as second-line therapy for patients with autoimmune hepatitis” (Clin Gastroenterol Hepatol. 2017 Dec;15[12]:1950-6), showed that both agents were generally well tolerated and that they were equally effective in patients who had responded completely to standard therapy but could not tolerate it. In nonresponders to standard therapy, tacrolimus was more effective.

Dr. Kanwal’s study entitled, “Risk of hepatocellular cancer in HCV patients treated with direct-acting antiviral agents” (Gastroenterology. 2017 Oct;153[4]:996-1005) was the third paper. This study found that sustained virologic response (SVR) resulted in a considerable reduction in the risk of HCC. However, the absolute risk of HCC was high in some patients who achieved sustained virologic response, including about 40% who had already progressed to cirrhosis, she said.
 

This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2018. Dr. Chang is the vice-chief of the Vatche and Tamar Manounkian division of digestive diseases, the program director of University of California, Los Angeles, GI fellowship program, the codirector of G. Oppenheimer Center for Neurobiology of Stress and Resilience, and a professor of medicine at UCLA. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

Rhonda Souza, MD, AGAF, started off this session with a review of eosinophilic esophagitis (EoE). She explained the challenges of the six-food elimination diet and described an alternative step-up elimination diet. In one study of the step-up elimination diet, food triggers were identified in 88% of patients during the reintroduction of food groups. Proton pump inhibitors are recommended for patients who do not respond to or refuse diet therapy; 30%-50% of patients with EoE will respond to the drugs. She explained that PPIs might have eosinophil-reducing effects independent of gastric acid–lowering effects, and said that PPIs should be stopped for 3-4 weeks before a diagnostic endoscopy is performed if EoE is suspected. Dr. Souza also spoke about topical steroids, biologic agents, and gradual esophageal dilation.

Ronnie Fass, MD, then addressed the management of patients with documented gastroesophageal reflux disease (GERD), or heartburn without documented GERD, who are unresponsive to PPIs. He referred to the management algorithm that he and Prakash Gyawali, MD, MRCP, published this year (Gastroenterology 2018;154:302-18), and described the optimization of PPI therapy before doubling the dose, as well as the testing that should be done if the dose increase does not relieve symptoms. Dr. Fass showed that there are various possible mechanisms for refractory GERD or heartburn, including weakly acidic or alkaline reflux, functional heartburn, and reflux hypersensitivity. He reviewed the Rome IV diagnostic criteria and treatment for the latter two conditions, and discussed the role of esophageal manometry to exclude esophageal motor disorders in patients with refractory GERD and heartburn.

Dr. Chang is vice-chief, Vatche and Tamar Manoukian division of digestive diseases, program director, UCLA GI fellowship program, codirector, G. Oppenheimer Center for Neurobiology of Stress and Resilience, and professor of medicine at the David Geffen School of Medicine at UCLA. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

Rhonda Souza, MD, AGAF, started off this session with a review of eosinophilic esophagitis (EoE). She explained the challenges of the six-food elimination diet and described an alternative step-up elimination diet. In one study of the step-up elimination diet, food triggers were identified in 88% of patients during the reintroduction of food groups. Proton pump inhibitors are recommended for patients who do not respond to or refuse diet therapy; 30%-50% of patients with EoE will respond to the drugs. She explained that PPIs might have eosinophil-reducing effects independent of gastric acid–lowering effects, and said that PPIs should be stopped for 3-4 weeks before a diagnostic endoscopy is performed if EoE is suspected. Dr. Souza also spoke about topical steroids, biologic agents, and gradual esophageal dilation.

Ronnie Fass, MD, then addressed the management of patients with documented gastroesophageal reflux disease (GERD), or heartburn without documented GERD, who are unresponsive to PPIs. He referred to the management algorithm that he and Prakash Gyawali, MD, MRCP, published this year (Gastroenterology 2018;154:302-18), and described the optimization of PPI therapy before doubling the dose, as well as the testing that should be done if the dose increase does not relieve symptoms. Dr. Fass showed that there are various possible mechanisms for refractory GERD or heartburn, including weakly acidic or alkaline reflux, functional heartburn, and reflux hypersensitivity. He reviewed the Rome IV diagnostic criteria and treatment for the latter two conditions, and discussed the role of esophageal manometry to exclude esophageal motor disorders in patients with refractory GERD and heartburn.

Dr. Chang is vice-chief, Vatche and Tamar Manoukian division of digestive diseases, program director, UCLA GI fellowship program, codirector, G. Oppenheimer Center for Neurobiology of Stress and Resilience, and professor of medicine at the David Geffen School of Medicine at UCLA. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

Rhonda Souza, MD, AGAF, started off this session with a review of eosinophilic esophagitis (EoE). She explained the challenges of the six-food elimination diet and described an alternative step-up elimination diet. In one study of the step-up elimination diet, food triggers were identified in 88% of patients during the reintroduction of food groups. Proton pump inhibitors are recommended for patients who do not respond to or refuse diet therapy; 30%-50% of patients with EoE will respond to the drugs. She explained that PPIs might have eosinophil-reducing effects independent of gastric acid–lowering effects, and said that PPIs should be stopped for 3-4 weeks before a diagnostic endoscopy is performed if EoE is suspected. Dr. Souza also spoke about topical steroids, biologic agents, and gradual esophageal dilation.

Ronnie Fass, MD, then addressed the management of patients with documented gastroesophageal reflux disease (GERD), or heartburn without documented GERD, who are unresponsive to PPIs. He referred to the management algorithm that he and Prakash Gyawali, MD, MRCP, published this year (Gastroenterology 2018;154:302-18), and described the optimization of PPI therapy before doubling the dose, as well as the testing that should be done if the dose increase does not relieve symptoms. Dr. Fass showed that there are various possible mechanisms for refractory GERD or heartburn, including weakly acidic or alkaline reflux, functional heartburn, and reflux hypersensitivity. He reviewed the Rome IV diagnostic criteria and treatment for the latter two conditions, and discussed the role of esophageal manometry to exclude esophageal motor disorders in patients with refractory GERD and heartburn.

Dr. Chang is vice-chief, Vatche and Tamar Manoukian division of digestive diseases, program director, UCLA GI fellowship program, codirector, G. Oppenheimer Center for Neurobiology of Stress and Resilience, and professor of medicine at the David Geffen School of Medicine at UCLA. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018. She is on the advisory board for Synergy, IM HealthSciences, and Salix; an adviser for Metameconnect.com and ModifyHealth; and a speaker for Allergan and Takeda.

The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.

William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.

Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.

The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.

Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.

Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
 

Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.

The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.

William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.

Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.

The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.

Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.

Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
 

Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.

The large bowel session focused on functional bowel complaints, colorectal cancer risk assessment, the management of serrated polyps, and finally, the spectrum of GI side effects resulting from checkpoint inhibitor therapy.

William Chey, MD, led with a review of novel topics in irritable bowel syndrome (IBS). He emphasized the growing influence of the microbiome considerations on current thinking about IBS, in addition to the more traditional concerns regarding altered motility, visceral perception, and brain-gut interaction. He presented data demonstrating the benefit of low-FODMAP and other diets, as well as the role of antibiotic therapy in selected patients. He also reviewed early data on fecal transplants for treating IBS.

Darren Brenner, MD, reviewed current guidelines for the management of chronic constipation. He emphasized the importance of early diagnostic testing for evacuation disorders as a possible explanation for chronic constipation (for example, anorectal manometry, balloon expulsion testing). He also suggested that earlier treatment with prescription-based agents may be warranted after failure of fiber or polyethylene glycol (PEG)–based laxatives. Finally, he discussed treatment options for constipation either induced or worsened by opioid exposure.

The role of serrated polyps in colorectal carcinogenesis has been increasingly recognized. Seth Crockett, MD, reviewed the optimal means for endoscopic recognition and removal of these lesions. Colonoscopy remains the gold standard to detect serrated polyps because stool tests (blood- and DNA-based) and computed tomography colonography typically have low sensitivities to detect these lesions.

Sapna Syngal, MD, discussed the growing role of gene panel testing for patients who have colorectal cancer (CRC) or who are at elevated risk. In most settings, all newly identified CRCs are tested for microsatellite instability – a characteristic of hereditary nonpolyposis colorectal cancer (Lynch syndrome). However, with the advent of less expensive multigene, blood-based screening tests, patients can be tested for a wide variety of genetic abnormalities, some that are typically associated with CRC and others that are not. Dr. Syngal emphasized the potential effects on immediate treatment, as well as risk stratification for other diseases, associated with broad mutation testing.

Finally, Edward Loftus, MD, reviewed the GI complications associated with checkpoint inhibitor therapy, a type of immunotherapy increasingly used for a wide range of cancers. These drugs cause colitis, hepatitis, and pancreatitis, among other adverse effects. Mild cases can typically be handled (usually as in outpatient settings) with oral steroids. However, more severe toxicities may require hospitalization and intravenous, high-dose steroids. Patients with colitis who fail steroids may require infliximab or other anti–tumor necrosis factor medications, while those with hepatitis may benefit from mycophenolate.
 

Dr. Weinberg is chairman of the department of medicine at Fox Chase Cancer Center, Philadelphia. He has no conflits of interest. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2018.

Here is an update on the rapidly moving field of inflammatory bowel disease (IBD), from the power of the microbiome to the prediction of IBD and new ways to use established drugs.

Predicting IBD

Although we have made advances in therapy, we continue to miss opportunities to prevent long-term complications. At Digestive Disease Week,^® Jean-Frederic Colombel, MD, a professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, presented data on the PREDICTS study (Aliment Pharacol Ther. 2016 Jun;43[12]:1300-10), in which serum samples collected from military recruits prior to development of IBD was used to identify serologic markers that could predict those who ultimately developed Crohn’s disease but not UC.

The pediatric medical community, meanwhile, has studied an inception cohort of newly diagnosed, untreated children – the RISK cohort ( Lancet. 2017 Apr 29;389[10080]:1710-8 ) – to define some of the risk factors that predict more aggressive disease. By using biopsy tissue from the time of diagnosis, investigators could predict who would develop stricturing disease versus penetrating disease. Patients who would develop penetrating disease had up-regulation of inflammatory pathways and responded to anti–tumor necrosis factor therapy, while those who developed a stricturing phenotype had increased expression of extracellular matrix pathways and were significantly less likely to respond to anti-TNF therapy ( Lancet. 2017 Apr 29;389[10080]:1710-8 ). These studies provide a proof of concept that we might someday be able to use for personalized approaches to treating IBD.
 

Using new drugs, targeting new pathways

The recently published CALM study tested the hypothesis that treating to a target of no biochemical inflammation (elevated C reactive protein or fecal calprotectin) would be better than symptom-driven treatment alone. Treatment escalation for active disease included adalimumab every other week, then weekly adalimumab, and finally the addition of azathioprine. At the end of the study, patients whose medical therapy was based on both symptoms and biochemical inflammation had a higher degree of mucosal healing than did patients in the clinical management group (Lancet. 2018 Dec 23;390[10114]:2779-89).

Ustekinumab is a monoclonal antibody that targets the p40 subunit of interleukin-12 and interleukin-23 and is approved for Crohn’s disease. Various pharmaceutical companies are now developing anti-p19 antibodies, which block IL-23 only; at DDW 2018, the anti–IL-23 mirikizumab was shown to be effective in UC. We are also seeing the availability of oral medications for IBD. Just prior to DDW, tofacitinib ( N Engl J Med. 2017 May 4;376:1723-36 ), a Janus kinase (JAK) 1/3 inhibitor, which has an effect on multiple different cytokine pathways, received approval for UC. Other JAK inhibitors with different specificities are being tested in trials of UC and Crohn’s disease.
 

Dr. Abreu is a professor of medicine, a professor of microbiology and immunology, and the director of the Crohn’s & Colitis Center at the University of Miami Miller School of Medicine. She has no conflicts of interest. Dr. Abreu made her comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

Here is an update on the rapidly moving field of inflammatory bowel disease (IBD), from the power of the microbiome to the prediction of IBD and new ways to use established drugs.

Predicting IBD

Although we have made advances in therapy, we continue to miss opportunities to prevent long-term complications. At Digestive Disease Week,^® Jean-Frederic Colombel, MD, a professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, presented data on the PREDICTS study (Aliment Pharacol Ther. 2016 Jun;43[12]:1300-10), in which serum samples collected from military recruits prior to development of IBD was used to identify serologic markers that could predict those who ultimately developed Crohn’s disease but not UC.

The pediatric medical community, meanwhile, has studied an inception cohort of newly diagnosed, untreated children – the RISK cohort ( Lancet. 2017 Apr 29;389[10080]:1710-8 ) – to define some of the risk factors that predict more aggressive disease. By using biopsy tissue from the time of diagnosis, investigators could predict who would develop stricturing disease versus penetrating disease. Patients who would develop penetrating disease had up-regulation of inflammatory pathways and responded to anti–tumor necrosis factor therapy, while those who developed a stricturing phenotype had increased expression of extracellular matrix pathways and were significantly less likely to respond to anti-TNF therapy ( Lancet. 2017 Apr 29;389[10080]:1710-8 ). These studies provide a proof of concept that we might someday be able to use for personalized approaches to treating IBD.
 

Using new drugs, targeting new pathways

The recently published CALM study tested the hypothesis that treating to a target of no biochemical inflammation (elevated C reactive protein or fecal calprotectin) would be better than symptom-driven treatment alone. Treatment escalation for active disease included adalimumab every other week, then weekly adalimumab, and finally the addition of azathioprine. At the end of the study, patients whose medical therapy was based on both symptoms and biochemical inflammation had a higher degree of mucosal healing than did patients in the clinical management group (Lancet. 2018 Dec 23;390[10114]:2779-89).

Ustekinumab is a monoclonal antibody that targets the p40 subunit of interleukin-12 and interleukin-23 and is approved for Crohn’s disease. Various pharmaceutical companies are now developing anti-p19 antibodies, which block IL-23 only; at DDW 2018, the anti–IL-23 mirikizumab was shown to be effective in UC. We are also seeing the availability of oral medications for IBD. Just prior to DDW, tofacitinib ( N Engl J Med. 2017 May 4;376:1723-36 ), a Janus kinase (JAK) 1/3 inhibitor, which has an effect on multiple different cytokine pathways, received approval for UC. Other JAK inhibitors with different specificities are being tested in trials of UC and Crohn’s disease.
 

Dr. Abreu is a professor of medicine, a professor of microbiology and immunology, and the director of the Crohn’s & Colitis Center at the University of Miami Miller School of Medicine. She has no conflicts of interest. Dr. Abreu made her comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

Here is an update on the rapidly moving field of inflammatory bowel disease (IBD), from the power of the microbiome to the prediction of IBD and new ways to use established drugs.

Predicting IBD

Although we have made advances in therapy, we continue to miss opportunities to prevent long-term complications. At Digestive Disease Week,^® Jean-Frederic Colombel, MD, a professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, presented data on the PREDICTS study (Aliment Pharacol Ther. 2016 Jun;43[12]:1300-10), in which serum samples collected from military recruits prior to development of IBD was used to identify serologic markers that could predict those who ultimately developed Crohn’s disease but not UC.

The pediatric medical community, meanwhile, has studied an inception cohort of newly diagnosed, untreated children – the RISK cohort ( Lancet. 2017 Apr 29;389[10080]:1710-8 ) – to define some of the risk factors that predict more aggressive disease. By using biopsy tissue from the time of diagnosis, investigators could predict who would develop stricturing disease versus penetrating disease. Patients who would develop penetrating disease had up-regulation of inflammatory pathways and responded to anti–tumor necrosis factor therapy, while those who developed a stricturing phenotype had increased expression of extracellular matrix pathways and were significantly less likely to respond to anti-TNF therapy ( Lancet. 2017 Apr 29;389[10080]:1710-8 ). These studies provide a proof of concept that we might someday be able to use for personalized approaches to treating IBD.
 

Using new drugs, targeting new pathways

The recently published CALM study tested the hypothesis that treating to a target of no biochemical inflammation (elevated C reactive protein or fecal calprotectin) would be better than symptom-driven treatment alone. Treatment escalation for active disease included adalimumab every other week, then weekly adalimumab, and finally the addition of azathioprine. At the end of the study, patients whose medical therapy was based on both symptoms and biochemical inflammation had a higher degree of mucosal healing than did patients in the clinical management group (Lancet. 2018 Dec 23;390[10114]:2779-89).

Ustekinumab is a monoclonal antibody that targets the p40 subunit of interleukin-12 and interleukin-23 and is approved for Crohn’s disease. Various pharmaceutical companies are now developing anti-p19 antibodies, which block IL-23 only; at DDW 2018, the anti–IL-23 mirikizumab was shown to be effective in UC. We are also seeing the availability of oral medications for IBD. Just prior to DDW, tofacitinib ( N Engl J Med. 2017 May 4;376:1723-36 ), a Janus kinase (JAK) 1/3 inhibitor, which has an effect on multiple different cytokine pathways, received approval for UC. Other JAK inhibitors with different specificities are being tested in trials of UC and Crohn’s disease.
 

Dr. Abreu is a professor of medicine, a professor of microbiology and immunology, and the director of the Crohn’s & Colitis Center at the University of Miami Miller School of Medicine. She has no conflicts of interest. Dr. Abreu made her comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.

Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.

Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.

Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.

WASHINGTON – The same Spanish research team who introduced an MRI-based formula for scoring the activity of luminal Crohn’s disease in 2011 have developed and validated a new, simplified version of their MRI score that speeds assessment.

“The simplified version of the MaRIA [Magnetic Resonance Index of Activity] score allows a faster and easier assessment of inflammation and quantification of severity in Crohn’s disease by keeping high accuracy for diagnosis and therapeutic response,” Ingrid Ordás, MD, said at the annual Digestive Disease Week®. The main advantage of the simplified MaRIA is that it is a “less time-consuming calculation that is not confounded by missing segments,” said Dr. Ordás, a gastroenterologist at the Hospital Clinic of Barcelona.

Although the data reported by Dr. Ordás included the derivation results, which used 98 patients enrolled in two separate prospective studies, and a separate prospective validation cohort of 37 patients, all these patients were evaluated by clinicians at the Hospital Clinic of Barcelona, and hence further validation with patients enrolled at other sites is now needed, Dr. Ordás said in an interview. Further accumulation of evidence for high sensitivity and specificity of Crohn’s disease assessment using the simplified MaRIA could allow it to replace endoscopy as the standard tool for assessing disease activity and severity in patients with luminal Crohn’s disease.

The derivation phase of the study identified four features that significantly correlated with disease activity and severity: bowel wall thickening to more than 3 mm, mural edema, perienteric fat stranding, and mucosal ulcerations. Limiting assessment to these four features cut in half the elements in the original MaRIA (Inflamm Bowel Dis. 2011 Aug;17[8];1759-68). Fat stranding – loss of the usual sharp interface between the wall and mesentery because of fluid – is a new parameter in the simplified MaRIA. The other three elements had been in the original index, but several other elements are now gone, including relative contrast enhancement wall signal intensity and consideration of lymph nodes.

In the validation phase, the researchers compared the MaRIA findings of the validation cohort with endoscopy findings both at baseline and then after they had received treatment. The sensitivity and specificity of the simplified MaRIA depended on the cutoff used, but as an example, a patient with a simplified MaRIA of 1 or greater as having active disease had a sensitivity of 90%, specificity of 81%, and an area under the receiver operator characteristic curve of 0.91. Using a simplified MaRIA of at least 2 as indicative of severe disease had a sensitivity of 85%, a specificity of 92%, and an AUROC of 0.94, Dr. Ordás reported.

Further assessment in patients who underwent treatment showed that reductions in the simplified MaRIA significantly correlated with treatment responses and remained essentially unchanged in patients who did not have clinical response to treatment. The analysis also showed a strong, positive correlation coefficient of 0.83 when the simplified MaRIA of an individual patient, compared with the patient’s Crohn’s disease endoscopy index of severity, and a correlation coefficient of 0.94 when a patient’s simplified MaRIA determined by one clinician, compared with the index score calculated by a second clinician.

Dr. Ordás had no disclosures to report.

[email protected]

SOURCE: Ordás I et al. DDW 2018, Presentation 437.

WASHINGTON – The same Spanish research team who introduced an MRI-based formula for scoring the activity of luminal Crohn’s disease in 2011 have developed and validated a new, simplified version of their MRI score that speeds assessment.

“The simplified version of the MaRIA [Magnetic Resonance Index of Activity] score allows a faster and easier assessment of inflammation and quantification of severity in Crohn’s disease by keeping high accuracy for diagnosis and therapeutic response,” Ingrid Ordás, MD, said at the annual Digestive Disease Week®. The main advantage of the simplified MaRIA is that it is a “less time-consuming calculation that is not confounded by missing segments,” said Dr. Ordás, a gastroenterologist at the Hospital Clinic of Barcelona.

Although the data reported by Dr. Ordás included the derivation results, which used 98 patients enrolled in two separate prospective studies, and a separate prospective validation cohort of 37 patients, all these patients were evaluated by clinicians at the Hospital Clinic of Barcelona, and hence further validation with patients enrolled at other sites is now needed, Dr. Ordás said in an interview. Further accumulation of evidence for high sensitivity and specificity of Crohn’s disease assessment using the simplified MaRIA could allow it to replace endoscopy as the standard tool for assessing disease activity and severity in patients with luminal Crohn’s disease.

The derivation phase of the study identified four features that significantly correlated with disease activity and severity: bowel wall thickening to more than 3 mm, mural edema, perienteric fat stranding, and mucosal ulcerations. Limiting assessment to these four features cut in half the elements in the original MaRIA (Inflamm Bowel Dis. 2011 Aug;17[8];1759-68). Fat stranding – loss of the usual sharp interface between the wall and mesentery because of fluid – is a new parameter in the simplified MaRIA. The other three elements had been in the original index, but several other elements are now gone, including relative contrast enhancement wall signal intensity and consideration of lymph nodes.

In the validation phase, the researchers compared the MaRIA findings of the validation cohort with endoscopy findings both at baseline and then after they had received treatment. The sensitivity and specificity of the simplified MaRIA depended on the cutoff used, but as an example, a patient with a simplified MaRIA of 1 or greater as having active disease had a sensitivity of 90%, specificity of 81%, and an area under the receiver operator characteristic curve of 0.91. Using a simplified MaRIA of at least 2 as indicative of severe disease had a sensitivity of 85%, a specificity of 92%, and an AUROC of 0.94, Dr. Ordás reported.

Further assessment in patients who underwent treatment showed that reductions in the simplified MaRIA significantly correlated with treatment responses and remained essentially unchanged in patients who did not have clinical response to treatment. The analysis also showed a strong, positive correlation coefficient of 0.83 when the simplified MaRIA of an individual patient, compared with the patient’s Crohn’s disease endoscopy index of severity, and a correlation coefficient of 0.94 when a patient’s simplified MaRIA determined by one clinician, compared with the index score calculated by a second clinician.

Dr. Ordás had no disclosures to report.

[email protected]

SOURCE: Ordás I et al. DDW 2018, Presentation 437.

WASHINGTON – The same Spanish research team who introduced an MRI-based formula for scoring the activity of luminal Crohn’s disease in 2011 have developed and validated a new, simplified version of their MRI score that speeds assessment.

“The simplified version of the MaRIA [Magnetic Resonance Index of Activity] score allows a faster and easier assessment of inflammation and quantification of severity in Crohn’s disease by keeping high accuracy for diagnosis and therapeutic response,” Ingrid Ordás, MD, said at the annual Digestive Disease Week®. The main advantage of the simplified MaRIA is that it is a “less time-consuming calculation that is not confounded by missing segments,” said Dr. Ordás, a gastroenterologist at the Hospital Clinic of Barcelona.

Although the data reported by Dr. Ordás included the derivation results, which used 98 patients enrolled in two separate prospective studies, and a separate prospective validation cohort of 37 patients, all these patients were evaluated by clinicians at the Hospital Clinic of Barcelona, and hence further validation with patients enrolled at other sites is now needed, Dr. Ordás said in an interview. Further accumulation of evidence for high sensitivity and specificity of Crohn’s disease assessment using the simplified MaRIA could allow it to replace endoscopy as the standard tool for assessing disease activity and severity in patients with luminal Crohn’s disease.

The derivation phase of the study identified four features that significantly correlated with disease activity and severity: bowel wall thickening to more than 3 mm, mural edema, perienteric fat stranding, and mucosal ulcerations. Limiting assessment to these four features cut in half the elements in the original MaRIA (Inflamm Bowel Dis. 2011 Aug;17[8];1759-68). Fat stranding – loss of the usual sharp interface between the wall and mesentery because of fluid – is a new parameter in the simplified MaRIA. The other three elements had been in the original index, but several other elements are now gone, including relative contrast enhancement wall signal intensity and consideration of lymph nodes.

In the validation phase, the researchers compared the MaRIA findings of the validation cohort with endoscopy findings both at baseline and then after they had received treatment. The sensitivity and specificity of the simplified MaRIA depended on the cutoff used, but as an example, a patient with a simplified MaRIA of 1 or greater as having active disease had a sensitivity of 90%, specificity of 81%, and an area under the receiver operator characteristic curve of 0.91. Using a simplified MaRIA of at least 2 as indicative of severe disease had a sensitivity of 85%, a specificity of 92%, and an AUROC of 0.94, Dr. Ordás reported.

Further assessment in patients who underwent treatment showed that reductions in the simplified MaRIA significantly correlated with treatment responses and remained essentially unchanged in patients who did not have clinical response to treatment. The analysis also showed a strong, positive correlation coefficient of 0.83 when the simplified MaRIA of an individual patient, compared with the patient’s Crohn’s disease endoscopy index of severity, and a correlation coefficient of 0.94 when a patient’s simplified MaRIA determined by one clinician, compared with the index score calculated by a second clinician.

Dr. Ordás had no disclosures to report.

[email protected]

SOURCE: Ordás I et al. DDW 2018, Presentation 437.

WASHINGTON – Several endoscopic bariatric procedures for weight loss have recently entered routine U.S. practice, but the procedures are much less likely to achieve meaningful weight loss for patients unless they are paired with frequent patient contact and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.^®

Mitchel L. Zoler/MDedge News

Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.

Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.

[email protected]

WASHINGTON – Several endoscopic bariatric procedures for weight loss have recently entered routine U.S. practice, but the procedures are much less likely to achieve meaningful weight loss for patients unless they are paired with frequent patient contact and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.^®

Mitchel L. Zoler/MDedge News

Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.

Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.

[email protected]

WASHINGTON – Several endoscopic bariatric procedures for weight loss have recently entered routine U.S. practice, but the procedures are much less likely to achieve meaningful weight loss for patients unless they are paired with frequent patient contact and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.^®

Mitchel L. Zoler/MDedge News

Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.

Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.

[email protected]