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Cyclic vomiting syndrome: A GI primer
Introduction
Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction (DGBI) and is characterized by recurrent episodes of severe nausea, vomiting, and often, abdominal pain. Patients are usually asymptomatic in between episodes.1 CVS was considered a pediatric disease but is now known to be as common in adults. The prevalence of CVS in adults was 2% in a recent population-based study.2 Patients are predominantly white. Both males and females are affected with some studies showing a female preponderance. The mean age of onset is 5 years in children and 35 years in adults.3
The etiology of CVS is not known, but various hypotheses have been proposed. Zaki et al. showed that two mitochondrial DNA polymorphisms 16519T and 3010A were associated with a 17-fold increased odds of having CVS in children.4 These polymorphisms were not associated with CVS in adults.5 Alterations in the brain-gut axis also have been shown in CVS. Functional neuroimaging studies demonstrate that patients with CVS displayed increased connectivity between insula and salience networks with concomitant decrease in connectivity to somatosensory networks.6 Recent data also indicate that the endocannabinoid system (ECS) and the hypothalamic-pituitary-adrenal axis are implicated in CVS with an increase in serum endocannabinoid concentration during an episode.7 The same study also showed a significant increase in salivary cortisol in CVS patients who used cannabis. Further, single nucleotide polymorphisms (SNPs) in the gene that encodes for the cannabinoid receptor type 1 (CB1R) are implicated in CVS.8 The CB1R is part of the ECS and is densely expressed in brain areas involved in emesis, such as the dorsal vagal complex consisting of the area postrema (AP), nucleus of the solitary tract (NTS), and also the dorsal motor nucleus of the vagus.9 Wasilewski et al. showed an increased risk of CVS among individuals with AG and GG genotypes of CNR1 rs806380 (P less than .01), whereas the CC genotype of CNR1 rs806368 was associated with a decreased risk of CVS (P less than .05).8 CB1R agonists – endocannabinoids and tetrahydrocannabinol (THC) – have acute antiemetic and anxiolytic effects.9-11 The apparent paradoxical effects of cannabis in this patient population are yet to be explained and need further study.
Diagnosis and clinical features of CVS
Figure 1: Phases of Cyclic Vomiting Syndrome12
Adapted from Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic Vomiting Syndrome in 41 adults: The illness, the patients, and problems of management. BMC Med 2005;3:20. This work is licensed under the Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/, which permits unrestricted use, distribution, modification, and reproduction in any medium.
CVS consists of four phases which include the a) prodromal phase, b) the episodic phase, c) recovery phase, and d) the interepisodic phase; and was first described by David Fleisher.12 The phases of CVS are important for clinicians and patients alike as they have therapeutic implications. The administration of abortive medications during a prodrome can terminate an episode. The phases of CVS are shown above.
Most patients (~ 93%) have a prodromal phase. Symptoms during this phase can include nausea, abdominal pain, diaphoresis, fatigue, weakness, hot flashes, chills, shivering, increased thirst, loss of appetite, burping, lightheadedness, and paresthesia.13 Some patients report a sense of impending doom and many have symptoms consistent with panic. If untreated, this progresses to the emetic phase and patients have unrelenting nausea, retching, vomiting, and other symptoms. During an episode, patients may vomit up to 20 times per hour and the episode may last several hours to days. During this phase, patients are sometimes described as being in a “conscious coma” and exhibit lethargy, listlessness, withdrawal, and sometimes disorientation.14,15 The emetic phase is followed by the recovery phase, during which symptoms subside and patients are able to resume oral intake. Patients are usually asymptomatic between episodes but ~ 30% can have interepisodic nausea and dyspepsia. In some patients, episodes become progressively longer and the interepisodic phase is considerably shortened and patients have a “coalescence of symptoms.”12 It is important to elicit a thorough history in all patients with vomiting in order to make an accurate diagnosis of CVS since coalescence of symptoms only occurs over a period of time. Episodes often are triggered by psychological stress, both positive and negative. Common triggers can include positive events such as birthdays, holidays, and negative ones like examinations, the death of a loved one, etc. Sleep deprivation and physical exhaustion also can trigger an episode.12 
CVS remains a clinical diagnosis since there are no biomarkers. While there is a lack of data on the optimal work-up in these patients, experts recommend an upper endoscopy or upper GI series in order to rule out alternative gastric and intestinal pathology (e.g., malrotation with volvulus).16 Of note, a gastric-emptying study is not recommended as part of the routine work-up as per recent guidelines because of the poor specificity of this test in establishing a diagnosis of CVS.16 Biochemical testing including a complete blood count, serum electrolytes, serum glucose, liver panel, and urinalysis is also warranted. Any additional testing is indicated when clinical features suggest an alternative diagnosis. For instance, neurologic symptoms might warrant a cranial MRI to exclude an intracerebral tumor or other lesions of the brain.
The severity and unpredictable nature of symptoms makes it difficult for some patients to attend school or work; one study found that 32% of patients with CVS were completely disabled.12 Despite increasing awareness of this disorder, patients often are misdiagnosed. The prevalence of CVS in an outpatient gastroenterology clinic in the United Kingdom was 11% and was markedly underdiagnosed in the community.17 Only 5% of patients who were subsequently diagnosed with CVS were initially diagnosed accurately by their referring physician despite meeting criteria for the disorder.17 A subset of patients with CVS even undergo futile surgeries.13 Fleisher et al. noted that 30% of a 41-patient cohort underwent cholecystectomy for CVS symptoms without any improvement in disease.12 Prompt diagnosis and appropriate therapy is essential to improve patient outcomes and improve quality of life.
CVS is associated with various comorbidities such as migraine, anxiety, depression and dysautonomia, which can further impair quality of life.18,19 Approximately 70% of CVS patients report a personal or family history of migraine. Anxiety and depression affects nearly half of patients with CVS.13 Cannabis use is significantly more prevalent among patients with CVS than patients without CVS.20
Role of cannabis in CVS
The role of cannabis in the pathogenesis of symptoms in CVS is controversial. While cannabis has antiemetic properties, there is a strong link between its use and CVS. The use of cannabis has increased over the past decade with increasing legalization.21 Several studies have shown that 40%-80% of patients with CVS use cannabis.22,23 Following this, cannabinoid hyperemesis syndrome (CHS) was coined as a separate entity based on this statistical association, though there are no data to support the notion that cannabis causes vomiting.24,25 CHS has clinical features that are indistinguishable from CVS except for the chronic heavy cannabis use. A peculiar bathing behavior called “compulsive hot-water bathing” has been described and was thought to be pathognomonic of cannabis use.26 During an episode, patients will take multiple hot showers/baths, which temporarily alleviate their symptoms. Many patients even report running out of hot water and sometimes check into a hotel for a continuous supply of hot water. A small number of patients may sustain burns from the hot-water bathing. However, studies show that this hot-water bathing behavior also is seen in about 50% of patents with CVS who do not use cannabis.22
CHS is now defined by Rome IV criteria, which include episodes of nausea and vomiting similar to CVS preceded by chronic, heavy cannabis use. Patients must have complete resolution of symptoms following cessation.1 A recent systematic review of 376 cases of purported CHS showed that only 59 (15.7%) met Rome IV criteria for this disorder.27 This is because of considerable heterogeneity in how the diagnosis of CHS was made and the lack of standard diagnostic criteria at the time. Some cases of CHS were diagnosed merely based on an association of vomiting, hot-water bathing, and cannabis use.28 Only a minority of patients (71,19%) had a duration of follow-up more than 4 weeks, which would make it impossible to establish a diagnosis of CHS. A period of at least a year or a duration of time that spans at least three episodes is generally recommended to determine if abstinence from cannabis causes a true resolution of symptoms.27 Whether CHS is a separate entity or a subtype of CVS remains to be determined. The paradoxical effects of cannabis may happen because of the use of highly potent cannabis products that are currently in use. A complete discussion of the role of cannabis in CVS is beyond the scope of this article, and the reader is referred to a recent systematic review and discussion.27
Treatment
CVS should be treated based on a biopsychosocial model with a multidisciplinary team that includes a gastroenterologist with knowledge of CVS, primary care physician, psychologist, psychiatrist, and sleep specialist if needed.16 Initiating prophylactic treatment is based on the severity of disease. An algorithm for the treatment of CVS based on severity of symptoms is shown below.
Figure 2. Adapted and reprinted by permission from the Licensor: Springer Nature, Current Treatment Options in Gastroenterology, Bhandari S, Venkatesan T. Novel Treatments for Cyclic Vomiting Syndrome: Beyond Ondansetron and Amitriptyline, 14:495-506, Copyright 2016.
Patients who have mild disease (defined as fewer than four episodes/year, episodes lasting up to 2 days, quick recovery from episodes, or episodes not requiring ED care or hospitalization) are usually prescribed abortive medications.16 These medications are best administered during the prodromal phase and can prevent progression to the emetic phase. Medications used for aborting episodes include sumatriptan (20 mg intranasal or 6 mg subcutaneous), ondansetron (8 mg sublingual), and diphenhydramine (25-50 mg).30,31 This combination can help abort symptoms and potentially avoid ED visits or hospitalizations. Patients with moderate-to-severe CVS are offered prophylactic therapy in addition to abortive therapy.16
Recent guidelines recommend tricyclic antidepressants (TCAs) as the first-line agent in the prophylaxis of CVS episodes. Data from 14 studies determined that 70% (413/600) of patients responded partially or completely to TCAs.16 An open-label study of 46 patients by Hejazi et al. noted a decline in the number of CVS episodes from 17 to 3, in the duration of a CVS episode from 6 to 2 days, and in the number of ED visits/ hospitalizations from 15 to 3.3.32Amitriptyline should be started at 25 mg at night and titrated up by 10-25 mg each week to minimize emergence of side effects. The mean effective dose is 75-100 mg or 1.0-1.5 mg/kg. An EKG should be checked at baseline and during titration to monitor the QT interval. Unfortunately, side effects from TCAs are quite common and include cognitive impairment, drowsiness, dryness of mouth, weight gain, constipation, and mood changes, which may warrant dose reduction or discontinuation. Antiepileptics such as topiramate, mitochondrial supplements such as Coenzyme Q10 and riboflavin are alternative prophylactic agents in CVS.33 Aprepitant, a newer NK1 receptor antagonist has been found to be effective in refractory CVS.34 In addition to pharmacotherapy, addressing comorbid conditions such as anxiety and depression and counseling patients to abstain from heavy cannabis use is also important to achieve good health care outcomes.
In summary, CVS is a common, chronic functional GI disorder with episodic nausea, vomiting, and often, abdominal pain. Symptoms can be disabling, and prompt diagnosis and therapy is important. CVS is associated with multiple comorbid conditions such as migraine, anxiety and depression, and a biopsychosocial model of care is essential. Medications such as amitriptyline are effective in the prophylaxis of CVS, but side effects hamper their use. Recent recommendations for management of CVS have been published.16 Cannabis is frequently used by patients for symptom relief but use of high potency products may cause worsening of symptoms or unmask symptoms in genetically predisposed individuals.23 Studies to elucidate the pathophysiology of CVS should help in the development of better therapies.
Dr. Mooers is PGY-2, an internal medicine resident in the department of medicine, Medical College of Wisconsin, Milwaukee; Dr. Venkatesan is professor of medicine, division of gastroenterology and hepatology, department of medicine, Medical College of Wisconsin, Milwaukee. The authors have no conflicts to disclose.
References
1. Stanghellini V et al. Gastroenterology. 2016;150:1380-92.
2. Aziz I et al. Clin Gastroenterol Hepatol. 2019 Apr;17(5):878-86.
3. Kovacic K et al. Curr Gastroenterol Rep. 2018;20(10):46.
4. Zaki EA et al. Cephalalgia. 2009;29:719-28.
5. Venkatesan T et al. BMC Gastroenterol. 2014;14:181.
6. Ellingsen DM et al. Neurogastroenterol Motil. 2017;29 (6)e13004 9.
7. Venkatesan T et al. Neurogastroenterol Motil. 2016;28:1409-18.
8. Wasilewski A et al. Am J Gastroenterol. 2017;112:933-9.
9. van Sickle MD et al. Am J Physiol Gastrointest Liver Physiol 2003;285:G566-76.
10. Parker LA et al. Br J Pharmacol. 2011;163:1411-22.
11. van Sickle MD et al. Gastroenterology. 2001;121:767-74.
12. Fleisher DR et al. BMC Med. 2005;3:20.
13. Kumar N et al. BMC Gastroenterol. 2012;12:52.
14. Li BU et al. J Pediatr Gastroenterol Nutr. 2008;47:379-93.
15. Bhandari S et al. Clin Auton Res. 2018 Apr;28(2):203-9.
16. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13604. doi: 10.1111/nmo.13604.
17. Sagar RC et al. Neurogastroenterol Motil. 2018;30. doi: 10.1111/nmo.13174.
18. Taranukha T et al. Neurogastroenterol Motil. 2018 Apr;30(4):e13245. doi: 10.1111/nmo.13245.
19. Bhandari S and Venkatesan T. Dig Dis Sci. 2017;62:2035-44.
20. Choung RS et al. Neurogastroenterol Motil. 2012;24:20-6, e21. doi: 10.1111/j.1365-2982.2011.01791.x.
21. Bhandari S et al. Intern Med J. 2019 May;49(5):649-55.
22. Venkatesan T et al. Exp Brain Res. 2014; 232:2563-70.
23. Venkatesan T et al. Clin Gastroenterol Hepatol. 2019 Jul 25. doi: 10.1016/j.cgh.2019.07.039.
24. Simonetto DA et al. Mayo Clin Proc. 2012;87:114-9.
25. Wallace EA et al. South Med J. 2011;104:659-64.
26. Allen JH et al. Gut. 2004;53:1566-70.
27. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13606. doi: 10.1111/nmo.13606.
28. Habboushe J et al. Basic Clin Pharmacol Toxicol. 2018;122:660-2.
29. Bhandari S and Venkatesan T. Curr Treat Options Gastroenterol. 2016;14:495-506.
30. Hikita T et al. Cephalalgia. 2011;31:504-7.
31. Fuseau E et al. Clin Pharmacokinet 2002;41:801-11.
32. Hejazi RA et al. J Clin Gastroenterol. 2010;44:18-21.
33. Sezer OB and Sezer T. J Neurogastroenterol Motil. 2016;22:656-60.
34. Cristofori F et al. Aliment Pharmacol Ther. 2014;40:309-17.
Introduction
Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction (DGBI) and is characterized by recurrent episodes of severe nausea, vomiting, and often, abdominal pain. Patients are usually asymptomatic in between episodes.1 CVS was considered a pediatric disease but is now known to be as common in adults. The prevalence of CVS in adults was 2% in a recent population-based study.2 Patients are predominantly white. Both males and females are affected with some studies showing a female preponderance. The mean age of onset is 5 years in children and 35 years in adults.3
The etiology of CVS is not known, but various hypotheses have been proposed. Zaki et al. showed that two mitochondrial DNA polymorphisms 16519T and 3010A were associated with a 17-fold increased odds of having CVS in children.4 These polymorphisms were not associated with CVS in adults.5 Alterations in the brain-gut axis also have been shown in CVS. Functional neuroimaging studies demonstrate that patients with CVS displayed increased connectivity between insula and salience networks with concomitant decrease in connectivity to somatosensory networks.6 Recent data also indicate that the endocannabinoid system (ECS) and the hypothalamic-pituitary-adrenal axis are implicated in CVS with an increase in serum endocannabinoid concentration during an episode.7 The same study also showed a significant increase in salivary cortisol in CVS patients who used cannabis. Further, single nucleotide polymorphisms (SNPs) in the gene that encodes for the cannabinoid receptor type 1 (CB1R) are implicated in CVS.8 The CB1R is part of the ECS and is densely expressed in brain areas involved in emesis, such as the dorsal vagal complex consisting of the area postrema (AP), nucleus of the solitary tract (NTS), and also the dorsal motor nucleus of the vagus.9 Wasilewski et al. showed an increased risk of CVS among individuals with AG and GG genotypes of CNR1 rs806380 (P less than .01), whereas the CC genotype of CNR1 rs806368 was associated with a decreased risk of CVS (P less than .05).8 CB1R agonists – endocannabinoids and tetrahydrocannabinol (THC) – have acute antiemetic and anxiolytic effects.9-11 The apparent paradoxical effects of cannabis in this patient population are yet to be explained and need further study.
Diagnosis and clinical features of CVS
Figure 1: Phases of Cyclic Vomiting Syndrome12
Adapted from Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic Vomiting Syndrome in 41 adults: The illness, the patients, and problems of management. BMC Med 2005;3:20. This work is licensed under the Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/, which permits unrestricted use, distribution, modification, and reproduction in any medium.
CVS consists of four phases which include the a) prodromal phase, b) the episodic phase, c) recovery phase, and d) the interepisodic phase; and was first described by David Fleisher.12 The phases of CVS are important for clinicians and patients alike as they have therapeutic implications. The administration of abortive medications during a prodrome can terminate an episode. The phases of CVS are shown above.
Most patients (~ 93%) have a prodromal phase. Symptoms during this phase can include nausea, abdominal pain, diaphoresis, fatigue, weakness, hot flashes, chills, shivering, increased thirst, loss of appetite, burping, lightheadedness, and paresthesia.13 Some patients report a sense of impending doom and many have symptoms consistent with panic. If untreated, this progresses to the emetic phase and patients have unrelenting nausea, retching, vomiting, and other symptoms. During an episode, patients may vomit up to 20 times per hour and the episode may last several hours to days. During this phase, patients are sometimes described as being in a “conscious coma” and exhibit lethargy, listlessness, withdrawal, and sometimes disorientation.14,15 The emetic phase is followed by the recovery phase, during which symptoms subside and patients are able to resume oral intake. Patients are usually asymptomatic between episodes but ~ 30% can have interepisodic nausea and dyspepsia. In some patients, episodes become progressively longer and the interepisodic phase is considerably shortened and patients have a “coalescence of symptoms.”12 It is important to elicit a thorough history in all patients with vomiting in order to make an accurate diagnosis of CVS since coalescence of symptoms only occurs over a period of time. Episodes often are triggered by psychological stress, both positive and negative. Common triggers can include positive events such as birthdays, holidays, and negative ones like examinations, the death of a loved one, etc. Sleep deprivation and physical exhaustion also can trigger an episode.12
CVS remains a clinical diagnosis since there are no biomarkers. While there is a lack of data on the optimal work-up in these patients, experts recommend an upper endoscopy or upper GI series in order to rule out alternative gastric and intestinal pathology (e.g., malrotation with volvulus).16 Of note, a gastric-emptying study is not recommended as part of the routine work-up as per recent guidelines because of the poor specificity of this test in establishing a diagnosis of CVS.16 Biochemical testing including a complete blood count, serum electrolytes, serum glucose, liver panel, and urinalysis is also warranted. Any additional testing is indicated when clinical features suggest an alternative diagnosis. For instance, neurologic symptoms might warrant a cranial MRI to exclude an intracerebral tumor or other lesions of the brain.
The severity and unpredictable nature of symptoms makes it difficult for some patients to attend school or work; one study found that 32% of patients with CVS were completely disabled.12 Despite increasing awareness of this disorder, patients often are misdiagnosed. The prevalence of CVS in an outpatient gastroenterology clinic in the United Kingdom was 11% and was markedly underdiagnosed in the community.17 Only 5% of patients who were subsequently diagnosed with CVS were initially diagnosed accurately by their referring physician despite meeting criteria for the disorder.17 A subset of patients with CVS even undergo futile surgeries.13 Fleisher et al. noted that 30% of a 41-patient cohort underwent cholecystectomy for CVS symptoms without any improvement in disease.12 Prompt diagnosis and appropriate therapy is essential to improve patient outcomes and improve quality of life.
CVS is associated with various comorbidities such as migraine, anxiety, depression and dysautonomia, which can further impair quality of life.18,19 Approximately 70% of CVS patients report a personal or family history of migraine. Anxiety and depression affects nearly half of patients with CVS.13 Cannabis use is significantly more prevalent among patients with CVS than patients without CVS.20
Role of cannabis in CVS
The role of cannabis in the pathogenesis of symptoms in CVS is controversial. While cannabis has antiemetic properties, there is a strong link between its use and CVS. The use of cannabis has increased over the past decade with increasing legalization.21 Several studies have shown that 40%-80% of patients with CVS use cannabis.22,23 Following this, cannabinoid hyperemesis syndrome (CHS) was coined as a separate entity based on this statistical association, though there are no data to support the notion that cannabis causes vomiting.24,25 CHS has clinical features that are indistinguishable from CVS except for the chronic heavy cannabis use. A peculiar bathing behavior called “compulsive hot-water bathing” has been described and was thought to be pathognomonic of cannabis use.26 During an episode, patients will take multiple hot showers/baths, which temporarily alleviate their symptoms. Many patients even report running out of hot water and sometimes check into a hotel for a continuous supply of hot water. A small number of patients may sustain burns from the hot-water bathing. However, studies show that this hot-water bathing behavior also is seen in about 50% of patents with CVS who do not use cannabis.22
CHS is now defined by Rome IV criteria, which include episodes of nausea and vomiting similar to CVS preceded by chronic, heavy cannabis use. Patients must have complete resolution of symptoms following cessation.1 A recent systematic review of 376 cases of purported CHS showed that only 59 (15.7%) met Rome IV criteria for this disorder.27 This is because of considerable heterogeneity in how the diagnosis of CHS was made and the lack of standard diagnostic criteria at the time. Some cases of CHS were diagnosed merely based on an association of vomiting, hot-water bathing, and cannabis use.28 Only a minority of patients (71,19%) had a duration of follow-up more than 4 weeks, which would make it impossible to establish a diagnosis of CHS. A period of at least a year or a duration of time that spans at least three episodes is generally recommended to determine if abstinence from cannabis causes a true resolution of symptoms.27 Whether CHS is a separate entity or a subtype of CVS remains to be determined. The paradoxical effects of cannabis may happen because of the use of highly potent cannabis products that are currently in use. A complete discussion of the role of cannabis in CVS is beyond the scope of this article, and the reader is referred to a recent systematic review and discussion.27
Treatment
CVS should be treated based on a biopsychosocial model with a multidisciplinary team that includes a gastroenterologist with knowledge of CVS, primary care physician, psychologist, psychiatrist, and sleep specialist if needed.16 Initiating prophylactic treatment is based on the severity of disease. An algorithm for the treatment of CVS based on severity of symptoms is shown below.
Figure 2. Adapted and reprinted by permission from the Licensor: Springer Nature, Current Treatment Options in Gastroenterology, Bhandari S, Venkatesan T. Novel Treatments for Cyclic Vomiting Syndrome: Beyond Ondansetron and Amitriptyline, 14:495-506, Copyright 2016.
Patients who have mild disease (defined as fewer than four episodes/year, episodes lasting up to 2 days, quick recovery from episodes, or episodes not requiring ED care or hospitalization) are usually prescribed abortive medications.16 These medications are best administered during the prodromal phase and can prevent progression to the emetic phase. Medications used for aborting episodes include sumatriptan (20 mg intranasal or 6 mg subcutaneous), ondansetron (8 mg sublingual), and diphenhydramine (25-50 mg).30,31 This combination can help abort symptoms and potentially avoid ED visits or hospitalizations. Patients with moderate-to-severe CVS are offered prophylactic therapy in addition to abortive therapy.16
Recent guidelines recommend tricyclic antidepressants (TCAs) as the first-line agent in the prophylaxis of CVS episodes. Data from 14 studies determined that 70% (413/600) of patients responded partially or completely to TCAs.16 An open-label study of 46 patients by Hejazi et al. noted a decline in the number of CVS episodes from 17 to 3, in the duration of a CVS episode from 6 to 2 days, and in the number of ED visits/ hospitalizations from 15 to 3.3.32Amitriptyline should be started at 25 mg at night and titrated up by 10-25 mg each week to minimize emergence of side effects. The mean effective dose is 75-100 mg or 1.0-1.5 mg/kg. An EKG should be checked at baseline and during titration to monitor the QT interval. Unfortunately, side effects from TCAs are quite common and include cognitive impairment, drowsiness, dryness of mouth, weight gain, constipation, and mood changes, which may warrant dose reduction or discontinuation. Antiepileptics such as topiramate, mitochondrial supplements such as Coenzyme Q10 and riboflavin are alternative prophylactic agents in CVS.33 Aprepitant, a newer NK1 receptor antagonist has been found to be effective in refractory CVS.34 In addition to pharmacotherapy, addressing comorbid conditions such as anxiety and depression and counseling patients to abstain from heavy cannabis use is also important to achieve good health care outcomes.
In summary, CVS is a common, chronic functional GI disorder with episodic nausea, vomiting, and often, abdominal pain. Symptoms can be disabling, and prompt diagnosis and therapy is important. CVS is associated with multiple comorbid conditions such as migraine, anxiety and depression, and a biopsychosocial model of care is essential. Medications such as amitriptyline are effective in the prophylaxis of CVS, but side effects hamper their use. Recent recommendations for management of CVS have been published.16 Cannabis is frequently used by patients for symptom relief but use of high potency products may cause worsening of symptoms or unmask symptoms in genetically predisposed individuals.23 Studies to elucidate the pathophysiology of CVS should help in the development of better therapies.
Dr. Mooers is PGY-2, an internal medicine resident in the department of medicine, Medical College of Wisconsin, Milwaukee; Dr. Venkatesan is professor of medicine, division of gastroenterology and hepatology, department of medicine, Medical College of Wisconsin, Milwaukee. The authors have no conflicts to disclose.
References
1. Stanghellini V et al. Gastroenterology. 2016;150:1380-92.
2. Aziz I et al. Clin Gastroenterol Hepatol. 2019 Apr;17(5):878-86.
3. Kovacic K et al. Curr Gastroenterol Rep. 2018;20(10):46.
4. Zaki EA et al. Cephalalgia. 2009;29:719-28.
5. Venkatesan T et al. BMC Gastroenterol. 2014;14:181.
6. Ellingsen DM et al. Neurogastroenterol Motil. 2017;29 (6)e13004 9.
7. Venkatesan T et al. Neurogastroenterol Motil. 2016;28:1409-18.
8. Wasilewski A et al. Am J Gastroenterol. 2017;112:933-9.
9. van Sickle MD et al. Am J Physiol Gastrointest Liver Physiol 2003;285:G566-76.
10. Parker LA et al. Br J Pharmacol. 2011;163:1411-22.
11. van Sickle MD et al. Gastroenterology. 2001;121:767-74.
12. Fleisher DR et al. BMC Med. 2005;3:20.
13. Kumar N et al. BMC Gastroenterol. 2012;12:52.
14. Li BU et al. J Pediatr Gastroenterol Nutr. 2008;47:379-93.
15. Bhandari S et al. Clin Auton Res. 2018 Apr;28(2):203-9.
16. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13604. doi: 10.1111/nmo.13604.
17. Sagar RC et al. Neurogastroenterol Motil. 2018;30. doi: 10.1111/nmo.13174.
18. Taranukha T et al. Neurogastroenterol Motil. 2018 Apr;30(4):e13245. doi: 10.1111/nmo.13245.
19. Bhandari S and Venkatesan T. Dig Dis Sci. 2017;62:2035-44.
20. Choung RS et al. Neurogastroenterol Motil. 2012;24:20-6, e21. doi: 10.1111/j.1365-2982.2011.01791.x.
21. Bhandari S et al. Intern Med J. 2019 May;49(5):649-55.
22. Venkatesan T et al. Exp Brain Res. 2014; 232:2563-70.
23. Venkatesan T et al. Clin Gastroenterol Hepatol. 2019 Jul 25. doi: 10.1016/j.cgh.2019.07.039.
24. Simonetto DA et al. Mayo Clin Proc. 2012;87:114-9.
25. Wallace EA et al. South Med J. 2011;104:659-64.
26. Allen JH et al. Gut. 2004;53:1566-70.
27. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13606. doi: 10.1111/nmo.13606.
28. Habboushe J et al. Basic Clin Pharmacol Toxicol. 2018;122:660-2.
29. Bhandari S and Venkatesan T. Curr Treat Options Gastroenterol. 2016;14:495-506.
30. Hikita T et al. Cephalalgia. 2011;31:504-7.
31. Fuseau E et al. Clin Pharmacokinet 2002;41:801-11.
32. Hejazi RA et al. J Clin Gastroenterol. 2010;44:18-21.
33. Sezer OB and Sezer T. J Neurogastroenterol Motil. 2016;22:656-60.
34. Cristofori F et al. Aliment Pharmacol Ther. 2014;40:309-17.
Introduction
Cyclic vomiting syndrome (CVS) is a chronic disorder of gut-brain interaction (DGBI) and is characterized by recurrent episodes of severe nausea, vomiting, and often, abdominal pain. Patients are usually asymptomatic in between episodes.1 CVS was considered a pediatric disease but is now known to be as common in adults. The prevalence of CVS in adults was 2% in a recent population-based study.2 Patients are predominantly white. Both males and females are affected with some studies showing a female preponderance. The mean age of onset is 5 years in children and 35 years in adults.3
The etiology of CVS is not known, but various hypotheses have been proposed. Zaki et al. showed that two mitochondrial DNA polymorphisms 16519T and 3010A were associated with a 17-fold increased odds of having CVS in children.4 These polymorphisms were not associated with CVS in adults.5 Alterations in the brain-gut axis also have been shown in CVS. Functional neuroimaging studies demonstrate that patients with CVS displayed increased connectivity between insula and salience networks with concomitant decrease in connectivity to somatosensory networks.6 Recent data also indicate that the endocannabinoid system (ECS) and the hypothalamic-pituitary-adrenal axis are implicated in CVS with an increase in serum endocannabinoid concentration during an episode.7 The same study also showed a significant increase in salivary cortisol in CVS patients who used cannabis. Further, single nucleotide polymorphisms (SNPs) in the gene that encodes for the cannabinoid receptor type 1 (CB1R) are implicated in CVS.8 The CB1R is part of the ECS and is densely expressed in brain areas involved in emesis, such as the dorsal vagal complex consisting of the area postrema (AP), nucleus of the solitary tract (NTS), and also the dorsal motor nucleus of the vagus.9 Wasilewski et al. showed an increased risk of CVS among individuals with AG and GG genotypes of CNR1 rs806380 (P less than .01), whereas the CC genotype of CNR1 rs806368 was associated with a decreased risk of CVS (P less than .05).8 CB1R agonists – endocannabinoids and tetrahydrocannabinol (THC) – have acute antiemetic and anxiolytic effects.9-11 The apparent paradoxical effects of cannabis in this patient population are yet to be explained and need further study.
Diagnosis and clinical features of CVS
Figure 1: Phases of Cyclic Vomiting Syndrome12
Adapted from Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic Vomiting Syndrome in 41 adults: The illness, the patients, and problems of management. BMC Med 2005;3:20. This work is licensed under the Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/, which permits unrestricted use, distribution, modification, and reproduction in any medium.
CVS consists of four phases which include the a) prodromal phase, b) the episodic phase, c) recovery phase, and d) the interepisodic phase; and was first described by David Fleisher.12 The phases of CVS are important for clinicians and patients alike as they have therapeutic implications. The administration of abortive medications during a prodrome can terminate an episode. The phases of CVS are shown above.
Most patients (~ 93%) have a prodromal phase. Symptoms during this phase can include nausea, abdominal pain, diaphoresis, fatigue, weakness, hot flashes, chills, shivering, increased thirst, loss of appetite, burping, lightheadedness, and paresthesia.13 Some patients report a sense of impending doom and many have symptoms consistent with panic. If untreated, this progresses to the emetic phase and patients have unrelenting nausea, retching, vomiting, and other symptoms. During an episode, patients may vomit up to 20 times per hour and the episode may last several hours to days. During this phase, patients are sometimes described as being in a “conscious coma” and exhibit lethargy, listlessness, withdrawal, and sometimes disorientation.14,15 The emetic phase is followed by the recovery phase, during which symptoms subside and patients are able to resume oral intake. Patients are usually asymptomatic between episodes but ~ 30% can have interepisodic nausea and dyspepsia. In some patients, episodes become progressively longer and the interepisodic phase is considerably shortened and patients have a “coalescence of symptoms.”12 It is important to elicit a thorough history in all patients with vomiting in order to make an accurate diagnosis of CVS since coalescence of symptoms only occurs over a period of time. Episodes often are triggered by psychological stress, both positive and negative. Common triggers can include positive events such as birthdays, holidays, and negative ones like examinations, the death of a loved one, etc. Sleep deprivation and physical exhaustion also can trigger an episode.12
CVS remains a clinical diagnosis since there are no biomarkers. While there is a lack of data on the optimal work-up in these patients, experts recommend an upper endoscopy or upper GI series in order to rule out alternative gastric and intestinal pathology (e.g., malrotation with volvulus).16 Of note, a gastric-emptying study is not recommended as part of the routine work-up as per recent guidelines because of the poor specificity of this test in establishing a diagnosis of CVS.16 Biochemical testing including a complete blood count, serum electrolytes, serum glucose, liver panel, and urinalysis is also warranted. Any additional testing is indicated when clinical features suggest an alternative diagnosis. For instance, neurologic symptoms might warrant a cranial MRI to exclude an intracerebral tumor or other lesions of the brain.
The severity and unpredictable nature of symptoms makes it difficult for some patients to attend school or work; one study found that 32% of patients with CVS were completely disabled.12 Despite increasing awareness of this disorder, patients often are misdiagnosed. The prevalence of CVS in an outpatient gastroenterology clinic in the United Kingdom was 11% and was markedly underdiagnosed in the community.17 Only 5% of patients who were subsequently diagnosed with CVS were initially diagnosed accurately by their referring physician despite meeting criteria for the disorder.17 A subset of patients with CVS even undergo futile surgeries.13 Fleisher et al. noted that 30% of a 41-patient cohort underwent cholecystectomy for CVS symptoms without any improvement in disease.12 Prompt diagnosis and appropriate therapy is essential to improve patient outcomes and improve quality of life.
CVS is associated with various comorbidities such as migraine, anxiety, depression and dysautonomia, which can further impair quality of life.18,19 Approximately 70% of CVS patients report a personal or family history of migraine. Anxiety and depression affects nearly half of patients with CVS.13 Cannabis use is significantly more prevalent among patients with CVS than patients without CVS.20
Role of cannabis in CVS
The role of cannabis in the pathogenesis of symptoms in CVS is controversial. While cannabis has antiemetic properties, there is a strong link between its use and CVS. The use of cannabis has increased over the past decade with increasing legalization.21 Several studies have shown that 40%-80% of patients with CVS use cannabis.22,23 Following this, cannabinoid hyperemesis syndrome (CHS) was coined as a separate entity based on this statistical association, though there are no data to support the notion that cannabis causes vomiting.24,25 CHS has clinical features that are indistinguishable from CVS except for the chronic heavy cannabis use. A peculiar bathing behavior called “compulsive hot-water bathing” has been described and was thought to be pathognomonic of cannabis use.26 During an episode, patients will take multiple hot showers/baths, which temporarily alleviate their symptoms. Many patients even report running out of hot water and sometimes check into a hotel for a continuous supply of hot water. A small number of patients may sustain burns from the hot-water bathing. However, studies show that this hot-water bathing behavior also is seen in about 50% of patents with CVS who do not use cannabis.22
CHS is now defined by Rome IV criteria, which include episodes of nausea and vomiting similar to CVS preceded by chronic, heavy cannabis use. Patients must have complete resolution of symptoms following cessation.1 A recent systematic review of 376 cases of purported CHS showed that only 59 (15.7%) met Rome IV criteria for this disorder.27 This is because of considerable heterogeneity in how the diagnosis of CHS was made and the lack of standard diagnostic criteria at the time. Some cases of CHS were diagnosed merely based on an association of vomiting, hot-water bathing, and cannabis use.28 Only a minority of patients (71,19%) had a duration of follow-up more than 4 weeks, which would make it impossible to establish a diagnosis of CHS. A period of at least a year or a duration of time that spans at least three episodes is generally recommended to determine if abstinence from cannabis causes a true resolution of symptoms.27 Whether CHS is a separate entity or a subtype of CVS remains to be determined. The paradoxical effects of cannabis may happen because of the use of highly potent cannabis products that are currently in use. A complete discussion of the role of cannabis in CVS is beyond the scope of this article, and the reader is referred to a recent systematic review and discussion.27
Treatment
CVS should be treated based on a biopsychosocial model with a multidisciplinary team that includes a gastroenterologist with knowledge of CVS, primary care physician, psychologist, psychiatrist, and sleep specialist if needed.16 Initiating prophylactic treatment is based on the severity of disease. An algorithm for the treatment of CVS based on severity of symptoms is shown below.
Figure 2. Adapted and reprinted by permission from the Licensor: Springer Nature, Current Treatment Options in Gastroenterology, Bhandari S, Venkatesan T. Novel Treatments for Cyclic Vomiting Syndrome: Beyond Ondansetron and Amitriptyline, 14:495-506, Copyright 2016.
Patients who have mild disease (defined as fewer than four episodes/year, episodes lasting up to 2 days, quick recovery from episodes, or episodes not requiring ED care or hospitalization) are usually prescribed abortive medications.16 These medications are best administered during the prodromal phase and can prevent progression to the emetic phase. Medications used for aborting episodes include sumatriptan (20 mg intranasal or 6 mg subcutaneous), ondansetron (8 mg sublingual), and diphenhydramine (25-50 mg).30,31 This combination can help abort symptoms and potentially avoid ED visits or hospitalizations. Patients with moderate-to-severe CVS are offered prophylactic therapy in addition to abortive therapy.16
Recent guidelines recommend tricyclic antidepressants (TCAs) as the first-line agent in the prophylaxis of CVS episodes. Data from 14 studies determined that 70% (413/600) of patients responded partially or completely to TCAs.16 An open-label study of 46 patients by Hejazi et al. noted a decline in the number of CVS episodes from 17 to 3, in the duration of a CVS episode from 6 to 2 days, and in the number of ED visits/ hospitalizations from 15 to 3.3.32Amitriptyline should be started at 25 mg at night and titrated up by 10-25 mg each week to minimize emergence of side effects. The mean effective dose is 75-100 mg or 1.0-1.5 mg/kg. An EKG should be checked at baseline and during titration to monitor the QT interval. Unfortunately, side effects from TCAs are quite common and include cognitive impairment, drowsiness, dryness of mouth, weight gain, constipation, and mood changes, which may warrant dose reduction or discontinuation. Antiepileptics such as topiramate, mitochondrial supplements such as Coenzyme Q10 and riboflavin are alternative prophylactic agents in CVS.33 Aprepitant, a newer NK1 receptor antagonist has been found to be effective in refractory CVS.34 In addition to pharmacotherapy, addressing comorbid conditions such as anxiety and depression and counseling patients to abstain from heavy cannabis use is also important to achieve good health care outcomes.
In summary, CVS is a common, chronic functional GI disorder with episodic nausea, vomiting, and often, abdominal pain. Symptoms can be disabling, and prompt diagnosis and therapy is important. CVS is associated with multiple comorbid conditions such as migraine, anxiety and depression, and a biopsychosocial model of care is essential. Medications such as amitriptyline are effective in the prophylaxis of CVS, but side effects hamper their use. Recent recommendations for management of CVS have been published.16 Cannabis is frequently used by patients for symptom relief but use of high potency products may cause worsening of symptoms or unmask symptoms in genetically predisposed individuals.23 Studies to elucidate the pathophysiology of CVS should help in the development of better therapies.
Dr. Mooers is PGY-2, an internal medicine resident in the department of medicine, Medical College of Wisconsin, Milwaukee; Dr. Venkatesan is professor of medicine, division of gastroenterology and hepatology, department of medicine, Medical College of Wisconsin, Milwaukee. The authors have no conflicts to disclose.
References
1. Stanghellini V et al. Gastroenterology. 2016;150:1380-92.
2. Aziz I et al. Clin Gastroenterol Hepatol. 2019 Apr;17(5):878-86.
3. Kovacic K et al. Curr Gastroenterol Rep. 2018;20(10):46.
4. Zaki EA et al. Cephalalgia. 2009;29:719-28.
5. Venkatesan T et al. BMC Gastroenterol. 2014;14:181.
6. Ellingsen DM et al. Neurogastroenterol Motil. 2017;29 (6)e13004 9.
7. Venkatesan T et al. Neurogastroenterol Motil. 2016;28:1409-18.
8. Wasilewski A et al. Am J Gastroenterol. 2017;112:933-9.
9. van Sickle MD et al. Am J Physiol Gastrointest Liver Physiol 2003;285:G566-76.
10. Parker LA et al. Br J Pharmacol. 2011;163:1411-22.
11. van Sickle MD et al. Gastroenterology. 2001;121:767-74.
12. Fleisher DR et al. BMC Med. 2005;3:20.
13. Kumar N et al. BMC Gastroenterol. 2012;12:52.
14. Li BU et al. J Pediatr Gastroenterol Nutr. 2008;47:379-93.
15. Bhandari S et al. Clin Auton Res. 2018 Apr;28(2):203-9.
16. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13604. doi: 10.1111/nmo.13604.
17. Sagar RC et al. Neurogastroenterol Motil. 2018;30. doi: 10.1111/nmo.13174.
18. Taranukha T et al. Neurogastroenterol Motil. 2018 Apr;30(4):e13245. doi: 10.1111/nmo.13245.
19. Bhandari S and Venkatesan T. Dig Dis Sci. 2017;62:2035-44.
20. Choung RS et al. Neurogastroenterol Motil. 2012;24:20-6, e21. doi: 10.1111/j.1365-2982.2011.01791.x.
21. Bhandari S et al. Intern Med J. 2019 May;49(5):649-55.
22. Venkatesan T et al. Exp Brain Res. 2014; 232:2563-70.
23. Venkatesan T et al. Clin Gastroenterol Hepatol. 2019 Jul 25. doi: 10.1016/j.cgh.2019.07.039.
24. Simonetto DA et al. Mayo Clin Proc. 2012;87:114-9.
25. Wallace EA et al. South Med J. 2011;104:659-64.
26. Allen JH et al. Gut. 2004;53:1566-70.
27. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13606. doi: 10.1111/nmo.13606.
28. Habboushe J et al. Basic Clin Pharmacol Toxicol. 2018;122:660-2.
29. Bhandari S and Venkatesan T. Curr Treat Options Gastroenterol. 2016;14:495-506.
30. Hikita T et al. Cephalalgia. 2011;31:504-7.
31. Fuseau E et al. Clin Pharmacokinet 2002;41:801-11.
32. Hejazi RA et al. J Clin Gastroenterol. 2010;44:18-21.
33. Sezer OB and Sezer T. J Neurogastroenterol Motil. 2016;22:656-60.
34. Cristofori F et al. Aliment Pharmacol Ther. 2014;40:309-17.
COVID-19: Implications in gastroenterology
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
What is coronavirus disease 2019 (COVID-19)?
COVID-19 is a viral respiratory illness that can be potentially life-threatening and is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The constellation of symptoms varies in severity but most often includes fever, fatigue, myalgias, cough, and dyspnea. Digestive symptoms such as anorexia, nausea, and diarrhea have also been reported.1 The incubation period of the virus appears to range from 1 to 14 days, most commonly between 3 and 7 days.2 The virus is characterized by its efficient person-to-person transmission, with each case leading to 1.4-3.9 additional infected individuals on average, which has led to a global pandemic and one of the most significant public health crises in modern history.
What are the most vulnerable patient populations within a typical gastroenterology practice?
While the virus can affect anyone, and there are increasing reports of young individuals requiring intensive care, older patients are thought to be at the highest risk for severe disease – particularly those older than age 60 years. Those who developed disease requiring admission to an ICU in Wuhan, China, had a median age of 66 years with comorbid conditions including hypertension, diabetes, and cardiovascular and cerebrovascular disease.3 In addition to these, the Centers for Disease Control and Prevention identifies those who live in a nursing home or long-term care facility to be at high risk, and patients with chronic lung disease, severe obesity, renal failure, or liver disease also may be at increased risk.4 There is often a question if patients on immunosuppression, such as those with inflammatory bowel disease, are at increased risk for the development of infection. At the time of writing, there are not available data that demonstrate this association. Regarding pregnant and lactating women, limited studies done on pregnant patients with COVID-19 revealed that the virus was not transmitted to the fetus in later stages of pregnancy or into breast milk.5 As there is much that has yet to be clearly elucidated, it is prudent to recommend that all patients adhere to social distancing guidelines (including working from home when possible) as well as frequent and thorough hand washing, avoidance of touching one’s face, and avoidance of sick contacts.
Can COVID-19 present with gastrointestinal symptoms?
While initial reports did not describe this as a common presentation, a subsequent multicenter study out of the Hubei province in China reported that nearly half of all patients in the study with COVID-19 had one or more digestive symptoms as their chief complaint. Of note, the study cited the most common digestive complaint as anorexia, which is not necessarily specific to the gastrointestinal tract. Twenty percent of the patients in their cohort did report either abdominal pain, vomiting, or diarrhea.1,6 The majority had concomitant respiratory symptoms, though a small minority (7%) had digestive symptoms only. In patients reporting diarrhea, it was not described as high volume or clinically severe, but the digestive symptoms worsened with severity of the overall disease. Interestingly, the first patient with COVID-19 in the United States presented with nausea, vomiting, and diarrhea; ultimately, stool and respiratory specimens tested positive for the virus. This has led to the question of fecal-oral transmission in addition to, or in lieu of, aerosolization, which has been thought to be the primary mode of transmission.7 There have also been increasing reports of ageusia and anosmia, sometimes as the presenting complaint.8 More data are certainly needed; however, the possibility of gastrointestinal symptoms as a manifestation of COVID-19 and of fecal-oral transmission should be kept in mind when evaluating patients and performing procedures.
What kind of personal protective equipment (PPE) should I wear while performing endoscopy?
An early publication from Italy suggested a risk-stratification system in order to dictate the type of PPE to wear for endoscopy; however, official recommendations from the American Gastroenterological Association (AGA) have since emerged.9,10 For both upper and lower endoscopic procedures, regardless of COVID-19 status, it is recommended to wear a respirator mask, which is specifically designed to block aerosols (N95, N99, or powered air purifying respirator). Given that upper endoscopic procedures are aerosol-generating procedures and there is a theoretic risk to aerosolization during colonoscopy (especially during insertion of instruments through the biopsy channel), respirator masks will provide the most protection to the endoscopist. In addition, the presence of SARS-CoV-2 RNA in fecal samples, although of unclear clinical significance at this time, led to the recommended use of respirators for lower endoscopic procedures as well.
Furthermore, endoscopists should double-glove for all endoscopic procedures in order to reduce viral transmission from contaminated PPE to hands or clothing. Also, in known or presumptive COVID-19 positive patients, negative pressure rooms for endoscopy should be utilized when available.10
If I have been exposed or if I develop symptoms suspicious for COVID-19, what should I do?
First and foremost, a health care provider should reach out to their physician as well as department leadership if in either situation. The CDC recommends immediate self-quarantine if there is any suspicion you may have COVID-19 to minimize further person-to-person transmission.11 This means staying home from work, avoiding public places, and if possible, separating yourself from others in your home. The decision for testing may be individualized based on regional availability of tests, nature of exposure, or severity of symptoms. Many institutions have a sick health care worker triage number in place to advise further. Be cognizant of your symptoms, particularly your respiratory status, and if your condition appears to be worsening seek prompt medical attention and, if possible, call ahead to facilitate being triaged appropriately upon arrival.
As a trainee, how can I minimize my risk while continuing medical education?
Most institutions are implementing ways to minimize exposure of trainees to patients. Ways of doing so include limiting the number of individuals on bedside rounds, providing consultative care and recommendations remotely, conducting team discussions of patients remotely, avoiding workrooms or common areas, and practicing social distancing at the hospital. Some institutions are also consolidating inpatient fellows/services in order to limit fellow time in the hospital, recommending against fellow participation in endoscopy and in-person ambulatory care in order to protect fellows as well as preserve PPE. The reduction in in-person clinical care should be tempered by continuing to prioritize medical education during this time. Fellows can still be involved in an outpatient clinic setting by conducting virtual visits and engaging in telehealth, as many specialties are instituting. Furthermore, clinical conferences, board reviews, and journal club can still be conducted through digital platforms and remain interactive. Trainees can also wisely utilize this unexpected period away from the hospital to complete research projects, case reports, and review articles, thereby strengthening resumes for upcoming job searches or advanced fellowship applications.
To engage in more discussion on how to navigate educational activities in fellowship at this time, visit the AGA community.
To learn more about COVID-19 and its implications for gastroenterologists, visit the AGA university site which features helpful educational modules.
Lastly, the Joint GI Society message on COVID-19 can be found here.
References
1. Pan L et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastro. 2020. doi: 10.14309/ajg.0000000000000620.
2. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506.
3. Wang D et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA. 2020 Feb 7;323(11):1061-9.
4. Centers for Disease Control and Prevention. Information for Healthcare Professionals: COVID-19 and Underlying Conditions. Accessed March 22, 2020.
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med. 2020. doi: 10.5858/arpa.2020-0901-SA.
6. Guan W et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032.
7. Gu J et al. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. doi: 10.1053/j.gastro.2020.02.054.
8. The New York Times. Roni Caryn Rabin, “Lost Sense of Smell May Be a Clue to Coronavirus Infection.” Accessed March 24, 2020.
9. Repici A et al. Coronavirus (COVID-19) outbreak: What the department of endoscopy should know. Gastrointest Endosc. 2020 Mar 14. doi: 10.1016/j.gie.2020.03.019.
10. Sultan S et al. AGA Institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020 Mar 31. doi: 10.1053/j.gastro.2020.03.072.
11. Centers for Disease Control and Prevention. COVID-19: What to do if you are sick. Accessed March 22, 2020.
Dr. V.L. Rao is assistant professor of medicine, section of gastroenterology, hepatology, nutrition, department of internal medicine, University of Chicago Medicine; Dr. K. Rao is assistant professor, division of infectious diseases, department of internal medicine, University of Michigan Medical School, Ann Arbor.
Calendar
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
May 2-5, 2020
Digestive Disease Week® (DDW)
DDW® 2020 and all associated events have been canceled. While we are disappointed to miss the science, education and networking that are hallmarks of DDW®, we must focus on the health and safety of our community. Certainly, this cancellation raises many questions. We have attempted to answer them in this FAQ and remain committed to keeping you informed of new details as they form.
Aug. 14-15, 2020
James W. Freston Single Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 James W. Freston Conference will take place as scheduled and continue to monitor the situation.
Chicago, IL
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 Principles of GI for the NP and PA will take place as scheduled and continue to monitor the situation.
Denver, CO
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
May 2-5, 2020
Digestive Disease Week® (DDW)
DDW® 2020 and all associated events have been canceled. While we are disappointed to miss the science, education and networking that are hallmarks of DDW®, we must focus on the health and safety of our community. Certainly, this cancellation raises many questions. We have attempted to answer them in this FAQ and remain committed to keeping you informed of new details as they form.
Aug. 14-15, 2020
James W. Freston Single Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 James W. Freston Conference will take place as scheduled and continue to monitor the situation.
Chicago, IL
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 Principles of GI for the NP and PA will take place as scheduled and continue to monitor the situation.
Denver, CO
For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.
UPCOMING EVENTS
May 2-5, 2020
Digestive Disease Week® (DDW)
DDW® 2020 and all associated events have been canceled. While we are disappointed to miss the science, education and networking that are hallmarks of DDW®, we must focus on the health and safety of our community. Certainly, this cancellation raises many questions. We have attempted to answer them in this FAQ and remain committed to keeping you informed of new details as they form.
Aug. 14-15, 2020
James W. Freston Single Topic Conference: Gastrointestinal Organoids and Engineered Organ Systems
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 James W. Freston Conference will take place as scheduled and continue to monitor the situation.
Chicago, IL
Aug. 14-16, 2020
2020 Principles of GI for the NP and PA
AGA is actively evaluating developments concerning coronavirus. We expect the 2020 Principles of GI for the NP and PA will take place as scheduled and continue to monitor the situation.
Denver, CO
AGA News
Coronavirus 101 for gastroenterologists
Now in AGA University: Gain a clear understanding of the lifespan and gastrointestinal manifestations of SARS-CoV-2 and best practices for protecting yourself while working with at-risk patients. http://agau.gastro.org/diweb/catalog/item/eid/COVID-19
Get the latest information and resources on coronavirus by visiting www.gastro.org/COVID.
A message from our president to the GI community
“Our commitment at AGA is to support you. We’ll get through this together,” says AGA President Hashem El-Serag, MD, MPH, AGAF.
Dear colleagues,
The coronavirus pandemic has affected every facet of society, bringing almost unprecedented challenges to our world, and especially to our world of health care.
But our profession has been ignited in the way only a crisis can spark. Many of you are working on the front lines of patient care, at personal risk, lacking sufficient information and adequate resources. This is heroic work.
AGA’s priority during this time of disruption is to get practical guidance into your hands to help you treat patients, and protect yourselves and your coworkers. We’re also advocating on your behalf to get the resources you need and economic relief necessitated by the measures taken to fight the pandemic.
We are continually updating our COVID-19 website, www.gastro.org/covid. Check it for the latest clinical guidance, practice management information, and advocacy initiatives.
Our journals have started a collection of submissions related to COVID-19. Your AGA colleagues on the Clinical Guidelines Committee and Clinical Practice Updates Committee have been hard at work developing guidance for questions that you have asked us on Twitter, @AmerGastroAssn, and the AGA Community. So join us there where resources and insights are being shared in real time.
Your commitment to our patients is a testament to your professionalism. Our commitment at AGA is to support you.
We’ll get through this together.
Hashem B. El-Serag, MD, MPH, AGAF
President, AGA Institute
AGA selects two new social media editors
Congratulations to our new social media editors, Mindy Engevik, PhD, and Sultan Mahmood, MD.
Both editors will have the opportunity to positively impact AGA journal engagement by increasing the dissemination of each of the AGA publications’ content across their social media platforms. Dr. Engevik will focus on basic and translational science research and Dr. Mahmood will focus on clinical research. They will be sharing noteworthy research and news across AGA’s diverse publication portfolio, which includes Gastroenterology, Clinical Gastroenterology and Hepatology, Cellular and Molecular Gastroenterology and Hepatology, Techniques and Innovations in Gastrointestinal Endoscopy, GI & Hepatology News, and the New Gastroenterologist.
Melinda Engevik, PhD
@MicroMindy
Dr. Engevik is an instructor at Baylor College of Medicine, Houston, in the department of pathology and immunology. She has a PhD in systems biology and physiology from the University of Cincinnati and completed her postdoctoral training at Baylor College of Medicine. Her research focuses on microbe-epithelial interactions in the gastrointestinal tract, with a particular focus on infection and inflammatory bowel disease. Dr. Engevik currently serves as an AGA Young Delegate and enjoys her involvement in the GI community.
Sultan Mahmood, MD
@SultanMahmoodMD
Dr. Mahmood finished his medical school in King Edward Medical University in Lahore, Pakistan. He did his internal medicine residency as well as GI fellowship training in University of Oklahoma Health Sciences Center, Oklahoma City, where he also served as the chief fellow from 2017 to 2018. He is the cofounder of @GIjournal, which is a weekly GI journal club on Twitter. He is currently an assistant professor in the department of medicine, division of gastroenterology, at the University at Buffalo (N.Y.). He also serves the role of coprogram director of the GI fellowship program in University at Buffalo. His research interests include medical education, work-life balance, quality improvement in the endoscopy suite, and cold snare.
The journals’ board of editors and editorial staff congratulate the new social media editors and are excited to work with them over the next 3 years.
Diversify GI: Fola May
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
The University of California, Los Angeles, Women’s Basketball Program recognized AGA FORWARD Scholar Fola May, MD, PhD, MPhil, for exemplifying their values of being “uncommon” and going above and beyond.
You’ll find proof she meets these criteria through extracurriculars like her participation in the AGA FORWARD program – a National Institute of Health–funded initiative that supports underrepresented minority physician scientists – and as a GI patient advocate on Capitol Hill.
Dr. May’s unconventional career path is also testament to her ability to color outside the lines while creating a masterpiece.
“Realizing late in my training that I wanted a career in research, I joined the STAR program at UCLA which allowed me to complete a PhD in health policy and management [a health services research degree] during my GI fellowship. With this training, I have been able to pursue a career in research and clinical care far beyond what I ever imagined.”
But she noticed a void along her career path that she couldn’t fill on her own: limited access to diverse research leaders in the field who can serve as her mentors, supporters, and advocators.
“Though I have a wonderful mentorship team that has been instrumental to my success thus far, there are currently no senior health services researchers in gastroenterology or gastroenterologists of color at my institution.”
At Dr. May’s institution, there are about 60 faculty members – only 1 Hispanic female. At the academic health center where Dr. May works, she is the only African American gastroenterologist. Other divisions and departments do not look much different, she explained.
“We serve a massive, diverse urban center. I don’t understand it, and I feel strongly that we can do better.”
She stressed that the key to breaking unjust cultural norms is for white colleagues to acknowledge the issues minorities face and to make intentional efforts to increase diversity in the workforce.
“We can’t expect black and brown faculty to do it on their own. The ‘minority tax’ that we face is a heavy toll and has the potential to paralyze our careers. We need members of the majority populations to also embrace diversity issues.”
Let’s get personal
- What do you know now that you wish someone told you when you started your career? “I wish that someone told me earlier that there will come a time when you will transition from working hard to check off all the check boxes to working hard in the things that make you happy. So much of medical school and residency is about doing what you are told you have to do to succeed. Finally, I feel that I am encouraged to find the research topics and patient populations that I am most passionate about. In dedicating ourselves to the things we care most about we have the best opportunity for real impact.”
- Who is your professional hero and why? “Wow. Honestly, I do not have one. Maybe Michelle Obama. I know she is not in medicine, but I pick her because she is an African American women who I know has been put through a lot and has to put up with a lot. But she keeps her head up high and stays strong. Reading her book transformed me. You can’t tell by just looking at her, all that she’s had to deal with. I would like to be seen as someone who is strong despite all of the background noise.”
- Something you may not know about me is: “I am pretty obsessed with CrossFit and fitness. I really enjoy staying active.”
- If I weren’t in gastroenterology, I would be: “A television/movie writer or movie producer.”
- In my free time I like to: “Spend time with my husband and kids, travel, stay active.”
Coronavirus 101 for gastroenterologists
Now in AGA University: Gain a clear understanding of the lifespan and gastrointestinal manifestations of SARS-CoV-2 and best practices for protecting yourself while working with at-risk patients. http://agau.gastro.org/diweb/catalog/item/eid/COVID-19
Get the latest information and resources on coronavirus by visiting www.gastro.org/COVID.
A message from our president to the GI community
“Our commitment at AGA is to support you. We’ll get through this together,” says AGA President Hashem El-Serag, MD, MPH, AGAF.
Dear colleagues,
The coronavirus pandemic has affected every facet of society, bringing almost unprecedented challenges to our world, and especially to our world of health care.
But our profession has been ignited in the way only a crisis can spark. Many of you are working on the front lines of patient care, at personal risk, lacking sufficient information and adequate resources. This is heroic work.
AGA’s priority during this time of disruption is to get practical guidance into your hands to help you treat patients, and protect yourselves and your coworkers. We’re also advocating on your behalf to get the resources you need and economic relief necessitated by the measures taken to fight the pandemic.
We are continually updating our COVID-19 website, www.gastro.org/covid. Check it for the latest clinical guidance, practice management information, and advocacy initiatives.
Our journals have started a collection of submissions related to COVID-19. Your AGA colleagues on the Clinical Guidelines Committee and Clinical Practice Updates Committee have been hard at work developing guidance for questions that you have asked us on Twitter, @AmerGastroAssn, and the AGA Community. So join us there where resources and insights are being shared in real time.
Your commitment to our patients is a testament to your professionalism. Our commitment at AGA is to support you.
We’ll get through this together.
Hashem B. El-Serag, MD, MPH, AGAF
President, AGA Institute
AGA selects two new social media editors
Congratulations to our new social media editors, Mindy Engevik, PhD, and Sultan Mahmood, MD.
Both editors will have the opportunity to positively impact AGA journal engagement by increasing the dissemination of each of the AGA publications’ content across their social media platforms. Dr. Engevik will focus on basic and translational science research and Dr. Mahmood will focus on clinical research. They will be sharing noteworthy research and news across AGA’s diverse publication portfolio, which includes Gastroenterology, Clinical Gastroenterology and Hepatology, Cellular and Molecular Gastroenterology and Hepatology, Techniques and Innovations in Gastrointestinal Endoscopy, GI & Hepatology News, and the New Gastroenterologist.
Melinda Engevik, PhD
@MicroMindy
Dr. Engevik is an instructor at Baylor College of Medicine, Houston, in the department of pathology and immunology. She has a PhD in systems biology and physiology from the University of Cincinnati and completed her postdoctoral training at Baylor College of Medicine. Her research focuses on microbe-epithelial interactions in the gastrointestinal tract, with a particular focus on infection and inflammatory bowel disease. Dr. Engevik currently serves as an AGA Young Delegate and enjoys her involvement in the GI community.
Sultan Mahmood, MD
@SultanMahmoodMD
Dr. Mahmood finished his medical school in King Edward Medical University in Lahore, Pakistan. He did his internal medicine residency as well as GI fellowship training in University of Oklahoma Health Sciences Center, Oklahoma City, where he also served as the chief fellow from 2017 to 2018. He is the cofounder of @GIjournal, which is a weekly GI journal club on Twitter. He is currently an assistant professor in the department of medicine, division of gastroenterology, at the University at Buffalo (N.Y.). He also serves the role of coprogram director of the GI fellowship program in University at Buffalo. His research interests include medical education, work-life balance, quality improvement in the endoscopy suite, and cold snare.
The journals’ board of editors and editorial staff congratulate the new social media editors and are excited to work with them over the next 3 years.
Diversify GI: Fola May
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
The University of California, Los Angeles, Women’s Basketball Program recognized AGA FORWARD Scholar Fola May, MD, PhD, MPhil, for exemplifying their values of being “uncommon” and going above and beyond.
You’ll find proof she meets these criteria through extracurriculars like her participation in the AGA FORWARD program – a National Institute of Health–funded initiative that supports underrepresented minority physician scientists – and as a GI patient advocate on Capitol Hill.
Dr. May’s unconventional career path is also testament to her ability to color outside the lines while creating a masterpiece.
“Realizing late in my training that I wanted a career in research, I joined the STAR program at UCLA which allowed me to complete a PhD in health policy and management [a health services research degree] during my GI fellowship. With this training, I have been able to pursue a career in research and clinical care far beyond what I ever imagined.”
But she noticed a void along her career path that she couldn’t fill on her own: limited access to diverse research leaders in the field who can serve as her mentors, supporters, and advocators.
“Though I have a wonderful mentorship team that has been instrumental to my success thus far, there are currently no senior health services researchers in gastroenterology or gastroenterologists of color at my institution.”
At Dr. May’s institution, there are about 60 faculty members – only 1 Hispanic female. At the academic health center where Dr. May works, she is the only African American gastroenterologist. Other divisions and departments do not look much different, she explained.
“We serve a massive, diverse urban center. I don’t understand it, and I feel strongly that we can do better.”
She stressed that the key to breaking unjust cultural norms is for white colleagues to acknowledge the issues minorities face and to make intentional efforts to increase diversity in the workforce.
“We can’t expect black and brown faculty to do it on their own. The ‘minority tax’ that we face is a heavy toll and has the potential to paralyze our careers. We need members of the majority populations to also embrace diversity issues.”
Let’s get personal
- What do you know now that you wish someone told you when you started your career? “I wish that someone told me earlier that there will come a time when you will transition from working hard to check off all the check boxes to working hard in the things that make you happy. So much of medical school and residency is about doing what you are told you have to do to succeed. Finally, I feel that I am encouraged to find the research topics and patient populations that I am most passionate about. In dedicating ourselves to the things we care most about we have the best opportunity for real impact.”
- Who is your professional hero and why? “Wow. Honestly, I do not have one. Maybe Michelle Obama. I know she is not in medicine, but I pick her because she is an African American women who I know has been put through a lot and has to put up with a lot. But she keeps her head up high and stays strong. Reading her book transformed me. You can’t tell by just looking at her, all that she’s had to deal with. I would like to be seen as someone who is strong despite all of the background noise.”
- Something you may not know about me is: “I am pretty obsessed with CrossFit and fitness. I really enjoy staying active.”
- If I weren’t in gastroenterology, I would be: “A television/movie writer or movie producer.”
- In my free time I like to: “Spend time with my husband and kids, travel, stay active.”
Coronavirus 101 for gastroenterologists
Now in AGA University: Gain a clear understanding of the lifespan and gastrointestinal manifestations of SARS-CoV-2 and best practices for protecting yourself while working with at-risk patients. http://agau.gastro.org/diweb/catalog/item/eid/COVID-19
Get the latest information and resources on coronavirus by visiting www.gastro.org/COVID.
A message from our president to the GI community
“Our commitment at AGA is to support you. We’ll get through this together,” says AGA President Hashem El-Serag, MD, MPH, AGAF.
Dear colleagues,
The coronavirus pandemic has affected every facet of society, bringing almost unprecedented challenges to our world, and especially to our world of health care.
But our profession has been ignited in the way only a crisis can spark. Many of you are working on the front lines of patient care, at personal risk, lacking sufficient information and adequate resources. This is heroic work.
AGA’s priority during this time of disruption is to get practical guidance into your hands to help you treat patients, and protect yourselves and your coworkers. We’re also advocating on your behalf to get the resources you need and economic relief necessitated by the measures taken to fight the pandemic.
We are continually updating our COVID-19 website, www.gastro.org/covid. Check it for the latest clinical guidance, practice management information, and advocacy initiatives.
Our journals have started a collection of submissions related to COVID-19. Your AGA colleagues on the Clinical Guidelines Committee and Clinical Practice Updates Committee have been hard at work developing guidance for questions that you have asked us on Twitter, @AmerGastroAssn, and the AGA Community. So join us there where resources and insights are being shared in real time.
Your commitment to our patients is a testament to your professionalism. Our commitment at AGA is to support you.
We’ll get through this together.
Hashem B. El-Serag, MD, MPH, AGAF
President, AGA Institute
AGA selects two new social media editors
Congratulations to our new social media editors, Mindy Engevik, PhD, and Sultan Mahmood, MD.
Both editors will have the opportunity to positively impact AGA journal engagement by increasing the dissemination of each of the AGA publications’ content across their social media platforms. Dr. Engevik will focus on basic and translational science research and Dr. Mahmood will focus on clinical research. They will be sharing noteworthy research and news across AGA’s diverse publication portfolio, which includes Gastroenterology, Clinical Gastroenterology and Hepatology, Cellular and Molecular Gastroenterology and Hepatology, Techniques and Innovations in Gastrointestinal Endoscopy, GI & Hepatology News, and the New Gastroenterologist.
Melinda Engevik, PhD
@MicroMindy
Dr. Engevik is an instructor at Baylor College of Medicine, Houston, in the department of pathology and immunology. She has a PhD in systems biology and physiology from the University of Cincinnati and completed her postdoctoral training at Baylor College of Medicine. Her research focuses on microbe-epithelial interactions in the gastrointestinal tract, with a particular focus on infection and inflammatory bowel disease. Dr. Engevik currently serves as an AGA Young Delegate and enjoys her involvement in the GI community.
Sultan Mahmood, MD
@SultanMahmoodMD
Dr. Mahmood finished his medical school in King Edward Medical University in Lahore, Pakistan. He did his internal medicine residency as well as GI fellowship training in University of Oklahoma Health Sciences Center, Oklahoma City, where he also served as the chief fellow from 2017 to 2018. He is the cofounder of @GIjournal, which is a weekly GI journal club on Twitter. He is currently an assistant professor in the department of medicine, division of gastroenterology, at the University at Buffalo (N.Y.). He also serves the role of coprogram director of the GI fellowship program in University at Buffalo. His research interests include medical education, work-life balance, quality improvement in the endoscopy suite, and cold snare.
The journals’ board of editors and editorial staff congratulate the new social media editors and are excited to work with them over the next 3 years.
Diversify GI: Fola May
We’re celebrating diversity in our field with a new series spotlighting members of the AGA Diversity Committee and AGA FORWARD Program.
The University of California, Los Angeles, Women’s Basketball Program recognized AGA FORWARD Scholar Fola May, MD, PhD, MPhil, for exemplifying their values of being “uncommon” and going above and beyond.
You’ll find proof she meets these criteria through extracurriculars like her participation in the AGA FORWARD program – a National Institute of Health–funded initiative that supports underrepresented minority physician scientists – and as a GI patient advocate on Capitol Hill.
Dr. May’s unconventional career path is also testament to her ability to color outside the lines while creating a masterpiece.
“Realizing late in my training that I wanted a career in research, I joined the STAR program at UCLA which allowed me to complete a PhD in health policy and management [a health services research degree] during my GI fellowship. With this training, I have been able to pursue a career in research and clinical care far beyond what I ever imagined.”
But she noticed a void along her career path that she couldn’t fill on her own: limited access to diverse research leaders in the field who can serve as her mentors, supporters, and advocators.
“Though I have a wonderful mentorship team that has been instrumental to my success thus far, there are currently no senior health services researchers in gastroenterology or gastroenterologists of color at my institution.”
At Dr. May’s institution, there are about 60 faculty members – only 1 Hispanic female. At the academic health center where Dr. May works, she is the only African American gastroenterologist. Other divisions and departments do not look much different, she explained.
“We serve a massive, diverse urban center. I don’t understand it, and I feel strongly that we can do better.”
She stressed that the key to breaking unjust cultural norms is for white colleagues to acknowledge the issues minorities face and to make intentional efforts to increase diversity in the workforce.
“We can’t expect black and brown faculty to do it on their own. The ‘minority tax’ that we face is a heavy toll and has the potential to paralyze our careers. We need members of the majority populations to also embrace diversity issues.”
Let’s get personal
- What do you know now that you wish someone told you when you started your career? “I wish that someone told me earlier that there will come a time when you will transition from working hard to check off all the check boxes to working hard in the things that make you happy. So much of medical school and residency is about doing what you are told you have to do to succeed. Finally, I feel that I am encouraged to find the research topics and patient populations that I am most passionate about. In dedicating ourselves to the things we care most about we have the best opportunity for real impact.”
- Who is your professional hero and why? “Wow. Honestly, I do not have one. Maybe Michelle Obama. I know she is not in medicine, but I pick her because she is an African American women who I know has been put through a lot and has to put up with a lot. But she keeps her head up high and stays strong. Reading her book transformed me. You can’t tell by just looking at her, all that she’s had to deal with. I would like to be seen as someone who is strong despite all of the background noise.”
- Something you may not know about me is: “I am pretty obsessed with CrossFit and fitness. I really enjoy staying active.”
- If I weren’t in gastroenterology, I would be: “A television/movie writer or movie producer.”
- In my free time I like to: “Spend time with my husband and kids, travel, stay active.”
May 2020 – ICYMI
Gastroenterology
February 2020
Gastric electrical stimulation reduces refractory vomiting in a randomized crossover trial. Philippe Ducrotte et al. 2020 Feb;158(3):506-14.e2. doi: 10.1053/j.gastro.2019.10.018
Efficacy and safety of vedolizumab subcutaneous formulation in a randomized trial of patients with ulcerative colitis. William J. Sandborn et al. 2020 Feb;158(3)562-72.e12. doi: 10.1053/j.gastro.2019.08.027
AGA Clinical Practice Guidelines on management of gastric intestinal metaplasia. Samir Gupta et al. 2020 Feb;158(3):693-702. doi: 10.1053/j.gastro.2019.12.003
March 2020
Approaches and challenges to management of pediatric and adult patients with eosinophilic esophagitis. Ikuo Hirano, Glenn T. Furuta. 2020 Mar;158(4):840-51. doi: 10.1053/j.gastro.2019.09.052
Uptake of colorectal cancer screening by physicians is associated with greater uptake by their patients. Owen Litwin et al. 2020 Mar;158(4):905-14. doi: 10.1053/j.gastro.2019.10.027
Recommendations for follow-up after colonoscopy and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Samir Gupta et al. 2020 Mar;158(4):1131-53.e5. doi: 10.1053/j.gastro.2019.10.026
Differences in fecal microbiomes and metabolomes of people with vs without irritable bowel syndrome and bile acid malabsorption. Ian B. Jeffery et al. 2020 Mar;158(4):1016-28.e8. doi: 10.1053/j.gastro.2019.11.301
April 2020
How to set up a successful motility lab. Rena Yadlapati et al. 2020 April;158(5):1202-10. doi: 10.1053/j.gastro.2020.01.030
Mechanisms, evaluation, and management of chronic constipation. Adil E. Bharucha, Brian E. Lacy. 2020 April;158(5):1232-49.e3. doi: 10.1053/j.gastro.2019.12.034.
Incidence of venous thromboembolism in patients with newly diagnosed pancreatic cancer and factors associated with outcomes. Corinne Frere et al. 2020 April;158(5):1346-58.e4. doi: 10.1053/j.gastro.2019.12.009
Clinical Gastroenterology and Hepatology
February 2020
Increased incidence and mortality of gastric cancer in immigrant populations from high to low regions of incidence: A systematic review and meta-analysis. Baldeep S. Pabla et al. 2020 Feb;18(2):347-59.e5. doi: 10.1016/j.cgh.2019.05.032
Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age. Neena S. Abraham et al. 2020 Feb;18(2):337-46.e19. doi: 10.1016/j.cgh.2019.05.017
Alcohol rehabilitation within 30 days of hospital discharge is associated with reduced readmission, relapse, and death in patients with alcoholic hepatitis. Thoetchai (Bee) Peeraphatdit et al. 2020 Feb;18(2):477-85.e5. doi: 10.1016/j.cgh.2019.04.048
March 2020
Telemedicine in gastroenterology: A value-added service for patients. Theresa Lee, Lawrence Kim. 2020 Mar;18(3):530-3. doi: 10.1016/j.cgh.2019.12.005
Best practices in teaching endoscopy based on a Delphi survey of gastroenterology program directors and experts in endoscopy education. Navin L. Kumar et al. 2020 Mar;18(3):574-9.e1. doi: 10.1016/j.cgh.2019.05.023
Consumption of fish and long-chain n-3 polyunsaturated fatty acids is associated with reduced risk of colorectal cancer in a large European cohort. Elom K. Aglago et al. 2020 Mar;18(3):654-66.e6. doi: 10.1016/j.cgh.2019.06.031
April 2020
Low incidence of aerodigestive cancers in patients with negative results from colonoscopies, regardless of findings from multitarget stool DNA tests. Barry M. Berger et al. 2020 April;18(4):864-71. doi: 10.1016/j.cgh.2019.07.057
Lifetime economic burden of Crohn’s disease and ulcerative colitis by age at diagnosis. Gary R. Lichtenstein et al. 2020 April;18(4):889-97.e10. doi: 10.1016/j.cgh.2019.07.022
Clinical and Molecular Gastroenterology and Hepatology
Etiopathogenetic mechanisms in diverticular disease of the colon. Michael Camilleri et al. 2020;9(1):15-32. doi: 10.1016/j.jcmgh.2019.07.007
Gastroenterology
February 2020
Gastric electrical stimulation reduces refractory vomiting in a randomized crossover trial. Philippe Ducrotte et al. 2020 Feb;158(3):506-14.e2. doi: 10.1053/j.gastro.2019.10.018
Efficacy and safety of vedolizumab subcutaneous formulation in a randomized trial of patients with ulcerative colitis. William J. Sandborn et al. 2020 Feb;158(3)562-72.e12. doi: 10.1053/j.gastro.2019.08.027
AGA Clinical Practice Guidelines on management of gastric intestinal metaplasia. Samir Gupta et al. 2020 Feb;158(3):693-702. doi: 10.1053/j.gastro.2019.12.003
March 2020
Approaches and challenges to management of pediatric and adult patients with eosinophilic esophagitis. Ikuo Hirano, Glenn T. Furuta. 2020 Mar;158(4):840-51. doi: 10.1053/j.gastro.2019.09.052
Uptake of colorectal cancer screening by physicians is associated with greater uptake by their patients. Owen Litwin et al. 2020 Mar;158(4):905-14. doi: 10.1053/j.gastro.2019.10.027
Recommendations for follow-up after colonoscopy and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Samir Gupta et al. 2020 Mar;158(4):1131-53.e5. doi: 10.1053/j.gastro.2019.10.026
Differences in fecal microbiomes and metabolomes of people with vs without irritable bowel syndrome and bile acid malabsorption. Ian B. Jeffery et al. 2020 Mar;158(4):1016-28.e8. doi: 10.1053/j.gastro.2019.11.301
April 2020
How to set up a successful motility lab. Rena Yadlapati et al. 2020 April;158(5):1202-10. doi: 10.1053/j.gastro.2020.01.030
Mechanisms, evaluation, and management of chronic constipation. Adil E. Bharucha, Brian E. Lacy. 2020 April;158(5):1232-49.e3. doi: 10.1053/j.gastro.2019.12.034.
Incidence of venous thromboembolism in patients with newly diagnosed pancreatic cancer and factors associated with outcomes. Corinne Frere et al. 2020 April;158(5):1346-58.e4. doi: 10.1053/j.gastro.2019.12.009
Clinical Gastroenterology and Hepatology
February 2020
Increased incidence and mortality of gastric cancer in immigrant populations from high to low regions of incidence: A systematic review and meta-analysis. Baldeep S. Pabla et al. 2020 Feb;18(2):347-59.e5. doi: 10.1016/j.cgh.2019.05.032
Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age. Neena S. Abraham et al. 2020 Feb;18(2):337-46.e19. doi: 10.1016/j.cgh.2019.05.017
Alcohol rehabilitation within 30 days of hospital discharge is associated with reduced readmission, relapse, and death in patients with alcoholic hepatitis. Thoetchai (Bee) Peeraphatdit et al. 2020 Feb;18(2):477-85.e5. doi: 10.1016/j.cgh.2019.04.048
March 2020
Telemedicine in gastroenterology: A value-added service for patients. Theresa Lee, Lawrence Kim. 2020 Mar;18(3):530-3. doi: 10.1016/j.cgh.2019.12.005
Best practices in teaching endoscopy based on a Delphi survey of gastroenterology program directors and experts in endoscopy education. Navin L. Kumar et al. 2020 Mar;18(3):574-9.e1. doi: 10.1016/j.cgh.2019.05.023
Consumption of fish and long-chain n-3 polyunsaturated fatty acids is associated with reduced risk of colorectal cancer in a large European cohort. Elom K. Aglago et al. 2020 Mar;18(3):654-66.e6. doi: 10.1016/j.cgh.2019.06.031
April 2020
Low incidence of aerodigestive cancers in patients with negative results from colonoscopies, regardless of findings from multitarget stool DNA tests. Barry M. Berger et al. 2020 April;18(4):864-71. doi: 10.1016/j.cgh.2019.07.057
Lifetime economic burden of Crohn’s disease and ulcerative colitis by age at diagnosis. Gary R. Lichtenstein et al. 2020 April;18(4):889-97.e10. doi: 10.1016/j.cgh.2019.07.022
Clinical and Molecular Gastroenterology and Hepatology
Etiopathogenetic mechanisms in diverticular disease of the colon. Michael Camilleri et al. 2020;9(1):15-32. doi: 10.1016/j.jcmgh.2019.07.007
Gastroenterology
February 2020
Gastric electrical stimulation reduces refractory vomiting in a randomized crossover trial. Philippe Ducrotte et al. 2020 Feb;158(3):506-14.e2. doi: 10.1053/j.gastro.2019.10.018
Efficacy and safety of vedolizumab subcutaneous formulation in a randomized trial of patients with ulcerative colitis. William J. Sandborn et al. 2020 Feb;158(3)562-72.e12. doi: 10.1053/j.gastro.2019.08.027
AGA Clinical Practice Guidelines on management of gastric intestinal metaplasia. Samir Gupta et al. 2020 Feb;158(3):693-702. doi: 10.1053/j.gastro.2019.12.003
March 2020
Approaches and challenges to management of pediatric and adult patients with eosinophilic esophagitis. Ikuo Hirano, Glenn T. Furuta. 2020 Mar;158(4):840-51. doi: 10.1053/j.gastro.2019.09.052
Uptake of colorectal cancer screening by physicians is associated with greater uptake by their patients. Owen Litwin et al. 2020 Mar;158(4):905-14. doi: 10.1053/j.gastro.2019.10.027
Recommendations for follow-up after colonoscopy and polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer. Samir Gupta et al. 2020 Mar;158(4):1131-53.e5. doi: 10.1053/j.gastro.2019.10.026
Differences in fecal microbiomes and metabolomes of people with vs without irritable bowel syndrome and bile acid malabsorption. Ian B. Jeffery et al. 2020 Mar;158(4):1016-28.e8. doi: 10.1053/j.gastro.2019.11.301
April 2020
How to set up a successful motility lab. Rena Yadlapati et al. 2020 April;158(5):1202-10. doi: 10.1053/j.gastro.2020.01.030
Mechanisms, evaluation, and management of chronic constipation. Adil E. Bharucha, Brian E. Lacy. 2020 April;158(5):1232-49.e3. doi: 10.1053/j.gastro.2019.12.034.
Incidence of venous thromboembolism in patients with newly diagnosed pancreatic cancer and factors associated with outcomes. Corinne Frere et al. 2020 April;158(5):1346-58.e4. doi: 10.1053/j.gastro.2019.12.009
Clinical Gastroenterology and Hepatology
February 2020
Increased incidence and mortality of gastric cancer in immigrant populations from high to low regions of incidence: A systematic review and meta-analysis. Baldeep S. Pabla et al. 2020 Feb;18(2):347-59.e5. doi: 10.1016/j.cgh.2019.05.032
Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age. Neena S. Abraham et al. 2020 Feb;18(2):337-46.e19. doi: 10.1016/j.cgh.2019.05.017
Alcohol rehabilitation within 30 days of hospital discharge is associated with reduced readmission, relapse, and death in patients with alcoholic hepatitis. Thoetchai (Bee) Peeraphatdit et al. 2020 Feb;18(2):477-85.e5. doi: 10.1016/j.cgh.2019.04.048
March 2020
Telemedicine in gastroenterology: A value-added service for patients. Theresa Lee, Lawrence Kim. 2020 Mar;18(3):530-3. doi: 10.1016/j.cgh.2019.12.005
Best practices in teaching endoscopy based on a Delphi survey of gastroenterology program directors and experts in endoscopy education. Navin L. Kumar et al. 2020 Mar;18(3):574-9.e1. doi: 10.1016/j.cgh.2019.05.023
Consumption of fish and long-chain n-3 polyunsaturated fatty acids is associated with reduced risk of colorectal cancer in a large European cohort. Elom K. Aglago et al. 2020 Mar;18(3):654-66.e6. doi: 10.1016/j.cgh.2019.06.031
April 2020
Low incidence of aerodigestive cancers in patients with negative results from colonoscopies, regardless of findings from multitarget stool DNA tests. Barry M. Berger et al. 2020 April;18(4):864-71. doi: 10.1016/j.cgh.2019.07.057
Lifetime economic burden of Crohn’s disease and ulcerative colitis by age at diagnosis. Gary R. Lichtenstein et al. 2020 April;18(4):889-97.e10. doi: 10.1016/j.cgh.2019.07.022
Clinical and Molecular Gastroenterology and Hepatology
Etiopathogenetic mechanisms in diverticular disease of the colon. Michael Camilleri et al. 2020;9(1):15-32. doi: 10.1016/j.jcmgh.2019.07.007
Fellowship Burnout: What can we do to identify those at risk and minimize the impact?
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.
Jeff is a high-performing first-year gastroenterology fellow who started with eagerness and enthusiasm. He seemed to enjoy talking to patients, wrote thorough notes, and often participated during case discussions at morning report. He initiated a quality improvement project and joined a hospital committee. Over the past few months, he has interacted less with his peers in the fellow’s office and stayed late to complete his patient encounters. He now frequently arrives late to work, is unprepared for rounds, and forgets to place important orders. One day, you notice him shuffling through several papers when the attending asks him a question about his patient. Later that day, he snapped at a nurse who paged to ask a question about a patient who just had a colonoscopy. When you ask him how he is doing, he becomes tearful and reports that he is under a lot of stress between work and home and does not feel the work he is doing is meaningful.
Introduction
The above scenario is all too familiar. Gastroenterology training can be a stressful period in an individual’s life. Long hours, steep learning curves for new cognitive and mechanical skill sets, as well as managing personal relationships and responsibilities at home all contribute to the stress of training and finding appropriate work-life balance. These stressors can result in burnout. The last decade has brought about a renewed emphasis on mitigating the impact of occupational burnout and improving trainee lifestyle through interventions such as work-hour restrictions, resiliency training, instruction on the importance of sleep, and team-building activities.
The problem
The World Health Organization (WHO) defines occupational burnout as chronic work-related stress, which may be characterized by feelings of energy depletion, mental distance from one’s job or feelings of negativity toward it, and reduced professional efficacy. Occupational burnout has been identified as an increasing problem both in practicing providers and trainees. Surveys in gastroenterologists show rates of burnout ranging between 37% and 50%,1 with trainees and early-career physicians disproportionately affected.1,2Physicians along the entire training spectrum are more likely to report high emotional exhaustion, high depersonalization, and burnout than a population control sample.2
Several individual factors identified for those at increased risk for burnout include younger age, not being married, and being male.2 Individuals spending less than 20% of their time working on activities they find meaningful and productive were more likely to show evidence of burnout.1
Symptoms of burnout can have a profound impact on trainees’ work performance, personal interactions, and the learning environment as a whole. The Accreditation Council for Graduate Medical Education (ACGME) annual survey of trainees asks them how strongly they agree or disagree on various components of burnout such as how meaningful they find their work, if they have enough time to think and reflect, if they feel emotionally drained at work, and if they feel worn out and weary after work. The intent of these questions is to provide anonymous feedback to training programs to help identify year to year trends and intervene early to prevent occupational burnout from becoming an increasing issue.
The solution
Considerations for any intervention should take several factors into account: the impact it may have on training and the development of a competent physician in their individualized specialty, the sustainability of the intervention, and whether it is something that will be accepted by the invested parties.
One method proposed for preventing burnout during fellowship has been designated as the three R’s: relaxation, reflection, and regrouping.3
- Relax. In order to relax, trainees need ways to decompress. Activities such as exercise and social events can be helpful. Within our own program the fellows have started their own group exercise program, playing wallyball weekly before clinical duties. We also encourage use of vacation days and build comradery by organizing potluck dinners for major holidays, graduation parties at the program director’s house, and an end-of-the-year golf outing in which trainees play against staff followed by a discussion regarding the state of the program. More recently we have added one half-day per a quarter for morale and team building. During this first year, the activities in which trainees have collectively decided to participate include an escape room, a rock-climbing facility, and laser tag. The addition of more team-building days has been well received by our program’s trainees and the simple addition of these team-building days has resulted in the trainees interacting more together outside of work, particularly in the form of group dinners.
Walter Reed National Military Medical Center fellows gathering for wallyball. - Reflect. They describe reflection as a necessary checkpoint which typically occurs every 6 months.3 These “checkpoints” provide an opportunity to provide feedback to the fellow as well as check in on their well-being and receive feedback about the program. We give frequent feedback to fellows in the form of spot, rotational, and mid-/end-of-year feedback. Additionally, we have developed a unique feedback system in which the trainees meet at the end of the year to discuss collective feedback for the staff and the program. This feedback is collated by the chief fellow and given to the program director as anonymous feedback, which is then passed to the individual staff.
- Regroup. Finally, regrouping to form new strategies.3 This regrouping provides an opportunity to improve on areas in which the trainee may have a deficiency and build on their strengths. To facilitate regrouping, we identify a mentor within the department and occasionally in other departments to meet regularly with the trainee. A successful mentor ensures effective regrouping and can help the trainee avoid pitfalls that they may have experienced in similar situations.
Moving forward
Occupational burnout is a systemic problem within the medical field, with trainees disproportionately affected. It is imperative that training programs continue to work toward creating a culture that prevents development of burnout. Along with the ideas presented here, the ACGME has launched AWARE, which is a suite of resources directed specifically at the GME community, with a goal of mitigating stress and preventing burnout. No one approach will be universally applicable but continued awareness and efforts to address this on an individual and programmatic level should be encouraged.
Dr. Ordway is a chief fellow, Dr. Tritsch and Dr. Singla are associate program directors, and Dr. Torres the program director, division of gastroenterology and hepatology, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
2. Dyrbye LN et al. Acad Med. 2014;89(3):443-51.
3. Waldo OA. J Am Coll Cardiol. 2015;66(11):1303-6.
Early liver transplantation for alcoholic hepatitis
Case
A 45-year-old male was admitted to the hospital with severe alcoholic hepatitis. After several days of supportive care and medical therapy, the patient continued to show clinical decline. The patient is now admitted to the intensive-care unit with a Maddrey’s Discriminant Function score of 45 and a Model for End-Stage Liver Disease score of 38. He has no other significant medical comorbidities. On rounds, the patient’s wife, who is at the bedside, asks the team whether her husband would be a candidate for liver transplantation.
Should this patient be offered liver transplantation? What medical and psychosocial factors should we consider? What ethical principles should we consider?
Medical considerations
With the advent of direct-acting antivirals (DAAs), there has been a decline in the number of liver transplants performed for hepatitis C virus–related cirrhosis.1 Instead, alcohol-related liver disease (ALD) has become the most common indication for liver transplant in the United States.2 The 6-month abstinence requirement was a widespread practice within the transplant community that would exclude any patients who were actively drinking from being considered for liver transplant. However, data are inconclusive whether the 6-month rule serves as a predictor of future drinking or poor outcomes after liver transplant.3,4 Unfortunately, many patients with severe alcoholic hepatitis will not survive long enough to fulfill the 6-month requirement.5
In 2011, Mathurin and colleagues led the pivotal European trial demonstrating the effectiveness of liver transplant as a rescue option for highly selected patients with severe alcoholic hepatitis.5 The selection criteria included patients with severe alcoholic hepatitis unresponsive to medical therapy, first liver-decompensating event, presence of close supportive family members, absence of severe psychiatric disorders, and agreement by patients to adhere to lifelong total alcohol abstinence. The study showed that the 6-month survival rate of patients who received early liver transplant was 77%, compared with 25% among those who did not. The positive outcomes were subsequently replicated at several centers in the United States, and this led to a wider adoption of early liver transplant for severe alcoholic hepatitis.6-8
Psychosocial considerations
At present, we do not have well-validated consensus selection criteria to identify patients with alcoholic hepatitis most suitable for liver transplant. Each transplant center employs its own set of selection criteria with slight variations from the original European trial which prompted a national expert consensus meeting in Dallas in 2019.9 The consortium published a set of guidelines for centers planning to or already performing alcoholic hepatitis transplants. The proposed criteria to determine liver transplant candidacy are the following: 1) patients presenting for the first time with decompensated liver disease who are nonresponders to medical therapy; 2) assessment by a multidisciplinary psychosocial team including a social worker and an additional specialist; 3) no repeated unsuccessful attempts at addiction rehabilitation; 4) lack of other substance use/dependence; 5) insight with a commitment to sobriety; 6) presence of close supportive family members. The goal was to select candidates with the least likelihood of relapse in the hope of preventing poor outcomes after liver transplant. A study by a Johns Hopkins group comparing patients with severe alcoholic hepatitis who underwent careful psychosocial evaluation versus alcoholic cirrhosis with at least 6 months abstinence found that the survival and alcohol relapse rates were similar between the two groups.7
Ethical considerations
Expanding liver transplant indications to include some patients with severe alcoholic hepatitis will uphold the principle of beneficence given clear evidence of a survival benefit. In addition, graft survival rates were comparable with those of patients who underwent liver transplant for other causes.10 However, in an era of persistent organ shortage, it is important to balance justice or fairness to the patient with utilitarian policies that optimize outcomes for all who are in need of liver transplantation.
Justice
Justice means fair and equal distribution of scarce health resources to patients without bias on account of sex, race, wealth, and the nature of a patient’s disease. Based on the principle of justice, a patient with alcoholic hepatitis should be afforded opportunities for liver transplant equal to patients with other etiologies of liver disease.
Opponents of adoption of liver transplant for alcoholic hepatitis often base their reluctance on the following: patients’ failure to gain control of their alcohol use disorder, fears of alcohol relapse, and ultimately perceptions that these patients may be less deserving, compared with patients with other etiologies of liver disease. But, is this fair to the patient?
Alcohol use disorder, in general, is stigmatized and is considered by some to be a self-inflicted condition. As a medical community, we do not withhold life-saving treatment from patients who had inflicted their own injuries. Nevertheless, the stigma against alcoholism is so entrenched in our society that some fear transplanting a patient who is actively drinking would negatively affect the public’s perception of the transplant community and thus diminish the organ donation rate and harm the common good. Interestingly, a public opinion survey actually showed that the majority of respondents were at least neutral about the idea of transplanting patients with alcoholic hepatitis.11
Utility
Utility means achieving the greatest good for the greatest number of patients. The absolute scarcity of available organs imposes a need for a strict allocation decision. A liver that is used for a patient with severe alcoholic hepatitis is an organ not used for another patient suffering chronic liver disease. It is worth noting that about 20% of patients with severe alcoholic hepatitis might recover without a transplant.5 That means about one out of five liver transplants performed for alcoholic hepatitis may have been done in a patient who would have recovered without a transplant. Does this policy optimize the greatest good for everyone who is on the wait list?
Moss and Siegler argued that it was not the alcoholism that made patients with alcoholic liver disease less deserving of liver transplant, but rather their failure to seek treatment for alcoholism that made their claim for liver transplant weaker, compared with those who developed cirrhosis through no fault of their own.12 This argument is problematic. For example, patients with nonalcoholic steatohepatitis (NASH) are often compared with patients with alcoholic liver disease when it comes to modifiable behaviors that affect their health, whether it is through weight loss or abstinence, respectively. Yet, there is very little argument for lower priority for NASH patients who failed to lose weight. Secondly, alcohol use disorder is a psychosocially complex disease that requires a multidisciplinary treatment approach. Substance abuse rehabilitation is not readily available to most patients and could single out vulnerable patients from lower socioeconomic classes who are at higher risk for developing alcohol use disorder. Imposing a strict abstinence period regardless of a patient’s medical need is punitive and does not treat the underlying disease. Instead of focusing on disease causality, we ought to advocate for medical treatment of the underlying disease.
Conclusions
Liver transplant effectively functions as a zero-sum game. Efforts to save individual patients with severe alcoholic hepatitis can result in trade-offs to other patients on the wait list. Balancing the ethical principles of utility and justice is challenging. A strict 6-month rule, while convenient, does not strike the balance. The decision to transplant a patient with alcoholic hepatitis should be made on a case-by-case basis. As stewards of donor organs, transplant centers have a duty to carefully evaluate a potential candidate based on medical needs and recipient outcome without the influence of bias. We feel that, when considering liver transplant in patients with severe alcoholic hepatitis, the principle of justice or fairness to the patient is the overriding ethical principle. Provided the patient meets medical and psychosocial criteria that available evidence suggests would result in long-term survival post transplantation, we would support listing for liver transplantation.
References
1. Goldberg D et al. Gastroenterology, 2017;152(5):1090-9.e1.
2. Cholankeril G, Ahmed A. Clin Gastroenterol Hepatol. 2018;16(8):1356-8.
3. Neuberger J et al. J Hepatol. 2002;36(1):130-7.
4. DiMartini A, et al. Clin Liver Dis. 2011;15(4):727-51.
5. Mathurin P et al. N Engl J Med, 2011;365(19):1790-800.
6. Im GY et al. Am J Transplant. 2016;16(3):841-9.
7. Lee BP et al. Ann Surg. 2017;265(1):20-9.
8. Lee BP et al. Gastroenterology. 2018. 155(2):422-30.e1.
9. Asrani SK et al. Liver Transpl. 2020;26(1):127-40.
10. Singal AK et al. Transplantation. 2013;95(5):755-60.
11. Stroh G et al. Am J Transplant. 2015;15(6):1598-604.
12. Moss AH, Siegler M. JAMA. 1991;265(10):1295-8.
Dr. Wang is a gastroenterology fellow in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine; Dr. Aronsohn is associate professor in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine.
Case
A 45-year-old male was admitted to the hospital with severe alcoholic hepatitis. After several days of supportive care and medical therapy, the patient continued to show clinical decline. The patient is now admitted to the intensive-care unit with a Maddrey’s Discriminant Function score of 45 and a Model for End-Stage Liver Disease score of 38. He has no other significant medical comorbidities. On rounds, the patient’s wife, who is at the bedside, asks the team whether her husband would be a candidate for liver transplantation.
Should this patient be offered liver transplantation? What medical and psychosocial factors should we consider? What ethical principles should we consider?
Medical considerations
With the advent of direct-acting antivirals (DAAs), there has been a decline in the number of liver transplants performed for hepatitis C virus–related cirrhosis.1 Instead, alcohol-related liver disease (ALD) has become the most common indication for liver transplant in the United States.2 The 6-month abstinence requirement was a widespread practice within the transplant community that would exclude any patients who were actively drinking from being considered for liver transplant. However, data are inconclusive whether the 6-month rule serves as a predictor of future drinking or poor outcomes after liver transplant.3,4 Unfortunately, many patients with severe alcoholic hepatitis will not survive long enough to fulfill the 6-month requirement.5
In 2011, Mathurin and colleagues led the pivotal European trial demonstrating the effectiveness of liver transplant as a rescue option for highly selected patients with severe alcoholic hepatitis.5 The selection criteria included patients with severe alcoholic hepatitis unresponsive to medical therapy, first liver-decompensating event, presence of close supportive family members, absence of severe psychiatric disorders, and agreement by patients to adhere to lifelong total alcohol abstinence. The study showed that the 6-month survival rate of patients who received early liver transplant was 77%, compared with 25% among those who did not. The positive outcomes were subsequently replicated at several centers in the United States, and this led to a wider adoption of early liver transplant for severe alcoholic hepatitis.6-8
Psychosocial considerations
At present, we do not have well-validated consensus selection criteria to identify patients with alcoholic hepatitis most suitable for liver transplant. Each transplant center employs its own set of selection criteria with slight variations from the original European trial which prompted a national expert consensus meeting in Dallas in 2019.9 The consortium published a set of guidelines for centers planning to or already performing alcoholic hepatitis transplants. The proposed criteria to determine liver transplant candidacy are the following: 1) patients presenting for the first time with decompensated liver disease who are nonresponders to medical therapy; 2) assessment by a multidisciplinary psychosocial team including a social worker and an additional specialist; 3) no repeated unsuccessful attempts at addiction rehabilitation; 4) lack of other substance use/dependence; 5) insight with a commitment to sobriety; 6) presence of close supportive family members. The goal was to select candidates with the least likelihood of relapse in the hope of preventing poor outcomes after liver transplant. A study by a Johns Hopkins group comparing patients with severe alcoholic hepatitis who underwent careful psychosocial evaluation versus alcoholic cirrhosis with at least 6 months abstinence found that the survival and alcohol relapse rates were similar between the two groups.7
Ethical considerations
Expanding liver transplant indications to include some patients with severe alcoholic hepatitis will uphold the principle of beneficence given clear evidence of a survival benefit. In addition, graft survival rates were comparable with those of patients who underwent liver transplant for other causes.10 However, in an era of persistent organ shortage, it is important to balance justice or fairness to the patient with utilitarian policies that optimize outcomes for all who are in need of liver transplantation.
Justice
Justice means fair and equal distribution of scarce health resources to patients without bias on account of sex, race, wealth, and the nature of a patient’s disease. Based on the principle of justice, a patient with alcoholic hepatitis should be afforded opportunities for liver transplant equal to patients with other etiologies of liver disease.
Opponents of adoption of liver transplant for alcoholic hepatitis often base their reluctance on the following: patients’ failure to gain control of their alcohol use disorder, fears of alcohol relapse, and ultimately perceptions that these patients may be less deserving, compared with patients with other etiologies of liver disease. But, is this fair to the patient?
Alcohol use disorder, in general, is stigmatized and is considered by some to be a self-inflicted condition. As a medical community, we do not withhold life-saving treatment from patients who had inflicted their own injuries. Nevertheless, the stigma against alcoholism is so entrenched in our society that some fear transplanting a patient who is actively drinking would negatively affect the public’s perception of the transplant community and thus diminish the organ donation rate and harm the common good. Interestingly, a public opinion survey actually showed that the majority of respondents were at least neutral about the idea of transplanting patients with alcoholic hepatitis.11
Utility
Utility means achieving the greatest good for the greatest number of patients. The absolute scarcity of available organs imposes a need for a strict allocation decision. A liver that is used for a patient with severe alcoholic hepatitis is an organ not used for another patient suffering chronic liver disease. It is worth noting that about 20% of patients with severe alcoholic hepatitis might recover without a transplant.5 That means about one out of five liver transplants performed for alcoholic hepatitis may have been done in a patient who would have recovered without a transplant. Does this policy optimize the greatest good for everyone who is on the wait list?
Moss and Siegler argued that it was not the alcoholism that made patients with alcoholic liver disease less deserving of liver transplant, but rather their failure to seek treatment for alcoholism that made their claim for liver transplant weaker, compared with those who developed cirrhosis through no fault of their own.12 This argument is problematic. For example, patients with nonalcoholic steatohepatitis (NASH) are often compared with patients with alcoholic liver disease when it comes to modifiable behaviors that affect their health, whether it is through weight loss or abstinence, respectively. Yet, there is very little argument for lower priority for NASH patients who failed to lose weight. Secondly, alcohol use disorder is a psychosocially complex disease that requires a multidisciplinary treatment approach. Substance abuse rehabilitation is not readily available to most patients and could single out vulnerable patients from lower socioeconomic classes who are at higher risk for developing alcohol use disorder. Imposing a strict abstinence period regardless of a patient’s medical need is punitive and does not treat the underlying disease. Instead of focusing on disease causality, we ought to advocate for medical treatment of the underlying disease.
Conclusions
Liver transplant effectively functions as a zero-sum game. Efforts to save individual patients with severe alcoholic hepatitis can result in trade-offs to other patients on the wait list. Balancing the ethical principles of utility and justice is challenging. A strict 6-month rule, while convenient, does not strike the balance. The decision to transplant a patient with alcoholic hepatitis should be made on a case-by-case basis. As stewards of donor organs, transplant centers have a duty to carefully evaluate a potential candidate based on medical needs and recipient outcome without the influence of bias. We feel that, when considering liver transplant in patients with severe alcoholic hepatitis, the principle of justice or fairness to the patient is the overriding ethical principle. Provided the patient meets medical and psychosocial criteria that available evidence suggests would result in long-term survival post transplantation, we would support listing for liver transplantation.
References
1. Goldberg D et al. Gastroenterology, 2017;152(5):1090-9.e1.
2. Cholankeril G, Ahmed A. Clin Gastroenterol Hepatol. 2018;16(8):1356-8.
3. Neuberger J et al. J Hepatol. 2002;36(1):130-7.
4. DiMartini A, et al. Clin Liver Dis. 2011;15(4):727-51.
5. Mathurin P et al. N Engl J Med, 2011;365(19):1790-800.
6. Im GY et al. Am J Transplant. 2016;16(3):841-9.
7. Lee BP et al. Ann Surg. 2017;265(1):20-9.
8. Lee BP et al. Gastroenterology. 2018. 155(2):422-30.e1.
9. Asrani SK et al. Liver Transpl. 2020;26(1):127-40.
10. Singal AK et al. Transplantation. 2013;95(5):755-60.
11. Stroh G et al. Am J Transplant. 2015;15(6):1598-604.
12. Moss AH, Siegler M. JAMA. 1991;265(10):1295-8.
Dr. Wang is a gastroenterology fellow in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine; Dr. Aronsohn is associate professor in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine.
Case
A 45-year-old male was admitted to the hospital with severe alcoholic hepatitis. After several days of supportive care and medical therapy, the patient continued to show clinical decline. The patient is now admitted to the intensive-care unit with a Maddrey’s Discriminant Function score of 45 and a Model for End-Stage Liver Disease score of 38. He has no other significant medical comorbidities. On rounds, the patient’s wife, who is at the bedside, asks the team whether her husband would be a candidate for liver transplantation.
Should this patient be offered liver transplantation? What medical and psychosocial factors should we consider? What ethical principles should we consider?
Medical considerations
With the advent of direct-acting antivirals (DAAs), there has been a decline in the number of liver transplants performed for hepatitis C virus–related cirrhosis.1 Instead, alcohol-related liver disease (ALD) has become the most common indication for liver transplant in the United States.2 The 6-month abstinence requirement was a widespread practice within the transplant community that would exclude any patients who were actively drinking from being considered for liver transplant. However, data are inconclusive whether the 6-month rule serves as a predictor of future drinking or poor outcomes after liver transplant.3,4 Unfortunately, many patients with severe alcoholic hepatitis will not survive long enough to fulfill the 6-month requirement.5
In 2011, Mathurin and colleagues led the pivotal European trial demonstrating the effectiveness of liver transplant as a rescue option for highly selected patients with severe alcoholic hepatitis.5 The selection criteria included patients with severe alcoholic hepatitis unresponsive to medical therapy, first liver-decompensating event, presence of close supportive family members, absence of severe psychiatric disorders, and agreement by patients to adhere to lifelong total alcohol abstinence. The study showed that the 6-month survival rate of patients who received early liver transplant was 77%, compared with 25% among those who did not. The positive outcomes were subsequently replicated at several centers in the United States, and this led to a wider adoption of early liver transplant for severe alcoholic hepatitis.6-8
Psychosocial considerations
At present, we do not have well-validated consensus selection criteria to identify patients with alcoholic hepatitis most suitable for liver transplant. Each transplant center employs its own set of selection criteria with slight variations from the original European trial which prompted a national expert consensus meeting in Dallas in 2019.9 The consortium published a set of guidelines for centers planning to or already performing alcoholic hepatitis transplants. The proposed criteria to determine liver transplant candidacy are the following: 1) patients presenting for the first time with decompensated liver disease who are nonresponders to medical therapy; 2) assessment by a multidisciplinary psychosocial team including a social worker and an additional specialist; 3) no repeated unsuccessful attempts at addiction rehabilitation; 4) lack of other substance use/dependence; 5) insight with a commitment to sobriety; 6) presence of close supportive family members. The goal was to select candidates with the least likelihood of relapse in the hope of preventing poor outcomes after liver transplant. A study by a Johns Hopkins group comparing patients with severe alcoholic hepatitis who underwent careful psychosocial evaluation versus alcoholic cirrhosis with at least 6 months abstinence found that the survival and alcohol relapse rates were similar between the two groups.7
Ethical considerations
Expanding liver transplant indications to include some patients with severe alcoholic hepatitis will uphold the principle of beneficence given clear evidence of a survival benefit. In addition, graft survival rates were comparable with those of patients who underwent liver transplant for other causes.10 However, in an era of persistent organ shortage, it is important to balance justice or fairness to the patient with utilitarian policies that optimize outcomes for all who are in need of liver transplantation.
Justice
Justice means fair and equal distribution of scarce health resources to patients without bias on account of sex, race, wealth, and the nature of a patient’s disease. Based on the principle of justice, a patient with alcoholic hepatitis should be afforded opportunities for liver transplant equal to patients with other etiologies of liver disease.
Opponents of adoption of liver transplant for alcoholic hepatitis often base their reluctance on the following: patients’ failure to gain control of their alcohol use disorder, fears of alcohol relapse, and ultimately perceptions that these patients may be less deserving, compared with patients with other etiologies of liver disease. But, is this fair to the patient?
Alcohol use disorder, in general, is stigmatized and is considered by some to be a self-inflicted condition. As a medical community, we do not withhold life-saving treatment from patients who had inflicted their own injuries. Nevertheless, the stigma against alcoholism is so entrenched in our society that some fear transplanting a patient who is actively drinking would negatively affect the public’s perception of the transplant community and thus diminish the organ donation rate and harm the common good. Interestingly, a public opinion survey actually showed that the majority of respondents were at least neutral about the idea of transplanting patients with alcoholic hepatitis.11
Utility
Utility means achieving the greatest good for the greatest number of patients. The absolute scarcity of available organs imposes a need for a strict allocation decision. A liver that is used for a patient with severe alcoholic hepatitis is an organ not used for another patient suffering chronic liver disease. It is worth noting that about 20% of patients with severe alcoholic hepatitis might recover without a transplant.5 That means about one out of five liver transplants performed for alcoholic hepatitis may have been done in a patient who would have recovered without a transplant. Does this policy optimize the greatest good for everyone who is on the wait list?
Moss and Siegler argued that it was not the alcoholism that made patients with alcoholic liver disease less deserving of liver transplant, but rather their failure to seek treatment for alcoholism that made their claim for liver transplant weaker, compared with those who developed cirrhosis through no fault of their own.12 This argument is problematic. For example, patients with nonalcoholic steatohepatitis (NASH) are often compared with patients with alcoholic liver disease when it comes to modifiable behaviors that affect their health, whether it is through weight loss or abstinence, respectively. Yet, there is very little argument for lower priority for NASH patients who failed to lose weight. Secondly, alcohol use disorder is a psychosocially complex disease that requires a multidisciplinary treatment approach. Substance abuse rehabilitation is not readily available to most patients and could single out vulnerable patients from lower socioeconomic classes who are at higher risk for developing alcohol use disorder. Imposing a strict abstinence period regardless of a patient’s medical need is punitive and does not treat the underlying disease. Instead of focusing on disease causality, we ought to advocate for medical treatment of the underlying disease.
Conclusions
Liver transplant effectively functions as a zero-sum game. Efforts to save individual patients with severe alcoholic hepatitis can result in trade-offs to other patients on the wait list. Balancing the ethical principles of utility and justice is challenging. A strict 6-month rule, while convenient, does not strike the balance. The decision to transplant a patient with alcoholic hepatitis should be made on a case-by-case basis. As stewards of donor organs, transplant centers have a duty to carefully evaluate a potential candidate based on medical needs and recipient outcome without the influence of bias. We feel that, when considering liver transplant in patients with severe alcoholic hepatitis, the principle of justice or fairness to the patient is the overriding ethical principle. Provided the patient meets medical and psychosocial criteria that available evidence suggests would result in long-term survival post transplantation, we would support listing for liver transplantation.
References
1. Goldberg D et al. Gastroenterology, 2017;152(5):1090-9.e1.
2. Cholankeril G, Ahmed A. Clin Gastroenterol Hepatol. 2018;16(8):1356-8.
3. Neuberger J et al. J Hepatol. 2002;36(1):130-7.
4. DiMartini A, et al. Clin Liver Dis. 2011;15(4):727-51.
5. Mathurin P et al. N Engl J Med, 2011;365(19):1790-800.
6. Im GY et al. Am J Transplant. 2016;16(3):841-9.
7. Lee BP et al. Ann Surg. 2017;265(1):20-9.
8. Lee BP et al. Gastroenterology. 2018. 155(2):422-30.e1.
9. Asrani SK et al. Liver Transpl. 2020;26(1):127-40.
10. Singal AK et al. Transplantation. 2013;95(5):755-60.
11. Stroh G et al. Am J Transplant. 2015;15(6):1598-604.
12. Moss AH, Siegler M. JAMA. 1991;265(10):1295-8.
Dr. Wang is a gastroenterology fellow in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine; Dr. Aronsohn is associate professor in the division of gastroenterology, hepatology, and nutrition, department of internal medicine, University of Chicago Medicine.
Ergonomics 101 for trainees
To the early trainee, often the goal of performing a colonoscopy is to reach the cecum using whatever technique necessary. Although the recommended amount of colonoscopies for safe independent practice is 140 (with some sources stating more than 500), this only relates to the safety of the patient.1 We receive scant education on how to form good procedural habits to preserve our own safety and efficiency over the course of our career. Here are some tips on how to prevent injury:
Maintain an appropriate stance. The optimal stance during endoscopy is an athletic stance: chest out, shoulders back to facilitate ease of neck movements, and a slight bend in the knees to facilitate good blood return and distribute weight. Feet should be hip width apart with toes pointed at the endoscopy screen to allow for easy pivoting of the hips and torque of upper body if needed. Ideally, this stance is complemented by the use of proper footwear and a cushioned mat to facilitate weight distribution while standing. An athletic stance facilitates a fluidity for movements from head to toe and an ability to use larger muscles groups to accomplish fine movements.
Handle the endoscope properly. Preserve energy by understanding your equipment and how to manipulate it. Orienting the endoscope directly in front of the endoscopist for upper endoscopy, and at a 45-degree angle for colonoscopy, places the instrument at optimal location to complete the procedure.5 Reviewing how to perform common techniques such as retroflexion, scope reduction, and instrumentation can also facilitate improved ergonomics and adjustment of incorrect techniques at an early stage of endoscopic training. An area of particular concern for most early trainees is the amount of rotational force placed on the right wrist with administration of torque to the endoscope. This is a foreign movement for most endoscopists and requires use of smaller muscle groups of the forearms. We suggest attempting torque with internal and external rotation of the left shoulder to utilize larger muscle groups. We can also combat fatigue during the procedure with the use of microrests intermittently to reduce prolonged muscle contraction. A common way to utilize microrests is by pinning the scope to the patient’s bed with the endoscopist’s hip to provide stability of endoscope and allow removal and relaxation of the right hand. This can be done periodically throughout the procedure to provide the ability to regroup mentally and physically.
Seek feedback. Because it is difficult to focus on ergonomics while performing a diagnostic procedure, utilize your team of observers to facilitate proper form during procedure. This includes your attending gastroenterologists, nurses, and technicians who can observe posture and technique to help detect incorrect positioning early and make corrections. A common practice is to discuss areas of desired improvement before procedures to facilitate a more vigilant observation of areas for improvement.
Assess and adjust often. As early trainees, these endoscopists perform all endoscopies under the direct supervision and often with significant assistance from a supervising gastroenterologist. This can lead to a sharp differential in psychological size; it can be hard to adjust a room to your needs when you have an intimidating and demanding attending physician who has different needs. Despite this disparity, we strongly encourage all trainees to be vigilant about adjusting the room (monitors and beds) to their own needs rather than their attendings’. A great way to head off potential conflict is to discuss the ergonomic positioning of the room before you start endoscopy with your attending, nurse, and technicians so that everyone is in agreement.
Conclusion
We offer this article as a guide for the novice endoscopist to make small changes early to prevent injuries later. Reaching competency with our skills is difficult, and we hope it can be achieved safely with our health in mind.
Dr. Magee, first-year fellow, NCC Gastroenterology; Dr. Singla, associate program director, NCC Gastroenterology, and gastroenterology service, department of internal medicine, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Spier B et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc. 2010 Feb;71(2):319-24G.
2. Malmström EM et al. A slouched body posture decreases arm mobility and changes muscle recruitment in the neck and shoulder region. Eur J Appl Physiol. 2015;115(12):2491-503.
3. Singla M et al. Training the endo-athlete: an update in ergonomics in endoscopy. Clin Gastroenterol Hepatol. 2018 Jul;16(7):1003-6.
4. Bexander CS, et al. Effect of gaze direction on neck muscle activity during cervical rotation. Exp Brain Res. 2005 Dec;167(3):422-32.
5. Soetikno R et al. Holding and manipulating the endoscope: A user’s guide. Techn Gastrointest Endosc. 2019;21:124-32.
To the early trainee, often the goal of performing a colonoscopy is to reach the cecum using whatever technique necessary. Although the recommended amount of colonoscopies for safe independent practice is 140 (with some sources stating more than 500), this only relates to the safety of the patient.1 We receive scant education on how to form good procedural habits to preserve our own safety and efficiency over the course of our career. Here are some tips on how to prevent injury:
Maintain an appropriate stance. The optimal stance during endoscopy is an athletic stance: chest out, shoulders back to facilitate ease of neck movements, and a slight bend in the knees to facilitate good blood return and distribute weight. Feet should be hip width apart with toes pointed at the endoscopy screen to allow for easy pivoting of the hips and torque of upper body if needed. Ideally, this stance is complemented by the use of proper footwear and a cushioned mat to facilitate weight distribution while standing. An athletic stance facilitates a fluidity for movements from head to toe and an ability to use larger muscles groups to accomplish fine movements.
Handle the endoscope properly. Preserve energy by understanding your equipment and how to manipulate it. Orienting the endoscope directly in front of the endoscopist for upper endoscopy, and at a 45-degree angle for colonoscopy, places the instrument at optimal location to complete the procedure.5 Reviewing how to perform common techniques such as retroflexion, scope reduction, and instrumentation can also facilitate improved ergonomics and adjustment of incorrect techniques at an early stage of endoscopic training. An area of particular concern for most early trainees is the amount of rotational force placed on the right wrist with administration of torque to the endoscope. This is a foreign movement for most endoscopists and requires use of smaller muscle groups of the forearms. We suggest attempting torque with internal and external rotation of the left shoulder to utilize larger muscle groups. We can also combat fatigue during the procedure with the use of microrests intermittently to reduce prolonged muscle contraction. A common way to utilize microrests is by pinning the scope to the patient’s bed with the endoscopist’s hip to provide stability of endoscope and allow removal and relaxation of the right hand. This can be done periodically throughout the procedure to provide the ability to regroup mentally and physically.
Seek feedback. Because it is difficult to focus on ergonomics while performing a diagnostic procedure, utilize your team of observers to facilitate proper form during procedure. This includes your attending gastroenterologists, nurses, and technicians who can observe posture and technique to help detect incorrect positioning early and make corrections. A common practice is to discuss areas of desired improvement before procedures to facilitate a more vigilant observation of areas for improvement.
Assess and adjust often. As early trainees, these endoscopists perform all endoscopies under the direct supervision and often with significant assistance from a supervising gastroenterologist. This can lead to a sharp differential in psychological size; it can be hard to adjust a room to your needs when you have an intimidating and demanding attending physician who has different needs. Despite this disparity, we strongly encourage all trainees to be vigilant about adjusting the room (monitors and beds) to their own needs rather than their attendings’. A great way to head off potential conflict is to discuss the ergonomic positioning of the room before you start endoscopy with your attending, nurse, and technicians so that everyone is in agreement.
Conclusion
We offer this article as a guide for the novice endoscopist to make small changes early to prevent injuries later. Reaching competency with our skills is difficult, and we hope it can be achieved safely with our health in mind.
Dr. Magee, first-year fellow, NCC Gastroenterology; Dr. Singla, associate program director, NCC Gastroenterology, and gastroenterology service, department of internal medicine, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Spier B et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc. 2010 Feb;71(2):319-24G.
2. Malmström EM et al. A slouched body posture decreases arm mobility and changes muscle recruitment in the neck and shoulder region. Eur J Appl Physiol. 2015;115(12):2491-503.
3. Singla M et al. Training the endo-athlete: an update in ergonomics in endoscopy. Clin Gastroenterol Hepatol. 2018 Jul;16(7):1003-6.
4. Bexander CS, et al. Effect of gaze direction on neck muscle activity during cervical rotation. Exp Brain Res. 2005 Dec;167(3):422-32.
5. Soetikno R et al. Holding and manipulating the endoscope: A user’s guide. Techn Gastrointest Endosc. 2019;21:124-32.
To the early trainee, often the goal of performing a colonoscopy is to reach the cecum using whatever technique necessary. Although the recommended amount of colonoscopies for safe independent practice is 140 (with some sources stating more than 500), this only relates to the safety of the patient.1 We receive scant education on how to form good procedural habits to preserve our own safety and efficiency over the course of our career. Here are some tips on how to prevent injury:
Maintain an appropriate stance. The optimal stance during endoscopy is an athletic stance: chest out, shoulders back to facilitate ease of neck movements, and a slight bend in the knees to facilitate good blood return and distribute weight. Feet should be hip width apart with toes pointed at the endoscopy screen to allow for easy pivoting of the hips and torque of upper body if needed. Ideally, this stance is complemented by the use of proper footwear and a cushioned mat to facilitate weight distribution while standing. An athletic stance facilitates a fluidity for movements from head to toe and an ability to use larger muscles groups to accomplish fine movements.
Handle the endoscope properly. Preserve energy by understanding your equipment and how to manipulate it. Orienting the endoscope directly in front of the endoscopist for upper endoscopy, and at a 45-degree angle for colonoscopy, places the instrument at optimal location to complete the procedure.5 Reviewing how to perform common techniques such as retroflexion, scope reduction, and instrumentation can also facilitate improved ergonomics and adjustment of incorrect techniques at an early stage of endoscopic training. An area of particular concern for most early trainees is the amount of rotational force placed on the right wrist with administration of torque to the endoscope. This is a foreign movement for most endoscopists and requires use of smaller muscle groups of the forearms. We suggest attempting torque with internal and external rotation of the left shoulder to utilize larger muscle groups. We can also combat fatigue during the procedure with the use of microrests intermittently to reduce prolonged muscle contraction. A common way to utilize microrests is by pinning the scope to the patient’s bed with the endoscopist’s hip to provide stability of endoscope and allow removal and relaxation of the right hand. This can be done periodically throughout the procedure to provide the ability to regroup mentally and physically.
Seek feedback. Because it is difficult to focus on ergonomics while performing a diagnostic procedure, utilize your team of observers to facilitate proper form during procedure. This includes your attending gastroenterologists, nurses, and technicians who can observe posture and technique to help detect incorrect positioning early and make corrections. A common practice is to discuss areas of desired improvement before procedures to facilitate a more vigilant observation of areas for improvement.
Assess and adjust often. As early trainees, these endoscopists perform all endoscopies under the direct supervision and often with significant assistance from a supervising gastroenterologist. This can lead to a sharp differential in psychological size; it can be hard to adjust a room to your needs when you have an intimidating and demanding attending physician who has different needs. Despite this disparity, we strongly encourage all trainees to be vigilant about adjusting the room (monitors and beds) to their own needs rather than their attendings’. A great way to head off potential conflict is to discuss the ergonomic positioning of the room before you start endoscopy with your attending, nurse, and technicians so that everyone is in agreement.
Conclusion
We offer this article as a guide for the novice endoscopist to make small changes early to prevent injuries later. Reaching competency with our skills is difficult, and we hope it can be achieved safely with our health in mind.
Dr. Magee, first-year fellow, NCC Gastroenterology; Dr. Singla, associate program director, NCC Gastroenterology, and gastroenterology service, department of internal medicine, Walter Reed National Military Medical Center, Bethesda, Md.
References
1. Spier B et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc. 2010 Feb;71(2):319-24G.
2. Malmström EM et al. A slouched body posture decreases arm mobility and changes muscle recruitment in the neck and shoulder region. Eur J Appl Physiol. 2015;115(12):2491-503.
3. Singla M et al. Training the endo-athlete: an update in ergonomics in endoscopy. Clin Gastroenterol Hepatol. 2018 Jul;16(7):1003-6.
4. Bexander CS, et al. Effect of gaze direction on neck muscle activity during cervical rotation. Exp Brain Res. 2005 Dec;167(3):422-32.
5. Soetikno R et al. Holding and manipulating the endoscope: A user’s guide. Techn Gastrointest Endosc. 2019;21:124-32.
Student loan management: An introduction for the young gastroenterologist
The young gastroenterologist has no shortage of personal finance topics to juggle, ranging from investments, to life and disability coverage, and planning for retirement. But the elephant in the room is student loan management. Average medical student debt today is approximately $240,000, and debt burdens greater than $300,000 are becoming common.1,2 With this staggering amount of debt, it is understandable why student loans are a major source of anxiety. Here, I will provide a brief introduction to student loan management for gastroenterologists.
Student loans: Basic strategy
It is important to distinguish between two major types of loans: private student loans and direct federal loans. With private student loans the best strategy in most cases is to refinance to a lower interest rate. For direct federal loans, however, the decision making is more complex. There are two major approaches to these federal loans – either 1) refinance, or 2) go for public service loan forgiveness (PSLF). See Figure 1 for a flowchart summarizing my general approach to student loan management.
Refinance basics
One potential approach is to refinance your federal loans. Most federal loans today are at a relatively high interest rate of 6%-8%.3 Private refinancing can yield rates in the 3%-5% range, depending on the type of loan and other factors. For a loan balance of $200,000, the savings by refinancing could be approximately $2,000-$10,000 per year in interest alone. However, refinancing your loans with a private company eliminates the possibility of PSLF. Hence, you should only refinance federal loans once you are sure that you will not be pursuing PSLF. You may refinance your private loans anytime since they do not qualify for PSLF. There are multiple companies that provide student loan refinancing. The process can be done online, sometimes in as little as 30 minutes. There is generally little or no cost to refinancing, and many companies even provide a small cash-back incentive to refinance.
PSLF basics
The PSLF program allows borrowers to have the remainder of their direct loans forgiven after 10 years (120 monthly payments) under a qualifying income-driven repayment (IDR) plan.4 Figure 2 shows an overview of the various IDR plans. During the 120 payments, the borrower must work full time for a qualifying employer, which includes a government employer or a not-for-profit 501(c)(3) organization. Loan forgiveness with PSLF is completely tax free. Importantly, the PSLF program only applies to direct federal loans. You can see your federal loan types and balances by visiting https://studentaid.gov/.
To PSLF or not to PSLF?
With direct federal loans, the decision to refinance or go for PSLF is a major fork in the road. PSLF can be a good option for borrowers with long training programs and with high student loan burdens (e.g., loan-to-income ratios of 1:1, 2:1 or higher). By contrast, borrowers with short training programs or relatively small loan burdens may be better off refinancing to a low interest rate and paying off loans quickly. Virtually all institutions that train residents and fellows are qualified government or 501(c)(3) organizations. Hence, a gastroenterology graduate generally will have completed at least 6 out of 10 years of payments by the end of training. Trainees who did a chief resident year or gastroenterology research track may have completed 7 or 8 years of qualifying payments already.
For trainees who are already planning an academic career, PSLF is often a good option. While PSLF can be a nice benefit, I would not advise making a career decision purely based on PSLF. Private practice jobs generally come with substantially higher salaries than academic and government jobs. This salary differential typically more than compensates for the loss of access to PSLF. Hence, I advise trainees to choose the practice setting that is best for their personal and career satisfaction, and then build a student loan management plan around that. The exception may be the trainee who has a very large student loan burden (e.g., loan-to-income ratio of 2:1 or 3:1).
Caveats with PSLF
There have been well publicized concerns about the future of PSLF, including proposals to eliminate or cap the program.5,6 However, most proposed legislation has only recommended changes to PSLF for new borrowers. If you currently have existing federal loans, you would very likely be grandfathered into the existing PSLF terms. All federal master promissory notes since 2007 have cited PSLF as a loan repayment option.7 Hence, eliminating PSLF for existing borrowers seems unlikely since it would be changing the terms of an executed contract.8
There have also been widespread reports of high numbers of borrowers being denied applications for PSLF.9,10 However, the majority of these applicants did not have correct types of loans, had not worked full time for qualifying employers or had not made the full 120 payments.11 Yet some denials have apparently resulted from errors in tracking qualifying payments by FedLoan servicing.12 Therefore it would be prudent to keep your own careful records of all qualifying payments towards PSLF.
The nuclear option: 20- to 25-year IDR-based forgiveness
An additional option allows borrowers to make IDRs for 20-25 years (details in Figure 2) and then having their remaining loan balance forgiven.13 This option is completely independent of PSLF. Borrowers can work full time or part time and can work for any employer, including private employers.
One additional option: NIH loan repayment programs
One additional solution to consider are the NIH Loan Repayment Programs (LRPs). These programs can provide substantial loan repayment (up to $50,000 annually) for trainees and attendings engaged in research that aligns with NIH priorities, including clinical research or health disparities research.14 Notably, the applicant’s research does not have to be NIH sponsored research.
Getting more information
The approach above is a general overview of student loan concepts for gastroenterologists. However, there are countless nuances and tactics that are beyond the scope of this introductory article. I encourage everyone to get additional information and advice when making your own loan management plan. There are many helpful online resources, podcasts, and books discussing the topic. Several companies provide detailed consultation on managing student loans. Such services may cost a few hundred dollars but could potentially save tens of thousands of dollars on student loan costs.
Dr. Jain is assistant professor of medicine, division of gastroenterology & hepatology, department of medicine, University of North Carolina School of Medicine, Chapel Hill. Dr. Jain has no conflicts of interest and no funding source.
References
1. https://nces.ed.gov/programs/digest/d18/tables/dt18_332.45.asp
2. https://www.credible.com/blog/statistics/average-medical-school-debt/
3. https://studentaid.gov/understand-aid/types/loans/interest-rates
4. https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service
5. https://www.forbes.com/sites/robertfarrington/2019/09/24/how-to-get-your-public-service-loan-forgiveness-qualifying-payments-recounted/#18567f061f5d
6. https://www.cbo.gov/budget-options/2018/54721
7. https://static.studentloans.gov/images/ApplicationAndPromissoryNote.pdf
8. https://www.biglawinvestor.com/pslf-promissory-note/
9. https://bostonstudentloanlawyer.com/scary-stats-for-public-service-loan-forgiveness/
10. https://www.marketwatch.com/story/this-government-loan-forgiveness-program-has-rejected-99-of-borrowers-so-far-2018-09-20
11. https://studentaid.gov/data-center/student/loan-forgiveness/pslf-data
12. https://www.nytimes.com/2019/04/12/your-money/public-service-loan-forgiveness.html
13. https://studentaid.gov/manage-loans/repayment/plans/income-driven
14. https://www.lrp.nih.gov/eligibility-programs
The young gastroenterologist has no shortage of personal finance topics to juggle, ranging from investments, to life and disability coverage, and planning for retirement. But the elephant in the room is student loan management. Average medical student debt today is approximately $240,000, and debt burdens greater than $300,000 are becoming common.1,2 With this staggering amount of debt, it is understandable why student loans are a major source of anxiety. Here, I will provide a brief introduction to student loan management for gastroenterologists.
Student loans: Basic strategy
It is important to distinguish between two major types of loans: private student loans and direct federal loans. With private student loans the best strategy in most cases is to refinance to a lower interest rate. For direct federal loans, however, the decision making is more complex. There are two major approaches to these federal loans – either 1) refinance, or 2) go for public service loan forgiveness (PSLF). See Figure 1 for a flowchart summarizing my general approach to student loan management.
Refinance basics
One potential approach is to refinance your federal loans. Most federal loans today are at a relatively high interest rate of 6%-8%.3 Private refinancing can yield rates in the 3%-5% range, depending on the type of loan and other factors. For a loan balance of $200,000, the savings by refinancing could be approximately $2,000-$10,000 per year in interest alone. However, refinancing your loans with a private company eliminates the possibility of PSLF. Hence, you should only refinance federal loans once you are sure that you will not be pursuing PSLF. You may refinance your private loans anytime since they do not qualify for PSLF. There are multiple companies that provide student loan refinancing. The process can be done online, sometimes in as little as 30 minutes. There is generally little or no cost to refinancing, and many companies even provide a small cash-back incentive to refinance.
PSLF basics
The PSLF program allows borrowers to have the remainder of their direct loans forgiven after 10 years (120 monthly payments) under a qualifying income-driven repayment (IDR) plan.4 Figure 2 shows an overview of the various IDR plans. During the 120 payments, the borrower must work full time for a qualifying employer, which includes a government employer or a not-for-profit 501(c)(3) organization. Loan forgiveness with PSLF is completely tax free. Importantly, the PSLF program only applies to direct federal loans. You can see your federal loan types and balances by visiting https://studentaid.gov/.
To PSLF or not to PSLF?
With direct federal loans, the decision to refinance or go for PSLF is a major fork in the road. PSLF can be a good option for borrowers with long training programs and with high student loan burdens (e.g., loan-to-income ratios of 1:1, 2:1 or higher). By contrast, borrowers with short training programs or relatively small loan burdens may be better off refinancing to a low interest rate and paying off loans quickly. Virtually all institutions that train residents and fellows are qualified government or 501(c)(3) organizations. Hence, a gastroenterology graduate generally will have completed at least 6 out of 10 years of payments by the end of training. Trainees who did a chief resident year or gastroenterology research track may have completed 7 or 8 years of qualifying payments already.
For trainees who are already planning an academic career, PSLF is often a good option. While PSLF can be a nice benefit, I would not advise making a career decision purely based on PSLF. Private practice jobs generally come with substantially higher salaries than academic and government jobs. This salary differential typically more than compensates for the loss of access to PSLF. Hence, I advise trainees to choose the practice setting that is best for their personal and career satisfaction, and then build a student loan management plan around that. The exception may be the trainee who has a very large student loan burden (e.g., loan-to-income ratio of 2:1 or 3:1).
Caveats with PSLF
There have been well publicized concerns about the future of PSLF, including proposals to eliminate or cap the program.5,6 However, most proposed legislation has only recommended changes to PSLF for new borrowers. If you currently have existing federal loans, you would very likely be grandfathered into the existing PSLF terms. All federal master promissory notes since 2007 have cited PSLF as a loan repayment option.7 Hence, eliminating PSLF for existing borrowers seems unlikely since it would be changing the terms of an executed contract.8
There have also been widespread reports of high numbers of borrowers being denied applications for PSLF.9,10 However, the majority of these applicants did not have correct types of loans, had not worked full time for qualifying employers or had not made the full 120 payments.11 Yet some denials have apparently resulted from errors in tracking qualifying payments by FedLoan servicing.12 Therefore it would be prudent to keep your own careful records of all qualifying payments towards PSLF.
The nuclear option: 20- to 25-year IDR-based forgiveness
An additional option allows borrowers to make IDRs for 20-25 years (details in Figure 2) and then having their remaining loan balance forgiven.13 This option is completely independent of PSLF. Borrowers can work full time or part time and can work for any employer, including private employers.
One additional option: NIH loan repayment programs
One additional solution to consider are the NIH Loan Repayment Programs (LRPs). These programs can provide substantial loan repayment (up to $50,000 annually) for trainees and attendings engaged in research that aligns with NIH priorities, including clinical research or health disparities research.14 Notably, the applicant’s research does not have to be NIH sponsored research.
Getting more information
The approach above is a general overview of student loan concepts for gastroenterologists. However, there are countless nuances and tactics that are beyond the scope of this introductory article. I encourage everyone to get additional information and advice when making your own loan management plan. There are many helpful online resources, podcasts, and books discussing the topic. Several companies provide detailed consultation on managing student loans. Such services may cost a few hundred dollars but could potentially save tens of thousands of dollars on student loan costs.
Dr. Jain is assistant professor of medicine, division of gastroenterology & hepatology, department of medicine, University of North Carolina School of Medicine, Chapel Hill. Dr. Jain has no conflicts of interest and no funding source.
References
1. https://nces.ed.gov/programs/digest/d18/tables/dt18_332.45.asp
2. https://www.credible.com/blog/statistics/average-medical-school-debt/
3. https://studentaid.gov/understand-aid/types/loans/interest-rates
4. https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service
5. https://www.forbes.com/sites/robertfarrington/2019/09/24/how-to-get-your-public-service-loan-forgiveness-qualifying-payments-recounted/#18567f061f5d
6. https://www.cbo.gov/budget-options/2018/54721
7. https://static.studentloans.gov/images/ApplicationAndPromissoryNote.pdf
8. https://www.biglawinvestor.com/pslf-promissory-note/
9. https://bostonstudentloanlawyer.com/scary-stats-for-public-service-loan-forgiveness/
10. https://www.marketwatch.com/story/this-government-loan-forgiveness-program-has-rejected-99-of-borrowers-so-far-2018-09-20
11. https://studentaid.gov/data-center/student/loan-forgiveness/pslf-data
12. https://www.nytimes.com/2019/04/12/your-money/public-service-loan-forgiveness.html
13. https://studentaid.gov/manage-loans/repayment/plans/income-driven
14. https://www.lrp.nih.gov/eligibility-programs
The young gastroenterologist has no shortage of personal finance topics to juggle, ranging from investments, to life and disability coverage, and planning for retirement. But the elephant in the room is student loan management. Average medical student debt today is approximately $240,000, and debt burdens greater than $300,000 are becoming common.1,2 With this staggering amount of debt, it is understandable why student loans are a major source of anxiety. Here, I will provide a brief introduction to student loan management for gastroenterologists.
Student loans: Basic strategy
It is important to distinguish between two major types of loans: private student loans and direct federal loans. With private student loans the best strategy in most cases is to refinance to a lower interest rate. For direct federal loans, however, the decision making is more complex. There are two major approaches to these federal loans – either 1) refinance, or 2) go for public service loan forgiveness (PSLF). See Figure 1 for a flowchart summarizing my general approach to student loan management.
Refinance basics
One potential approach is to refinance your federal loans. Most federal loans today are at a relatively high interest rate of 6%-8%.3 Private refinancing can yield rates in the 3%-5% range, depending on the type of loan and other factors. For a loan balance of $200,000, the savings by refinancing could be approximately $2,000-$10,000 per year in interest alone. However, refinancing your loans with a private company eliminates the possibility of PSLF. Hence, you should only refinance federal loans once you are sure that you will not be pursuing PSLF. You may refinance your private loans anytime since they do not qualify for PSLF. There are multiple companies that provide student loan refinancing. The process can be done online, sometimes in as little as 30 minutes. There is generally little or no cost to refinancing, and many companies even provide a small cash-back incentive to refinance.
PSLF basics
The PSLF program allows borrowers to have the remainder of their direct loans forgiven after 10 years (120 monthly payments) under a qualifying income-driven repayment (IDR) plan.4 Figure 2 shows an overview of the various IDR plans. During the 120 payments, the borrower must work full time for a qualifying employer, which includes a government employer or a not-for-profit 501(c)(3) organization. Loan forgiveness with PSLF is completely tax free. Importantly, the PSLF program only applies to direct federal loans. You can see your federal loan types and balances by visiting https://studentaid.gov/.
To PSLF or not to PSLF?
With direct federal loans, the decision to refinance or go for PSLF is a major fork in the road. PSLF can be a good option for borrowers with long training programs and with high student loan burdens (e.g., loan-to-income ratios of 1:1, 2:1 or higher). By contrast, borrowers with short training programs or relatively small loan burdens may be better off refinancing to a low interest rate and paying off loans quickly. Virtually all institutions that train residents and fellows are qualified government or 501(c)(3) organizations. Hence, a gastroenterology graduate generally will have completed at least 6 out of 10 years of payments by the end of training. Trainees who did a chief resident year or gastroenterology research track may have completed 7 or 8 years of qualifying payments already.
For trainees who are already planning an academic career, PSLF is often a good option. While PSLF can be a nice benefit, I would not advise making a career decision purely based on PSLF. Private practice jobs generally come with substantially higher salaries than academic and government jobs. This salary differential typically more than compensates for the loss of access to PSLF. Hence, I advise trainees to choose the practice setting that is best for their personal and career satisfaction, and then build a student loan management plan around that. The exception may be the trainee who has a very large student loan burden (e.g., loan-to-income ratio of 2:1 or 3:1).
Caveats with PSLF
There have been well publicized concerns about the future of PSLF, including proposals to eliminate or cap the program.5,6 However, most proposed legislation has only recommended changes to PSLF for new borrowers. If you currently have existing federal loans, you would very likely be grandfathered into the existing PSLF terms. All federal master promissory notes since 2007 have cited PSLF as a loan repayment option.7 Hence, eliminating PSLF for existing borrowers seems unlikely since it would be changing the terms of an executed contract.8
There have also been widespread reports of high numbers of borrowers being denied applications for PSLF.9,10 However, the majority of these applicants did not have correct types of loans, had not worked full time for qualifying employers or had not made the full 120 payments.11 Yet some denials have apparently resulted from errors in tracking qualifying payments by FedLoan servicing.12 Therefore it would be prudent to keep your own careful records of all qualifying payments towards PSLF.
The nuclear option: 20- to 25-year IDR-based forgiveness
An additional option allows borrowers to make IDRs for 20-25 years (details in Figure 2) and then having their remaining loan balance forgiven.13 This option is completely independent of PSLF. Borrowers can work full time or part time and can work for any employer, including private employers.
One additional option: NIH loan repayment programs
One additional solution to consider are the NIH Loan Repayment Programs (LRPs). These programs can provide substantial loan repayment (up to $50,000 annually) for trainees and attendings engaged in research that aligns with NIH priorities, including clinical research or health disparities research.14 Notably, the applicant’s research does not have to be NIH sponsored research.
Getting more information
The approach above is a general overview of student loan concepts for gastroenterologists. However, there are countless nuances and tactics that are beyond the scope of this introductory article. I encourage everyone to get additional information and advice when making your own loan management plan. There are many helpful online resources, podcasts, and books discussing the topic. Several companies provide detailed consultation on managing student loans. Such services may cost a few hundred dollars but could potentially save tens of thousands of dollars on student loan costs.
Dr. Jain is assistant professor of medicine, division of gastroenterology & hepatology, department of medicine, University of North Carolina School of Medicine, Chapel Hill. Dr. Jain has no conflicts of interest and no funding source.
References
1. https://nces.ed.gov/programs/digest/d18/tables/dt18_332.45.asp
2. https://www.credible.com/blog/statistics/average-medical-school-debt/
3. https://studentaid.gov/understand-aid/types/loans/interest-rates
4. https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service
5. https://www.forbes.com/sites/robertfarrington/2019/09/24/how-to-get-your-public-service-loan-forgiveness-qualifying-payments-recounted/#18567f061f5d
6. https://www.cbo.gov/budget-options/2018/54721
7. https://static.studentloans.gov/images/ApplicationAndPromissoryNote.pdf
8. https://www.biglawinvestor.com/pslf-promissory-note/
9. https://bostonstudentloanlawyer.com/scary-stats-for-public-service-loan-forgiveness/
10. https://www.marketwatch.com/story/this-government-loan-forgiveness-program-has-rejected-99-of-borrowers-so-far-2018-09-20
11. https://studentaid.gov/data-center/student/loan-forgiveness/pslf-data
12. https://www.nytimes.com/2019/04/12/your-money/public-service-loan-forgiveness.html
13. https://studentaid.gov/manage-loans/repayment/plans/income-driven
14. https://www.lrp.nih.gov/eligibility-programs
Promoting diversity through the AGA
As gastroenterologists and gastrointestinal researchers, we work with an increasingly diverse patient population amid known disparities in health care delivery and health outcomes. The American Gastroenterological Association values diversity and inclusion, and part of its strategic plan is to increase and diversify its membership and leaders. The AGA Diversity Committee supports this strategic goal by fostering and promoting involvement, advancement, and recognition of underrepresented diverse constituencies. This is accomplished through policy recommendations and programs, providing resources to AGA members for addressing barriers to access and utilization of health care services among diverse patient populations with attention to linguistic, racial, cultural, religious, sexual orientation, gender identity, disability, age, and economic diversity.
There are eight clinician and investigator members, including the chair as well as one trainee member on the AGA Diversity Committee. Four members are appointed at-large and three members are appointed from the AGA Institute Committees and the AGA Institute Council. The committee has set out to achieve mission-driven goals with several initiatives that align with its intention to cultivate a diverse, inclusive, and engaged membership, armed with the necessary tools to provide the highest quality care and perform the most effective research that will benefit our patient population.
The communications task force highlights programs and topics that support the committee’s missions. Members of the committee coauthored a paper on colorectal disparities published in GI & Hepatology News in May 2018.1 In addition to presenting the disparities in colorectal screening, it provided ways to close this gap. A more recent publication in AGA Perspectives focused on unconscious bias as a prelude to the committee’s workshop at Digestive Disease Week® (DDW) 2019.2 An important initiative has been promoting Black History Month in February and Pride Month in June by posting cases or displaying prominent trailblazers on the AGA Community. In the upcoming months, profiles of several committee members will be featured in eDigest, GI & Hepatology News, and on AGA’s social media platforms.
DDW programming sponsored by the Diversity Committee is an important way to engage our members. At DDW 2019, the committee sponsored a clinical symposium title “Beyond Starbucks: Mitigating Bias Through Awareness.” This session was inspired by the 2018 incidence hallmarked by the inappropriate arrest of two African American men at a Philadelphia Starbucks. This event led to a nationwide educational breakout for all employees aimed at providing unconscious bias training. The Diversity Committee drew inspiration from these events, holding a symposium with set goals of defining unconscious bias and identifying areas within health care where unconscious bias can influence patient care. The committee invited Allyson Dylan Robinson, a portfolio lead from the Association of American Medical Colleges–endorsed Cook Ross Firm, who is nationally recognized as a leader in unconscious bias training. The assembly began with an introductory lecture followed by breakout sessions where small groups reviewed selected patient cases to determine the influence of unconscious bias in clinical scenarios. It was a well-attended symposium and was complementary to the wide array of didactic lectures offered at DDW. Bringing to light significant issues and barriers to health care is one key aspect of the mission set forth by the Diversity Committee.
The AGA Diversity Committee e-poster tour at DDW 2019 promoted the research led by scientist and physician members of underrepresented groups in medicine and/or research focused on gastrointestinal diseases in underrepresented populations. Several high-quality abstracts were reviewed and four were selected for the e-poster tour. Each scientist presented their research in front of an enthusiastic audience of DDW attendees, followed by a question and answer session. Gonzalo Parodi, BS (Cedars-Sinai Medical Center, Los Angeles), presented an elegant study showing that the antibiotic changes to intestinal microbiome were sex specific in mice. Alexis Rivera, MD (University of Puerto Rico, San Juan), found no association between inflammatory bowel disease (IBD) serologic markers and risk of surgery in patients with IBD in Puerto Rico. Maria Gonzalez-Pons, PhD (University of Puerto Rico Comprehensive Cancer Center, San Juan), presented the first study looking at the mutational landscape of early-onset colorectal cancer tumors in Puerto Rican Hispanics, as a first step toward personalizing early screening in this population. Finally, Sushrut Jangi, MD (Brigham and Women’s Hospital, Boston), presented the first longitudinal study describing the unique demographic and phenotypic characteristics of IBD in South Asians living in the United States, showing that smoking was less relevant as a risk factor, and that Crohn’s presented with a more aggressive penetrating phenotype in this population. At the conclusion of the e-poster tour, attendees and presenters had the opportunity to exchange future research ideas or follow-up and network.
The upcoming DDW 2020 AGA Diversity Committee–sponsored symposium entitled “GI Health Disparities and Creating Affirming Environments for the LGBT+ Community: The Gastroenterologist, Patient, Researcher and Educator Perspectives” will provide attendees with the opportunity to learn not only about challenges faced by the LGBTQ+ community as patients, learners, and scientists, but how we as educators, researchers, clinicians, and leaders can strategically address these challenges and intentionally create inclusive spaces in an effort to reduce health care disparities and inequities in both clinical and academic environments.
A current initiative is the creation of an archive of notable underrepresented gastroenterologists and GI scientists. The database will serve as a resource for conference organizers and committee members to identify junior speakers and mentors from diverse minority, ethnic, and racial backgrounds. This will be a platform for divisional chairs, program directors, and mentors to recommend and promote upcoming stars in their designated fields. Once the website and cloud database have been built, the diversity committee will reach out to divisional chairs, program directors, committee members, and leaders in the field to recommend physicians and scientists to include in this database. We will then reach out to nominees with an invitation and link to complete their profile in the database. We believe that this will be an opportunity for young physicians and scientists and a resource to promote diversity in medicine and science.
While we share many common experiences as ethnic minorities, the gastroenterologists comprising the AGA Diversity Committee come from various cultural backgrounds, ethnicities, and clinical practice settings. Yet rather than creating contention, our differences are the strength of this committee. Our diverse backgrounds lead to a plethora of innovative ideas and perspectives in group discussions, resulting in very robust and productive meetings. In recognizing that a diverse group can render novel solutions to many topics and issues, one of our goals is to increase membership of underrepresented groups in the AGA, as well as participation in AGA committees. This entails direct outreach to gastroenterologists in these groups and acquainting them with the ways active participation in the numerous AGA committees will support the issues affecting their profession and patients.
The process of serving on an AGA committee is simple. Interested members can nominate themselves or be nominated by another AGA member and fill out a short application. The list of AGA committees, responsibilities, open positions, and application can be found at https://www.gastro.org/aga-leadership/committees. We believe committee participation is personally and professionally rewarding, and serving on the Diversity Committee is particularly gratifying, as we can address pertinent issues that may otherwise be neglected.
Dr. Badurdeen is assistant professor at Johns Hopkins Medicine, Columbia, Md; Dr. Charabaty Pishvaian is associate professor, clinical director of the GI division, and director of the IBD Center at Sibley Memorial Hospital, Washington; Dr. Malespin is assistant professor at the University of South Florida, Tampa, and transplant hepatologist, Tampa General Hospital; Dr. Oduyebo is a gastroenterologist for Mid-Atlantic Permanente Medical Group, Shady Grove, Md; Dr. Quezada is associate professor and assistant dean for academic and multicultural affairs, University of Maryland, Baltimore County; and Dr. Stephen is a gastroenterologist at Annadel Medical Group, Santa Rosa, Calif.
References
1. Oduyebo I et al. Underserved populations and colorectal cancer screening: Patient perceptions of barriers to care and effective interventions. GI & Hepatology News. May 2018.
2. Munroe CA et al. The AGA Diversity Committee: Opening up a conversation about unconscious bias in GI practice. AGA Perspectives. July 2019.
As gastroenterologists and gastrointestinal researchers, we work with an increasingly diverse patient population amid known disparities in health care delivery and health outcomes. The American Gastroenterological Association values diversity and inclusion, and part of its strategic plan is to increase and diversify its membership and leaders. The AGA Diversity Committee supports this strategic goal by fostering and promoting involvement, advancement, and recognition of underrepresented diverse constituencies. This is accomplished through policy recommendations and programs, providing resources to AGA members for addressing barriers to access and utilization of health care services among diverse patient populations with attention to linguistic, racial, cultural, religious, sexual orientation, gender identity, disability, age, and economic diversity.
There are eight clinician and investigator members, including the chair as well as one trainee member on the AGA Diversity Committee. Four members are appointed at-large and three members are appointed from the AGA Institute Committees and the AGA Institute Council. The committee has set out to achieve mission-driven goals with several initiatives that align with its intention to cultivate a diverse, inclusive, and engaged membership, armed with the necessary tools to provide the highest quality care and perform the most effective research that will benefit our patient population.
The communications task force highlights programs and topics that support the committee’s missions. Members of the committee coauthored a paper on colorectal disparities published in GI & Hepatology News in May 2018.1 In addition to presenting the disparities in colorectal screening, it provided ways to close this gap. A more recent publication in AGA Perspectives focused on unconscious bias as a prelude to the committee’s workshop at Digestive Disease Week® (DDW) 2019.2 An important initiative has been promoting Black History Month in February and Pride Month in June by posting cases or displaying prominent trailblazers on the AGA Community. In the upcoming months, profiles of several committee members will be featured in eDigest, GI & Hepatology News, and on AGA’s social media platforms.
DDW programming sponsored by the Diversity Committee is an important way to engage our members. At DDW 2019, the committee sponsored a clinical symposium title “Beyond Starbucks: Mitigating Bias Through Awareness.” This session was inspired by the 2018 incidence hallmarked by the inappropriate arrest of two African American men at a Philadelphia Starbucks. This event led to a nationwide educational breakout for all employees aimed at providing unconscious bias training. The Diversity Committee drew inspiration from these events, holding a symposium with set goals of defining unconscious bias and identifying areas within health care where unconscious bias can influence patient care. The committee invited Allyson Dylan Robinson, a portfolio lead from the Association of American Medical Colleges–endorsed Cook Ross Firm, who is nationally recognized as a leader in unconscious bias training. The assembly began with an introductory lecture followed by breakout sessions where small groups reviewed selected patient cases to determine the influence of unconscious bias in clinical scenarios. It was a well-attended symposium and was complementary to the wide array of didactic lectures offered at DDW. Bringing to light significant issues and barriers to health care is one key aspect of the mission set forth by the Diversity Committee.
The AGA Diversity Committee e-poster tour at DDW 2019 promoted the research led by scientist and physician members of underrepresented groups in medicine and/or research focused on gastrointestinal diseases in underrepresented populations. Several high-quality abstracts were reviewed and four were selected for the e-poster tour. Each scientist presented their research in front of an enthusiastic audience of DDW attendees, followed by a question and answer session. Gonzalo Parodi, BS (Cedars-Sinai Medical Center, Los Angeles), presented an elegant study showing that the antibiotic changes to intestinal microbiome were sex specific in mice. Alexis Rivera, MD (University of Puerto Rico, San Juan), found no association between inflammatory bowel disease (IBD) serologic markers and risk of surgery in patients with IBD in Puerto Rico. Maria Gonzalez-Pons, PhD (University of Puerto Rico Comprehensive Cancer Center, San Juan), presented the first study looking at the mutational landscape of early-onset colorectal cancer tumors in Puerto Rican Hispanics, as a first step toward personalizing early screening in this population. Finally, Sushrut Jangi, MD (Brigham and Women’s Hospital, Boston), presented the first longitudinal study describing the unique demographic and phenotypic characteristics of IBD in South Asians living in the United States, showing that smoking was less relevant as a risk factor, and that Crohn’s presented with a more aggressive penetrating phenotype in this population. At the conclusion of the e-poster tour, attendees and presenters had the opportunity to exchange future research ideas or follow-up and network.
The upcoming DDW 2020 AGA Diversity Committee–sponsored symposium entitled “GI Health Disparities and Creating Affirming Environments for the LGBT+ Community: The Gastroenterologist, Patient, Researcher and Educator Perspectives” will provide attendees with the opportunity to learn not only about challenges faced by the LGBTQ+ community as patients, learners, and scientists, but how we as educators, researchers, clinicians, and leaders can strategically address these challenges and intentionally create inclusive spaces in an effort to reduce health care disparities and inequities in both clinical and academic environments.
A current initiative is the creation of an archive of notable underrepresented gastroenterologists and GI scientists. The database will serve as a resource for conference organizers and committee members to identify junior speakers and mentors from diverse minority, ethnic, and racial backgrounds. This will be a platform for divisional chairs, program directors, and mentors to recommend and promote upcoming stars in their designated fields. Once the website and cloud database have been built, the diversity committee will reach out to divisional chairs, program directors, committee members, and leaders in the field to recommend physicians and scientists to include in this database. We will then reach out to nominees with an invitation and link to complete their profile in the database. We believe that this will be an opportunity for young physicians and scientists and a resource to promote diversity in medicine and science.
While we share many common experiences as ethnic minorities, the gastroenterologists comprising the AGA Diversity Committee come from various cultural backgrounds, ethnicities, and clinical practice settings. Yet rather than creating contention, our differences are the strength of this committee. Our diverse backgrounds lead to a plethora of innovative ideas and perspectives in group discussions, resulting in very robust and productive meetings. In recognizing that a diverse group can render novel solutions to many topics and issues, one of our goals is to increase membership of underrepresented groups in the AGA, as well as participation in AGA committees. This entails direct outreach to gastroenterologists in these groups and acquainting them with the ways active participation in the numerous AGA committees will support the issues affecting their profession and patients.
The process of serving on an AGA committee is simple. Interested members can nominate themselves or be nominated by another AGA member and fill out a short application. The list of AGA committees, responsibilities, open positions, and application can be found at https://www.gastro.org/aga-leadership/committees. We believe committee participation is personally and professionally rewarding, and serving on the Diversity Committee is particularly gratifying, as we can address pertinent issues that may otherwise be neglected.
Dr. Badurdeen is assistant professor at Johns Hopkins Medicine, Columbia, Md; Dr. Charabaty Pishvaian is associate professor, clinical director of the GI division, and director of the IBD Center at Sibley Memorial Hospital, Washington; Dr. Malespin is assistant professor at the University of South Florida, Tampa, and transplant hepatologist, Tampa General Hospital; Dr. Oduyebo is a gastroenterologist for Mid-Atlantic Permanente Medical Group, Shady Grove, Md; Dr. Quezada is associate professor and assistant dean for academic and multicultural affairs, University of Maryland, Baltimore County; and Dr. Stephen is a gastroenterologist at Annadel Medical Group, Santa Rosa, Calif.
References
1. Oduyebo I et al. Underserved populations and colorectal cancer screening: Patient perceptions of barriers to care and effective interventions. GI & Hepatology News. May 2018.
2. Munroe CA et al. The AGA Diversity Committee: Opening up a conversation about unconscious bias in GI practice. AGA Perspectives. July 2019.
As gastroenterologists and gastrointestinal researchers, we work with an increasingly diverse patient population amid known disparities in health care delivery and health outcomes. The American Gastroenterological Association values diversity and inclusion, and part of its strategic plan is to increase and diversify its membership and leaders. The AGA Diversity Committee supports this strategic goal by fostering and promoting involvement, advancement, and recognition of underrepresented diverse constituencies. This is accomplished through policy recommendations and programs, providing resources to AGA members for addressing barriers to access and utilization of health care services among diverse patient populations with attention to linguistic, racial, cultural, religious, sexual orientation, gender identity, disability, age, and economic diversity.
There are eight clinician and investigator members, including the chair as well as one trainee member on the AGA Diversity Committee. Four members are appointed at-large and three members are appointed from the AGA Institute Committees and the AGA Institute Council. The committee has set out to achieve mission-driven goals with several initiatives that align with its intention to cultivate a diverse, inclusive, and engaged membership, armed with the necessary tools to provide the highest quality care and perform the most effective research that will benefit our patient population.
The communications task force highlights programs and topics that support the committee’s missions. Members of the committee coauthored a paper on colorectal disparities published in GI & Hepatology News in May 2018.1 In addition to presenting the disparities in colorectal screening, it provided ways to close this gap. A more recent publication in AGA Perspectives focused on unconscious bias as a prelude to the committee’s workshop at Digestive Disease Week® (DDW) 2019.2 An important initiative has been promoting Black History Month in February and Pride Month in June by posting cases or displaying prominent trailblazers on the AGA Community. In the upcoming months, profiles of several committee members will be featured in eDigest, GI & Hepatology News, and on AGA’s social media platforms.
DDW programming sponsored by the Diversity Committee is an important way to engage our members. At DDW 2019, the committee sponsored a clinical symposium title “Beyond Starbucks: Mitigating Bias Through Awareness.” This session was inspired by the 2018 incidence hallmarked by the inappropriate arrest of two African American men at a Philadelphia Starbucks. This event led to a nationwide educational breakout for all employees aimed at providing unconscious bias training. The Diversity Committee drew inspiration from these events, holding a symposium with set goals of defining unconscious bias and identifying areas within health care where unconscious bias can influence patient care. The committee invited Allyson Dylan Robinson, a portfolio lead from the Association of American Medical Colleges–endorsed Cook Ross Firm, who is nationally recognized as a leader in unconscious bias training. The assembly began with an introductory lecture followed by breakout sessions where small groups reviewed selected patient cases to determine the influence of unconscious bias in clinical scenarios. It was a well-attended symposium and was complementary to the wide array of didactic lectures offered at DDW. Bringing to light significant issues and barriers to health care is one key aspect of the mission set forth by the Diversity Committee.
The AGA Diversity Committee e-poster tour at DDW 2019 promoted the research led by scientist and physician members of underrepresented groups in medicine and/or research focused on gastrointestinal diseases in underrepresented populations. Several high-quality abstracts were reviewed and four were selected for the e-poster tour. Each scientist presented their research in front of an enthusiastic audience of DDW attendees, followed by a question and answer session. Gonzalo Parodi, BS (Cedars-Sinai Medical Center, Los Angeles), presented an elegant study showing that the antibiotic changes to intestinal microbiome were sex specific in mice. Alexis Rivera, MD (University of Puerto Rico, San Juan), found no association between inflammatory bowel disease (IBD) serologic markers and risk of surgery in patients with IBD in Puerto Rico. Maria Gonzalez-Pons, PhD (University of Puerto Rico Comprehensive Cancer Center, San Juan), presented the first study looking at the mutational landscape of early-onset colorectal cancer tumors in Puerto Rican Hispanics, as a first step toward personalizing early screening in this population. Finally, Sushrut Jangi, MD (Brigham and Women’s Hospital, Boston), presented the first longitudinal study describing the unique demographic and phenotypic characteristics of IBD in South Asians living in the United States, showing that smoking was less relevant as a risk factor, and that Crohn’s presented with a more aggressive penetrating phenotype in this population. At the conclusion of the e-poster tour, attendees and presenters had the opportunity to exchange future research ideas or follow-up and network.
The upcoming DDW 2020 AGA Diversity Committee–sponsored symposium entitled “GI Health Disparities and Creating Affirming Environments for the LGBT+ Community: The Gastroenterologist, Patient, Researcher and Educator Perspectives” will provide attendees with the opportunity to learn not only about challenges faced by the LGBTQ+ community as patients, learners, and scientists, but how we as educators, researchers, clinicians, and leaders can strategically address these challenges and intentionally create inclusive spaces in an effort to reduce health care disparities and inequities in both clinical and academic environments.
A current initiative is the creation of an archive of notable underrepresented gastroenterologists and GI scientists. The database will serve as a resource for conference organizers and committee members to identify junior speakers and mentors from diverse minority, ethnic, and racial backgrounds. This will be a platform for divisional chairs, program directors, and mentors to recommend and promote upcoming stars in their designated fields. Once the website and cloud database have been built, the diversity committee will reach out to divisional chairs, program directors, committee members, and leaders in the field to recommend physicians and scientists to include in this database. We will then reach out to nominees with an invitation and link to complete their profile in the database. We believe that this will be an opportunity for young physicians and scientists and a resource to promote diversity in medicine and science.
While we share many common experiences as ethnic minorities, the gastroenterologists comprising the AGA Diversity Committee come from various cultural backgrounds, ethnicities, and clinical practice settings. Yet rather than creating contention, our differences are the strength of this committee. Our diverse backgrounds lead to a plethora of innovative ideas and perspectives in group discussions, resulting in very robust and productive meetings. In recognizing that a diverse group can render novel solutions to many topics and issues, one of our goals is to increase membership of underrepresented groups in the AGA, as well as participation in AGA committees. This entails direct outreach to gastroenterologists in these groups and acquainting them with the ways active participation in the numerous AGA committees will support the issues affecting their profession and patients.
The process of serving on an AGA committee is simple. Interested members can nominate themselves or be nominated by another AGA member and fill out a short application. The list of AGA committees, responsibilities, open positions, and application can be found at https://www.gastro.org/aga-leadership/committees. We believe committee participation is personally and professionally rewarding, and serving on the Diversity Committee is particularly gratifying, as we can address pertinent issues that may otherwise be neglected.
Dr. Badurdeen is assistant professor at Johns Hopkins Medicine, Columbia, Md; Dr. Charabaty Pishvaian is associate professor, clinical director of the GI division, and director of the IBD Center at Sibley Memorial Hospital, Washington; Dr. Malespin is assistant professor at the University of South Florida, Tampa, and transplant hepatologist, Tampa General Hospital; Dr. Oduyebo is a gastroenterologist for Mid-Atlantic Permanente Medical Group, Shady Grove, Md; Dr. Quezada is associate professor and assistant dean for academic and multicultural affairs, University of Maryland, Baltimore County; and Dr. Stephen is a gastroenterologist at Annadel Medical Group, Santa Rosa, Calif.
References
1. Oduyebo I et al. Underserved populations and colorectal cancer screening: Patient perceptions of barriers to care and effective interventions. GI & Hepatology News. May 2018.
2. Munroe CA et al. The AGA Diversity Committee: Opening up a conversation about unconscious bias in GI practice. AGA Perspectives. July 2019.