The New Gastroenterologist

As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.

What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”

The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
 

Discovery and translational medicine

These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.

Early-stage clinical development

Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.

Late-stage clinical development

Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.

Medical affairs

This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.

Patient safety

As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.

Epidemiology

Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.

Commercial development

Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.

A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.

Is industry a good career choice for you? Consider the following factors:

• Travel capabilities.
• Small biotech versus big pharma versus CRO.
• Capability to function in a team environment.
• Communication skills, resilience, self-awareness.
• Therapeutic area and category.
• Early stage versus late stage versus translational versus medical affairs.
• Additional education: MBA, MPH, PhD.
• Geography.

The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
 

As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.

What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”

The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
 

Discovery and translational medicine

These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.

Early-stage clinical development

Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.

Late-stage clinical development

Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.

Medical affairs

This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.

Patient safety

As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.

Epidemiology

Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.

Commercial development

Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.

A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.

Is industry a good career choice for you? Consider the following factors:

• Travel capabilities.
• Small biotech versus big pharma versus CRO.
• Capability to function in a team environment.
• Communication skills, resilience, self-awareness.
• Therapeutic area and category.
• Early stage versus late stage versus translational versus medical affairs.
• Additional education: MBA, MPH, PhD.
• Geography.

The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
 

As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.

What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”

The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
 

Discovery and translational medicine

These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.

Early-stage clinical development

Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.

Late-stage clinical development

Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.

Medical affairs

This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.

Patient safety

As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.

Epidemiology

Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.

Commercial development

Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.

A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.

Is industry a good career choice for you? Consider the following factors:

• Travel capabilities.
• Small biotech versus big pharma versus CRO.
• Capability to function in a team environment.
• Communication skills, resilience, self-awareness.
• Therapeutic area and category.
• Early stage versus late stage versus translational versus medical affairs.
• Additional education: MBA, MPH, PhD.
• Geography.

The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
 

Let’s imagine you landed your first job in a private gastroenterology practice or are trying to find the perfect job that allows you to put your energy toward your passions. And, like many GI doctors, you spent additional time in your fellowship training focusing on a specific interest – whether inflammatory bowel disease, advanced endoscopy, motility, hepatology, or maybe the lesser-traveled paths of weight management, geriatrics, or public policy.

Perhaps you haven’t taken an extra year of training, but you have a desire to specialize. What steps should you take to create your own niche in a private practice? How do you go about growing a practice that allows you to utilize your training?

Why specialize? Know your market!

Without a focus, unless you plan to work in an underserved area or to take over a retiring physician’s practice, a generalist position can be challenging because the demand for your skills may not be met with the supply of patients. Much like in any business, the more focused you are, the more you have a differentiator that separates you from your colleagues, increasing your chances of success.

With specialization, however, comes the importance of understanding your patient catchment area. If your focus is highly specialized and serves a less-diagnosed entity, you’ll need a larger catchment area or you won’t have the volume of patients. Also, be mindful about an oversupply of subspecialists in your given area. If you are the third or fourth subspecialist in your group, the only way you will get patients is if you are far superior in talent or personality (sorry – not typical!) or your more senior colleagues are looking to turn over work to you.

Economic considerations for subspecialties

Compensation for subspecializing is often a major factor. Understanding the economics of your specialty are important, as providers can become disappointed and disenchanted when they realize that their desire for income, especially when compared to other colleagues, differs from what their subspecialty can provide.

For instance, in GI, a physician pursuing a procedurally focused subspecialty like advanced endoscopy is likely to be compensated more highly than one who focuses on a more office-based, evaluation and management (E/M) billing-driven specialty, like motility, geriatric gastroenterology, or even hepatology. These office-based specialties are no less important, but the reality is that they create less revenue for a private practice.

Negotiating a fair contract at the beginning is critical, as you may need your income to be supplemented by your higher revenue-producing colleagues and partners for long-term success. Academic centers are often able to provide the supplement through endowments, grants, or better payer reimbursement for E/M codes, compared with a private practice.

Remember, everyone’s in sales

From my vantage point as a partner at Atlanta Gastroenterology Associates, there are several ways new GI physicians can set about a path toward specialization.

One of the first things that you should ask yourself during training is whether you want to spend another year beyond the typical 3 years. Best-case scenario would be figuring out a way to get the necessary training during the 3 years, possibly spending the third year dedicated to the specialty. Another possibility is to simply get on-the-job training during your first few years in practice without the extra year.

Whichever path you choose, building up a specialized niche within a private practice won’t come overnight. You have to create a plan and navigate a course. Here are a few ways to do that:

Take the case, especially the hard ones!

Have the mentality: “I will take care of it.” One of the best ways to specialize is to offer to help with all cases, but especially the most challenging ones. Be open to helping take on any patient. In the beginning, if you develop a reputation that you enjoy caring for all patients, even when the case requires more time and effort, this will translate into future referrals. Naturally, it may be slower in the beginning, as there may not be enough patients to treat within your specialty. Being willing to do everything will expedite the growth of your practice. No consult should be rebuffed, even when it appears unnecessary (i.e., heme-positive stool in an elderly, septic ICU patient – we all have gotten them); think of it as your opportunity to show off your skills and share your interests.

Market yourself.

This is perhaps one of the most important steps you can take. Get out in the community! This includes:

• Attend your hospital grand rounds and offer to be a presenter. There is no better way to show your enthusiasm and knowledge on a topic than to teach it. Many state GI societies have meetings, which provide opportunities to introduce yourself to physicians in other practices that can act as a good referral source if you are a local expert.
• Remember, as a subspecialist, always communicate back with the primary gastroenterologist. In doing so, feel out whether the referring doctor wants you to take over the patient’s management or send the patient back.
• Reach out to foundations, pharmaceutical companies, and advocacy groups in the area. Understand each specialty has an ecosystem beyond just a doctor-patient relationship. Participating in events that support the patient outside of the office will provide goodwill. Further, many patients rely on foundations for referrals.
• Consider research studies. Many pharmaceutical companies have the opportunity for you to register patients in investigational drug studies. By being a part of these studies, you will be included in publications, which will build your brand.
• Many disease processes need a multidisciplinary approach to treating them. Attending multidisciplinary conferences will allow you to lend your expertise. Also, presenting interesting cases and asking for help from more experienced physicians will show humility and leads to more referrals; it won’t be viewed as a weakness.
• Be creative. Develop relationships with providers who are not often considered to be a primary referral source. Motility experts may want to work closely with the local speech pathologists. An IBD specialist should develop a network of specialists for patients with extraintestinal manifestations. Advanced endoscopists and oncologists work closely together.
• Get involved in social media. Engage with other specialists and become part of the online community. Follow the subspecialty organizations or key thought leaders in your space on Twitter, Facebook, and LinkedIn. You should share relevant articles or interesting cases.

There are so many aspects of gastroenterology that present great opportunities to specialize. Following your passions will lead to long-term happiness and prevent burnout. Remember that, even once you’ve built your practice, you must continue to stay involved and nurture what you’ve built. Go to the conferences. Make connections. Continue your education. Your career will thank you.
 

Dr. Sonenshine joined Atlanta Gastroenterology Associates in 2012. An Atlanta native, he graduated magna cum laude from the University of Georgia in Athens where he received a bachelor’s degree in microbiology and was selected to the Phi Beta Kappa Academic Honor Society. He received his medical degree from the Medical College of Georgia in Augusta, where he was named to the Alpha Omega Alpha Medical Honor Society. He completed both his internship and residency through the Osler Housestaff Training Program at Johns Hopkins Hospital in Baltimore. Following his residency, Dr. Sonenshine completed a fellowship in digestive diseases at Emory University in Atlanta while earning a master of business administration degree from the Terry College of Business at the University of Georgia. He is a partner in United Digestive and the chairman of medicine at Northside Hospital.

Let’s imagine you landed your first job in a private gastroenterology practice or are trying to find the perfect job that allows you to put your energy toward your passions. And, like many GI doctors, you spent additional time in your fellowship training focusing on a specific interest – whether inflammatory bowel disease, advanced endoscopy, motility, hepatology, or maybe the lesser-traveled paths of weight management, geriatrics, or public policy.

Perhaps you haven’t taken an extra year of training, but you have a desire to specialize. What steps should you take to create your own niche in a private practice? How do you go about growing a practice that allows you to utilize your training?

Why specialize? Know your market!

Without a focus, unless you plan to work in an underserved area or to take over a retiring physician’s practice, a generalist position can be challenging because the demand for your skills may not be met with the supply of patients. Much like in any business, the more focused you are, the more you have a differentiator that separates you from your colleagues, increasing your chances of success.

With specialization, however, comes the importance of understanding your patient catchment area. If your focus is highly specialized and serves a less-diagnosed entity, you’ll need a larger catchment area or you won’t have the volume of patients. Also, be mindful about an oversupply of subspecialists in your given area. If you are the third or fourth subspecialist in your group, the only way you will get patients is if you are far superior in talent or personality (sorry – not typical!) or your more senior colleagues are looking to turn over work to you.

Economic considerations for subspecialties

Compensation for subspecializing is often a major factor. Understanding the economics of your specialty are important, as providers can become disappointed and disenchanted when they realize that their desire for income, especially when compared to other colleagues, differs from what their subspecialty can provide.

For instance, in GI, a physician pursuing a procedurally focused subspecialty like advanced endoscopy is likely to be compensated more highly than one who focuses on a more office-based, evaluation and management (E/M) billing-driven specialty, like motility, geriatric gastroenterology, or even hepatology. These office-based specialties are no less important, but the reality is that they create less revenue for a private practice.

Negotiating a fair contract at the beginning is critical, as you may need your income to be supplemented by your higher revenue-producing colleagues and partners for long-term success. Academic centers are often able to provide the supplement through endowments, grants, or better payer reimbursement for E/M codes, compared with a private practice.

Remember, everyone’s in sales

From my vantage point as a partner at Atlanta Gastroenterology Associates, there are several ways new GI physicians can set about a path toward specialization.

One of the first things that you should ask yourself during training is whether you want to spend another year beyond the typical 3 years. Best-case scenario would be figuring out a way to get the necessary training during the 3 years, possibly spending the third year dedicated to the specialty. Another possibility is to simply get on-the-job training during your first few years in practice without the extra year.

Whichever path you choose, building up a specialized niche within a private practice won’t come overnight. You have to create a plan and navigate a course. Here are a few ways to do that:

Take the case, especially the hard ones!

Have the mentality: “I will take care of it.” One of the best ways to specialize is to offer to help with all cases, but especially the most challenging ones. Be open to helping take on any patient. In the beginning, if you develop a reputation that you enjoy caring for all patients, even when the case requires more time and effort, this will translate into future referrals. Naturally, it may be slower in the beginning, as there may not be enough patients to treat within your specialty. Being willing to do everything will expedite the growth of your practice. No consult should be rebuffed, even when it appears unnecessary (i.e., heme-positive stool in an elderly, septic ICU patient – we all have gotten them); think of it as your opportunity to show off your skills and share your interests.

Market yourself.

This is perhaps one of the most important steps you can take. Get out in the community! This includes:

• Attend your hospital grand rounds and offer to be a presenter. There is no better way to show your enthusiasm and knowledge on a topic than to teach it. Many state GI societies have meetings, which provide opportunities to introduce yourself to physicians in other practices that can act as a good referral source if you are a local expert.
• Remember, as a subspecialist, always communicate back with the primary gastroenterologist. In doing so, feel out whether the referring doctor wants you to take over the patient’s management or send the patient back.
• Reach out to foundations, pharmaceutical companies, and advocacy groups in the area. Understand each specialty has an ecosystem beyond just a doctor-patient relationship. Participating in events that support the patient outside of the office will provide goodwill. Further, many patients rely on foundations for referrals.
• Consider research studies. Many pharmaceutical companies have the opportunity for you to register patients in investigational drug studies. By being a part of these studies, you will be included in publications, which will build your brand.
• Many disease processes need a multidisciplinary approach to treating them. Attending multidisciplinary conferences will allow you to lend your expertise. Also, presenting interesting cases and asking for help from more experienced physicians will show humility and leads to more referrals; it won’t be viewed as a weakness.
• Be creative. Develop relationships with providers who are not often considered to be a primary referral source. Motility experts may want to work closely with the local speech pathologists. An IBD specialist should develop a network of specialists for patients with extraintestinal manifestations. Advanced endoscopists and oncologists work closely together.
• Get involved in social media. Engage with other specialists and become part of the online community. Follow the subspecialty organizations or key thought leaders in your space on Twitter, Facebook, and LinkedIn. You should share relevant articles or interesting cases.

There are so many aspects of gastroenterology that present great opportunities to specialize. Following your passions will lead to long-term happiness and prevent burnout. Remember that, even once you’ve built your practice, you must continue to stay involved and nurture what you’ve built. Go to the conferences. Make connections. Continue your education. Your career will thank you.
 

Dr. Sonenshine joined Atlanta Gastroenterology Associates in 2012. An Atlanta native, he graduated magna cum laude from the University of Georgia in Athens where he received a bachelor’s degree in microbiology and was selected to the Phi Beta Kappa Academic Honor Society. He received his medical degree from the Medical College of Georgia in Augusta, where he was named to the Alpha Omega Alpha Medical Honor Society. He completed both his internship and residency through the Osler Housestaff Training Program at Johns Hopkins Hospital in Baltimore. Following his residency, Dr. Sonenshine completed a fellowship in digestive diseases at Emory University in Atlanta while earning a master of business administration degree from the Terry College of Business at the University of Georgia. He is a partner in United Digestive and the chairman of medicine at Northside Hospital.

Let’s imagine you landed your first job in a private gastroenterology practice or are trying to find the perfect job that allows you to put your energy toward your passions. And, like many GI doctors, you spent additional time in your fellowship training focusing on a specific interest – whether inflammatory bowel disease, advanced endoscopy, motility, hepatology, or maybe the lesser-traveled paths of weight management, geriatrics, or public policy.

Perhaps you haven’t taken an extra year of training, but you have a desire to specialize. What steps should you take to create your own niche in a private practice? How do you go about growing a practice that allows you to utilize your training?

Why specialize? Know your market!

Without a focus, unless you plan to work in an underserved area or to take over a retiring physician’s practice, a generalist position can be challenging because the demand for your skills may not be met with the supply of patients. Much like in any business, the more focused you are, the more you have a differentiator that separates you from your colleagues, increasing your chances of success.

With specialization, however, comes the importance of understanding your patient catchment area. If your focus is highly specialized and serves a less-diagnosed entity, you’ll need a larger catchment area or you won’t have the volume of patients. Also, be mindful about an oversupply of subspecialists in your given area. If you are the third or fourth subspecialist in your group, the only way you will get patients is if you are far superior in talent or personality (sorry – not typical!) or your more senior colleagues are looking to turn over work to you.

Economic considerations for subspecialties

Compensation for subspecializing is often a major factor. Understanding the economics of your specialty are important, as providers can become disappointed and disenchanted when they realize that their desire for income, especially when compared to other colleagues, differs from what their subspecialty can provide.

For instance, in GI, a physician pursuing a procedurally focused subspecialty like advanced endoscopy is likely to be compensated more highly than one who focuses on a more office-based, evaluation and management (E/M) billing-driven specialty, like motility, geriatric gastroenterology, or even hepatology. These office-based specialties are no less important, but the reality is that they create less revenue for a private practice.

Negotiating a fair contract at the beginning is critical, as you may need your income to be supplemented by your higher revenue-producing colleagues and partners for long-term success. Academic centers are often able to provide the supplement through endowments, grants, or better payer reimbursement for E/M codes, compared with a private practice.

Remember, everyone’s in sales

From my vantage point as a partner at Atlanta Gastroenterology Associates, there are several ways new GI physicians can set about a path toward specialization.

One of the first things that you should ask yourself during training is whether you want to spend another year beyond the typical 3 years. Best-case scenario would be figuring out a way to get the necessary training during the 3 years, possibly spending the third year dedicated to the specialty. Another possibility is to simply get on-the-job training during your first few years in practice without the extra year.

Whichever path you choose, building up a specialized niche within a private practice won’t come overnight. You have to create a plan and navigate a course. Here are a few ways to do that:

Take the case, especially the hard ones!

Have the mentality: “I will take care of it.” One of the best ways to specialize is to offer to help with all cases, but especially the most challenging ones. Be open to helping take on any patient. In the beginning, if you develop a reputation that you enjoy caring for all patients, even when the case requires more time and effort, this will translate into future referrals. Naturally, it may be slower in the beginning, as there may not be enough patients to treat within your specialty. Being willing to do everything will expedite the growth of your practice. No consult should be rebuffed, even when it appears unnecessary (i.e., heme-positive stool in an elderly, septic ICU patient – we all have gotten them); think of it as your opportunity to show off your skills and share your interests.

Market yourself.

This is perhaps one of the most important steps you can take. Get out in the community! This includes:

• Attend your hospital grand rounds and offer to be a presenter. There is no better way to show your enthusiasm and knowledge on a topic than to teach it. Many state GI societies have meetings, which provide opportunities to introduce yourself to physicians in other practices that can act as a good referral source if you are a local expert.
• Remember, as a subspecialist, always communicate back with the primary gastroenterologist. In doing so, feel out whether the referring doctor wants you to take over the patient’s management or send the patient back.
• Reach out to foundations, pharmaceutical companies, and advocacy groups in the area. Understand each specialty has an ecosystem beyond just a doctor-patient relationship. Participating in events that support the patient outside of the office will provide goodwill. Further, many patients rely on foundations for referrals.
• Consider research studies. Many pharmaceutical companies have the opportunity for you to register patients in investigational drug studies. By being a part of these studies, you will be included in publications, which will build your brand.
• Many disease processes need a multidisciplinary approach to treating them. Attending multidisciplinary conferences will allow you to lend your expertise. Also, presenting interesting cases and asking for help from more experienced physicians will show humility and leads to more referrals; it won’t be viewed as a weakness.
• Be creative. Develop relationships with providers who are not often considered to be a primary referral source. Motility experts may want to work closely with the local speech pathologists. An IBD specialist should develop a network of specialists for patients with extraintestinal manifestations. Advanced endoscopists and oncologists work closely together.
• Get involved in social media. Engage with other specialists and become part of the online community. Follow the subspecialty organizations or key thought leaders in your space on Twitter, Facebook, and LinkedIn. You should share relevant articles or interesting cases.

There are so many aspects of gastroenterology that present great opportunities to specialize. Following your passions will lead to long-term happiness and prevent burnout. Remember that, even once you’ve built your practice, you must continue to stay involved and nurture what you’ve built. Go to the conferences. Make connections. Continue your education. Your career will thank you.
 

Dr. Sonenshine joined Atlanta Gastroenterology Associates in 2012. An Atlanta native, he graduated magna cum laude from the University of Georgia in Athens where he received a bachelor’s degree in microbiology and was selected to the Phi Beta Kappa Academic Honor Society. He received his medical degree from the Medical College of Georgia in Augusta, where he was named to the Alpha Omega Alpha Medical Honor Society. He completed both his internship and residency through the Osler Housestaff Training Program at Johns Hopkins Hospital in Baltimore. Following his residency, Dr. Sonenshine completed a fellowship in digestive diseases at Emory University in Atlanta while earning a master of business administration degree from the Terry College of Business at the University of Georgia. He is a partner in United Digestive and the chairman of medicine at Northside Hospital.

AGA’s cutting-edge, trainee and early-career focused e-newsletter The New Gastroenterologist (TNG) is seeking applications for the position of editor-in-chief (EIC). The role will facilitate the communication of the latest clinical advances among peers and build strong leadership skills managing editorial responsibilities as well as working with reviewers and fellow editors at AGA’s journals.

The term is from Oct. 1, 2019 – Sept. 30, 2022, with a transition period starting July 2019.

Courtesy AGA

About TNG

TNG content covers highly relevant clinical topics, such as endoscopic management of obesity and quality metrics on colonoscopy. Also included in each issue are articles that focus on career pathways, financial and legal matters, perspectives from private practice, and other topics that are relevant to early-career GIs.

Honorarium

The EIC will receive an annual honorarium of $5,000.

Qualifications

• AGA member, between second year of fellowship and five years post-fellowship.

• Experience identifying and promoting newsworthy content that is relevant to the trainee and early-career GI community, as well as excellent judgment that expands the outstanding reputation of TNG and AGA.

• Experience in medical, scientific or news-related publishing is preferred, but not required.

• Familiarity with AGA and its priorities, activities and stances on important issues is ideal, preferably via past volunteer member experience with the association.

• The EIC must be able to devote sufficient time to TNG matters and may not accept editorial appointments to competing publications during their tenure as EIC.

For more information or to apply view the full request for application.

If you have questions, please contact Ryan Farrell, managing editor, The New Gastroenterologist, at [email protected].
 

AGA’s cutting-edge, trainee and early-career focused e-newsletter The New Gastroenterologist (TNG) is seeking applications for the position of editor-in-chief (EIC). The role will facilitate the communication of the latest clinical advances among peers and build strong leadership skills managing editorial responsibilities as well as working with reviewers and fellow editors at AGA’s journals.

The term is from Oct. 1, 2019 – Sept. 30, 2022, with a transition period starting July 2019.

Courtesy AGA

About TNG

TNG content covers highly relevant clinical topics, such as endoscopic management of obesity and quality metrics on colonoscopy. Also included in each issue are articles that focus on career pathways, financial and legal matters, perspectives from private practice, and other topics that are relevant to early-career GIs.

Honorarium

The EIC will receive an annual honorarium of $5,000.

Qualifications

• AGA member, between second year of fellowship and five years post-fellowship.

• Experience identifying and promoting newsworthy content that is relevant to the trainee and early-career GI community, as well as excellent judgment that expands the outstanding reputation of TNG and AGA.

• Experience in medical, scientific or news-related publishing is preferred, but not required.

• Familiarity with AGA and its priorities, activities and stances on important issues is ideal, preferably via past volunteer member experience with the association.

• The EIC must be able to devote sufficient time to TNG matters and may not accept editorial appointments to competing publications during their tenure as EIC.

For more information or to apply view the full request for application.

If you have questions, please contact Ryan Farrell, managing editor, The New Gastroenterologist, at [email protected].
 

AGA’s cutting-edge, trainee and early-career focused e-newsletter The New Gastroenterologist (TNG) is seeking applications for the position of editor-in-chief (EIC). The role will facilitate the communication of the latest clinical advances among peers and build strong leadership skills managing editorial responsibilities as well as working with reviewers and fellow editors at AGA’s journals.

The term is from Oct. 1, 2019 – Sept. 30, 2022, with a transition period starting July 2019.

Courtesy AGA

About TNG

TNG content covers highly relevant clinical topics, such as endoscopic management of obesity and quality metrics on colonoscopy. Also included in each issue are articles that focus on career pathways, financial and legal matters, perspectives from private practice, and other topics that are relevant to early-career GIs.

Honorarium

The EIC will receive an annual honorarium of $5,000.

Qualifications

• AGA member, between second year of fellowship and five years post-fellowship.

• Experience identifying and promoting newsworthy content that is relevant to the trainee and early-career GI community, as well as excellent judgment that expands the outstanding reputation of TNG and AGA.

• Experience in medical, scientific or news-related publishing is preferred, but not required.

• Familiarity with AGA and its priorities, activities and stances on important issues is ideal, preferably via past volunteer member experience with the association.

• The EIC must be able to devote sufficient time to TNG matters and may not accept editorial appointments to competing publications during their tenure as EIC.

For more information or to apply view the full request for application.

If you have questions, please contact Ryan Farrell, managing editor, The New Gastroenterologist, at [email protected].
 

I’m very excited about the first issue of The New Gastroenterologist in 2019, which has some fantastic articles that I hope you will find interesting and useful. The In Focus feature this month covers acute pancreatitis, which is an incredibly important topic for all in our field. Amar Mandalia and Matthew DiMagno (University of Michigan) provide a comprehensive overview of the management of acute pancreatitis, including a review of the recent AGA guideline on this topic. This article can be found online, as well as in print in the February issue of GI & Hepatology News.

Rhonda Cole (Michael E. DeBakey VAMC/Baylor) addresses the important topic of how to deal with difficult people, and she provides some useful tips for situations that many of us struggle with. Also in this issue, Rishi Naik (Vanderbilt) and current Associate Editor of Gastroenterology John Inadomi (University of Washington) provide some tips on how to write an effective cover letter for a journal submission. Anna Duloy and Sachin Wani (University of Colorado) provide an overview of the current state of training in advanced endoscopy, which will be very helpful for all those considering a fellowship or incorporation of these procedures into their practices.

For those looking to pick the right private practice position, David Ramsay (Digestive Health Specialists, Winston-Salem, N.C.) provides some useful tips to help you find the job that will be the best fit. In prior issues of The New Gastroenterologist, there have been several articles discussing saving for retirement, but how about how to effectively save for your children’s education? To address that topic, Michael Clancy (Drexel) provides an informative overview of 529 college savings accounts.

Finally, Gyanprakash Ketwaroo (Baylor), Peter Liang (NYU Langone), Carol Brown, and Celena NuQuay (AGA) provide an overview of one of the most important and impactful initiatives from the AGA for the early career community – the AGA Regional Practice Skills Workshops. These workshops are a tremendous resource for early career GIs, and I would recommend that you check one out if you have not already had the opportunity.

If you’re interested in browsing older articles from The New Gastroenterologist, articles from previous issues can be found on our webpage. Also, we are always looking for new ideas and new contributors. If you have suggestions or are interested, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected]

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

I’m very excited about the first issue of The New Gastroenterologist in 2019, which has some fantastic articles that I hope you will find interesting and useful. The In Focus feature this month covers acute pancreatitis, which is an incredibly important topic for all in our field. Amar Mandalia and Matthew DiMagno (University of Michigan) provide a comprehensive overview of the management of acute pancreatitis, including a review of the recent AGA guideline on this topic. This article can be found online, as well as in print in the February issue of GI & Hepatology News.

Rhonda Cole (Michael E. DeBakey VAMC/Baylor) addresses the important topic of how to deal with difficult people, and she provides some useful tips for situations that many of us struggle with. Also in this issue, Rishi Naik (Vanderbilt) and current Associate Editor of Gastroenterology John Inadomi (University of Washington) provide some tips on how to write an effective cover letter for a journal submission. Anna Duloy and Sachin Wani (University of Colorado) provide an overview of the current state of training in advanced endoscopy, which will be very helpful for all those considering a fellowship or incorporation of these procedures into their practices.

For those looking to pick the right private practice position, David Ramsay (Digestive Health Specialists, Winston-Salem, N.C.) provides some useful tips to help you find the job that will be the best fit. In prior issues of The New Gastroenterologist, there have been several articles discussing saving for retirement, but how about how to effectively save for your children’s education? To address that topic, Michael Clancy (Drexel) provides an informative overview of 529 college savings accounts.

Finally, Gyanprakash Ketwaroo (Baylor), Peter Liang (NYU Langone), Carol Brown, and Celena NuQuay (AGA) provide an overview of one of the most important and impactful initiatives from the AGA for the early career community – the AGA Regional Practice Skills Workshops. These workshops are a tremendous resource for early career GIs, and I would recommend that you check one out if you have not already had the opportunity.

If you’re interested in browsing older articles from The New Gastroenterologist, articles from previous issues can be found on our webpage. Also, we are always looking for new ideas and new contributors. If you have suggestions or are interested, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected]

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

I’m very excited about the first issue of The New Gastroenterologist in 2019, which has some fantastic articles that I hope you will find interesting and useful. The In Focus feature this month covers acute pancreatitis, which is an incredibly important topic for all in our field. Amar Mandalia and Matthew DiMagno (University of Michigan) provide a comprehensive overview of the management of acute pancreatitis, including a review of the recent AGA guideline on this topic. This article can be found online, as well as in print in the February issue of GI & Hepatology News.

Rhonda Cole (Michael E. DeBakey VAMC/Baylor) addresses the important topic of how to deal with difficult people, and she provides some useful tips for situations that many of us struggle with. Also in this issue, Rishi Naik (Vanderbilt) and current Associate Editor of Gastroenterology John Inadomi (University of Washington) provide some tips on how to write an effective cover letter for a journal submission. Anna Duloy and Sachin Wani (University of Colorado) provide an overview of the current state of training in advanced endoscopy, which will be very helpful for all those considering a fellowship or incorporation of these procedures into their practices.

For those looking to pick the right private practice position, David Ramsay (Digestive Health Specialists, Winston-Salem, N.C.) provides some useful tips to help you find the job that will be the best fit. In prior issues of The New Gastroenterologist, there have been several articles discussing saving for retirement, but how about how to effectively save for your children’s education? To address that topic, Michael Clancy (Drexel) provides an informative overview of 529 college savings accounts.

Finally, Gyanprakash Ketwaroo (Baylor), Peter Liang (NYU Langone), Carol Brown, and Celena NuQuay (AGA) provide an overview of one of the most important and impactful initiatives from the AGA for the early career community – the AGA Regional Practice Skills Workshops. These workshops are a tremendous resource for early career GIs, and I would recommend that you check one out if you have not already had the opportunity.

If you’re interested in browsing older articles from The New Gastroenterologist, articles from previous issues can be found on our webpage. Also, we are always looking for new ideas and new contributors. If you have suggestions or are interested, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected]

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Introduction

Acute pancreatitis (AP) is a major clinical and financial burden in the United States. Several major clinical guidelines provide evidence-based recommendations for the clinical management decisions in AP, including those from the American College of Gastroenterology (ACG; 2013),¹ and the International Association of Pancreatology (IAP; 2013).² More recently, the American Gastroenterological Association (AGA) released their own set of guidelines.^3,4 In this update on AP, we review these guidelines and reference recent literature focused on epidemiology, risk factors, etiology, diagnosis, risk stratification, and recent advances in the early medical management of AP. Regarding the latter, we review six treatment interventions (pain management, intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis) and four preventive interventions (alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis [PEP]). Updates on multidisciplinary management of (infected) pancreatic necrosis is beyond the scope of this review. Table 1 summarizes the concepts discussed in this article.

Recent advances in epidemiology and evaluation of AP

Epidemiology

AP is the third most common cause of gastrointestinal-related hospitalizations and fourth most common cause of readmission in 2014.⁵ Recent epidemiologic studies show conflicting trends for the incidence of AP, both increasing⁶ and decreasing,⁷ likely attributable to significant differences in study designs. Importantly, multiple studies have demonstrated that hospital length of stay, costs, and mortality have declined since 2009.^6,8-10

Persistent organ failure (POF), defined as organ failure lasting more than 48 hours, is the major cause of death in AP. POF, if only a single organ during AP, is associated with 27%-36% mortality; if it is multiorgan, it is associated with 47% mortality.^1,11 Other factors associated with increased hospital mortality include infected pancreatic necrosis,^12-14 diabetes mellitus,¹⁵ hospital-acquired infection,¹⁶ advanced age (70 years and older),¹⁷ and obesity.¹⁸ Predictive factors of 1-year mortality include readmission within 30 days, higher Charlson Comorbidity Index, and longer hospitalization.¹⁹

Risk factors

We briefly highlight recent insights into risk factors for AP (Table 1) and refer to a recent review for further discussion.²⁰ Current and former tobacco use are independent risk factors for AP.²¹ The dose-response relationship of alcohol to the risk of pancreatitis is complex,²² but five standard drinks per day for 5 years is a commonly used cut-off.^1,23 New evidence suggests that the relationship between the dose of alcohol and risk of AP differs by sex, linearly in men but nonlinearly (J-shaped) in women.²⁴ Risk of AP in women was decreased with alcohol consumption of up to 40 g/day (one standard drink contains 14 g of alcohol) and increased above this amount. Cannabis is a possible risk factor for toxin-induced AP and abstinence appears to abolish risk of recurrent attacks.²⁵

Patients with inflammatory bowel disease (IBD) have a 2.9-fold higher risk for AP versus non-IBD cohorts²⁶ with the most common etiologies are from gallstones and medications.²⁷ In patients with end-stage renal disease (ESRD), the risk of AP is higher in those who receive peritoneal dialysis, compared with hemodialysis^28-33 and who are women, older, or have cholelithiasis or liver disease.³⁴As recently reviewed,³⁵ pancreatic cancer appears to be associated with first-attack pancreatitis with few exceptions.³⁶ In this setting, the overall incidence of pancreatic cancer is low (1.5%). The risk is greatest within the first year of the attack of AP, negligible below age 40 years but steadily rising through the fifth to eighth decades.³⁷ Pancreatic cancer screening is a conditional recommendation of the ACG guidelines in patients with unexplained AP, particularly those aged 40 years or older.¹

Etiology and diagnosis

Alcohol and gallstones remain the most prevalent etiologies for AP.¹ While hypertriglyceridemia accounted for 9% of AP in a systematic review of acute pancreatitis in 15 different countries,³⁸ it is the second most common cause of acute pancreatitis in Asia (especially China).³⁹ Figure 1 provides a breakdown of the etiologies and risk factors of pancreatitis. Importantly, it remains challenging to assign several toxic-metabolic etiologies as either a cause or risk factor for AP, particularly with regards to alcohol, smoking, and cannabis to name a few.

Guidelines and recent studies of AP raise questions about the threshold above which hypertriglyceridemia causes or poses as an important cofactor for AP. American and European societies define the threshold for triglycerides at 885-1,000 mg/dL.^1,42,43 Pedersen et al. provide evidence of a graded risk of AP with hypertriglyceridemia: In multivariable analysis, adjusted hazard ratios for AP were much higher with nonfasting mild to moderately elevated plasma triglycerides (177-885 mg/dL), compared with normal values (below 89 mg/dL).⁴⁴ Moreover, the risk of severe AP (developing POF) increases in proportion to triglyceride value, independent of the underlying cause of AP.⁴⁵

Vidyard Video

Diagnosis of AP is derived from the revised Atlanta classification.⁴⁶ The recommended timing and indications for offering cross-sectional imaging are after 48-72 hours in patients with no improvement to initial care.¹ Endoscopic ultrasonography (EUS) has better diagnostic accuracy and sensitivity, compared with magnetic resonance cholangiopancreatography (MRCP) for choledocholithiasis, and has comparable specificity.^47,48 Among noninvasive imaging modalities, MRCP is more sensitive than computed tomography (CT) for diagnosing choledocholithiasis.⁴⁹ Despite guideline recommendations for more selective use of pancreatic imaging in the early assessment of AP, utilization of early CT or MRCP imaging (within the first 24 hours of care) remained high during 2014-2015, compared with 2006-2007.⁵⁰

ERCP is not recommended as a pure diagnostic tool, owing to the availability of other diagnostic tests and a complication rate of 5%-10% with risks involving PEP, cholangitis, perforation, and hemorrhage.⁵¹ A recent systematic review of EUS and ERCP in acute biliary pancreatitis concluded that EUS had lower failure rates and had no complications, and the use of EUS avoided ERCP in 71.2% of cases.⁵²

 

 

 

Risk stratification

The goals of using risk stratification tools in AP are to identify patients at risk for developing major outcomes, including POF, infected pancreatic necrosis, and death, and to ensure timely triaging of patients to an appropriate level of care. Existing prediction models have only moderate predictive value.^53,54 Examples include simple risk stratification tools such as blood urea nitrogen (BUN) and hemoconcentration,^55,56 disease-modifying patient variables (age, obesity, etc.), biomarkers (i.e., angiopoietin 2),⁵⁷ and more complex clinical scoring systems such as Acute Physiology and Chronic Health Evaluation II (APACHE II), BISAP (BUN, impaired mental status, SIRS criteria, age, pleural effusion) score, early warning system (EWS), Glasgow-Imrie score, Japanese severity score, and recently the Pancreatitis Activity Scoring System (PASS).⁵⁸ Two recent guidelines affirmed the importance of predicting the severity of AP, using one or more predictive tools.^1,2 The recent 2018 AGA technical review does not debate this commonsense approach, but does highlight that there is no published observational study or randomized, controlled trial (RCT) investigating whether prediction tools affect clinical outcomes.⁴

Recent advances in early treatment of AP

Literature review and definitions

The AP literature contains heterogeneous definitions of severe AP and of what constitutes a major outcome in AP. Based on definitions of the 2013 revised Atlanta Criteria, the 2018 AGA technical review and clinical guidelines emphasized precise definitions of primary outcomes of clinical importance in AP, including death, persistent single organ failure, or persistent multiple organ failure, each requiring a duration of more than 48 hours, and infected pancreatic or peripancreatic necrosis or both (Table 2).^3,4

 

Pain management

Management of pain in AP is complex and requires a detailed discussion beyond the scope of this review, but recent clinical and translational studies raise questions about the current practice of using opioids for pain management in AP. A provocative, multicenter, retrospective cohort study reported lower 30-day mortality among critically ill patients who received epidural analgesia versus standard care without epidural analgesia.⁵⁹ The possible mechanism of protection and the drugs administered are unclear. An interesting hypothesis is that the epidural cohort may have received lower exposure to morphine, which may increase gut permeability, the risk of infectious complications, and severity of AP, based on a translational study in mice.⁶⁰

Intravenous fluid administration

Supportive care with the use of IV fluid hydration is a mainstay of treatment for AP in the first 12-24 hours. Table 3 summarizes the guidelines in regards to IV fluid administration as delineated by the ACG and AGA guidelines on the management of pancreatitis.^1,3 Guidelines advocate for early fluid resuscitation to correct intravascular depletion in order to reduce morbidity and mortality associated with AP.^1,2,4 The 2018 AGA guidelines endorse a conditional recommendation for using goal-directed therapy for initial fluid management,³ do not recommend for or against normal saline versus lactated Ringer’s (LR), but do advise against the use of hydroxyethyl starch fluids.³ Consistent with these recommendations, two recent RCTs published subsequent to the prespecified time periods of the AGA technical review and guideline, observed no significant differences between LR and normal saline on clinically meaningful outcomes.^61,62 The AGA guidelines acknowledge that evidence was of very-low quality in support of goal-directed therapy,^3,4 which has not been shown to have a significant reduction in persistent multiple organ failure, mortality, or pancreatic necrosis, compared with usual care. As the authors noted, interpretation of the data was limited by the absence of other critical outcomes in these trials (infected pancreatic necrosis), lack of uniformity of specific outcomes and definitions of transient and POF, few trials, and risk of bias. There is a clear need for a large RCT to provide evidence to guide decision making with fluid resuscitation in AP, particularly in regard to fluid type, volume, rate, duration, endpoints, and clinical outcomes.

 

 

Feeding

More recently, the focus of nutrition in the management of AP has shifted away from patients remaining nil per os (NPO). Current guidelines advocate for early oral feeding (within 24 hours) in mild AP,^3,4 in order to protect the gut-mucosal barrier. Remaining NPO when compared with early oral feeding has a 2.5-fold higher risk for interventions for necrosis.⁴ The recently published AGA technical review identified no significant impact on outcomes of early versus delayed oral feeding, which is consistent with observations of a landmark Dutch PYTHON trial entitled “Early versus on-demand nasoenteric tube feeding in acute pancreatitis.”^4,63 There is no clear cutoff point for initiating feeding for those with severe AP. A suggested practical approach is to initiate feeding within 24-72 hours and offer enteral nutrition for those intolerant to oral feeds. In severe AP and moderately severe AP, enteral nutrition is recommended over parenteral nutrition.^3,4 Enteral nutrition significantly reduces the risk of infected peripancreatic necrosis, single organ failure, and multiorgan failure.⁴ Finally, the AGA guidelines provide a conditional recommendation for providing enteral nutrition support through either the nasogastric or nasoenteric route.³ Further studies are required to determine the optimal timing, rate, and formulation of enteral nutrition in severe AP.

 

Antibiotics and probiotics

Current guidelines do not support the use of prophylactic antibiotics to prevent infection in necrotizing AP and severe AP.^1-3 The AGA technical review reported that prophylactic antibiotics did not reduce infected pancreatic or peripancreatic necrosis, persistent single organ failure, or mortality.⁴ Guidelines advocate against the use of probiotics for severe AP, because of increased mortality risk.¹

Timing of ERCP in acute biliary pancreatitis

There is universal agreement for offering urgent ERCP (within 24 hours) in biliary AP complicated by cholangitis.^1-3,64 Figure 2 demonstrates an example of a cholangiogram completed within 24 hours of presentation of biliary AP complicated by cholangitis.

In the absence of cholangitis, the timing of ERCP for AP with persistent biliary obstruction is less clear.^1-3 In line with recent guidelines, the 2018 AGA guidelines advocate against routine use of urgent ERCP for biliary AP without cholangitis,³ a conditional recommendation with overall low quality of data.⁴ The AGA technical review found that urgent ERCP, compared with conservative management in acute biliary pancreatitis without cholangitis had no significant effect on mortality, organ failure, infected pancreatic necrosis, and total necrotizing pancreatitis, but did significantly shorten hospital length of stay.⁴ There are limited data to guide decision making of when nonurgent ERCP should be performed in hospitalized patients with biliary AP with persistent obstruction and no cholangitis.^3,64

 

 

Alcohol and smoking cessation

The AGA technical review advocates for brief alcohol intervention during hospitalization for alcohol-induced AP on the basis of one RCT that addresses the impact of alcohol counseling on recurrent bouts of AP⁴ plus evidence from a Cochrane review of alcohol-reduction strategies in primary care populations.⁶⁵ Cessation of smoking – an established independent risk factor of AP – recurrent AP and chronic pancreatitis, should also be recommended as part of the management of AP.

Cholecystectomy

Evidence supports same-admission cholecystectomy for mild gallstone AP, a strong recommendation of published AGA guidelines.³ When compared with delayed cholecystectomy, same-admission cholecystectomy significantly reduced gallstone-related complications, readmissions for recurrent pancreatitis, and pancreaticobiliary complications, without having a significant impact on mortality during a 6-month follow-up period.⁶⁶ Delaying cholecystectomy 6 weeks in patients with moderate-severe gallstone AP appears to reduce morbidity, including the development of infected collections, and mortality.⁴ An ongoing RCT, the APEC trial, aims to determine whether early ERCP with biliary sphincterotomy reduces major complications or death when compared with no intervention for biliary AP in patients at high risk of complications.⁶⁷

Chemoprevention and IV fluid management of post-ERCP pancreatitis

Accumulating data support the effectiveness of chemoprevention, pancreatic stent placement, and fluid administration to prevent post-ERCP pancreatitis. Multiple RCTs, meta-analyses, and systematic reviews indicate that rectal NSAIDs) reduce post-ERCP pancreatitis onset^68-71 and moderate-severe post-ERCP pancreatitis. Additionally, placement of a pancreatic duct stent may decrease the risk of severe post-ERCP pancreatitis in high-risk patients.³ Guidelines do not comment on fluid administrations for prevention of post-ERCP pancreatitis, but studies have shown that greater periprocedural IV fluid was an independent protective factor against moderate to severe PEP⁷² and was associated with shorter hospital length of stay.⁷³ Recent meta-analyses and RCTs support using LR prior to ERCP to prevent PEP.^74-77 Interestingly, a recent RCT shows that the combination of rectal indomethacin and LR, compared with combination placebo and normal saline reduced the risk of PEP in high-risk patients.⁷⁸

Two ongoing multicenter RCTs will clarify the role of combination therapy. The Dutch FLUYT RCT aims to determine the optimal combination of rectal NSAIDs and periprocedural infusion of IV fluids to reduce the incidence of PEP and moderate-severe PEP⁷⁹ and the Stent vs. Indomethacin (SVI) trial aims to determine the whether combination pancreatic stent placement plus rectal indomethacin is superior to monotherapy indomethacin for preventing post-ERCP pancreatitis in high-risk cases.⁸⁰

Implications for clinical practice

The diagnosis and optimal management of AP require a systematic approach with multidisciplinary decision making. Morbidity and mortality in AP are driven by early or late POF, and the latter often is triggered by infected necrosis. Risk stratification of these patients at the point of contact is a commonsense approach to enable triaging of patients to the appropriate level of care. Regardless of pancreatitis severity, recommended treatment interventions include goal-directed IV fluid resuscitation, early feeding by mouth or enteral tube when necessary, avoidance of prophylactic antibiotics, avoidance of probiotics, and urgent ERCP for patients with acute biliary pancreatitis complicated by cholangitis. Key measures for preventing hospital readmission and pancreatitis include same-admission cholecystectomy for acute biliary pancreatitis and alcohol and smoking cessation. Preventive measures for post-ERCP pancreatitis in patients undergoing ERCP include rectal indomethacin, prophylactic pancreatic duct stent placement, and periprocedural fluid resuscitation.

Dr. Mandalia is a fellow, gastroenterology, department of internal medicine, division of gastroenterology, Michigan Medicine, Ann Arbor; Dr. DiMagno is associate professor of medicine, director, comprehensive pancreas program, department of internal medicine, division of gastroenterology, University of Michigan, Ann Arbor. Dr. Mandalia reports no conflicts of interest.

 

 

References

1. Tenner S et al. Am J Gastroenterol. 2013;108:1400.

2. Besseline M et al. Pancreatology. 2013;13(4, Supplement 2):e1-15.

3. Crockett SD et al. Gastroenterology. 2018;154(4):1096-101.

4. Vege SS et al. Gastroenterology. 2018;154(4):1103-39.

5. Peery AF et al. Gastroenterology. 2019 Jan;156(1):254-72.e11.

6. Krishna SG et al. Pancreas. 2017;46(4):482-8.

7. Sellers ZM et al. Gastroenterology. 2018;155(2):469-78.e1.

8. Brown A et al. JOP. 2008;9(4):408-14.

9. Fagenholz PJ et al. Ann Epidemiol. 2007;17(7):491.e1-.e8.

10. McNabb-Baltar J et al. Pancreas. 2014;43(5):687-91.

11. Johnson CD et al. Gut. 2004;53(9):1340-4.

12. Dellinger EP et al. Ann Surg. 2012;256(6):875-80.

13. Petrov MS et al. Gastroenterology. 2010;139(3):813-20.

14. Sternby H et al. Ann Surg. Apr 18. doi: 10.1097/SLA.0000000000002766.

15. Huh JH et al. J Clin Gastroenterol. 2018;52(2):178-83.

16. Wu BU et al. Gastroenterology. 2008;135(3):816-20.

17. Gardner TB et al. Clin Gastroenterol Hepatol. 2008;6(10):1070-6.

18. Krishna SG et al. Am J Gastroenterol. 2015;110(11):1608-19.

19. Lee PJ et al. Pancreas. 2016;45(4):561-4.

20. Mandalia A et al. F1000Research. 2018 Jun 28;7.

21. Majumder S et al. Pancreas. 2015;44(4):540-6.

22. DiMagno MJ. Clin Gastroenterol Hepatol. 2011;9(11):920-2.

23. Yadav D, Whitcomb DC. Nature Rev Gastroenterol Hepatol. 2010;7(3):131-45.

24. Samokhvalov AV et al. EBioMedicine. 2015;2(12):1996-2002.

25. Barkin JA et al. Pancreas. 2017;46(8):1035-8.

26. Chen Y-T et al. J Gastroenterol Hepatol. 2016;31(4):782-7.

27. Ramos LR et al. J Crohns Colitis. 2016;10(1):95-104.

28. Avram MM. Nephron. 1977;18(1):68-71.

29. Lankisch PG et al. Nephrol Dial Transplant. 2008;23(4):1401-5.

30. Owyang C et al. Mayo Clin Proc. 1979;54(12):769-73.

31. Owyang Cet al. Gut. 1982;23(5):357-61.

32. Quraishi ER et al. Am J Gastroenterol. 2005;100:2288.

33. Vaziri ND et al. Nephron. 1987;46(4):347-9.

34. Chen HJ et al. Nephrol Dial Transplant. 2017;32(10):1731-6.

35. Kirkegard J et al. Gastroenterology. 2018;May;154(6):1729-36.

36. Karlson BM, et al. Gastroenterology. 1997;113(2):587-92.

37. Munigala S et al. Clin Gastroenterol Hepatol. 2014;12(7):1143-50.e1.

38. Carr RA et al. Pancreatology. 2016;16(4):469-76.

39. Li X et al. BMC Gastroenterol. 2018;18(1):89.

40. Ahmed AU et al. Clin Gastroenterol Hepatol. 2016;14(5):738-46.

41. Sankaran SJ et al. Gastroenterology. 2015;149(6):1490-500.e1.

42. Berglund L et al. J Clin Endocrinol Metab. 2012;97(9):2969-89.

43. Catapano AL et al. Atherosclerosis. 2011;217(1):3-46.

44. Pedersen SB et al. JAMA Intern Med. 2016;176(12):1834-42.

45. Nawaz H et al. Am J Gastroenterol. 2015;110(10):1497-503.

46. Banks PA et al. Gut. 2013;62(1):102-11.

47. Kondo S et al. Eur J Radiol. 2005;54(2):271-5.

48. Meeralam Y et al. Gastrointest Endosc. 2017;86(6):986-93.

49. Stimac D et al. Am J Gastroenterol. 2007;102(5):997-1004.

50. Jin DX et al. Dig Dis Sci. 2017;62(10):2894-9.

51. Freeman ML. Gastrointest Endosc Clin N Am. 2012;22(3):567-86.

52. De Lisi S et al. Eur J Gastroenterol Hepatol. 2011;23(5):367-74.

53. Di MY et al. Ann Int Med. 2016;165(7):482-90.

54. Mounzer R et al. Gastroenterology. 2012;142(7):1476-82; quiz e15-6.

55. Koutroumpakis E et al. Am J Gastroenterol. 2015;110(12):1707-16.

56. Wu BU et al. Gastroenterology. 2009;137(1):129-35.

57. Buddingh KT et al. J Am Coll Surg. 2014;218(1):26-32.

58. Buxbaum J et al. Am J Gastroenterol. 2018;113(5):755-64.

59. Jabaudon M et al. Crit Car Med. 2018;46(3):e198-e205.

60. Barlass U et al. Gut. 2018;67(4):600-2.

61. Buxbaum JL et al. Am J Gastroenterol. 2017;112(5):797-803.

62. de-Madaria E et al. United Eur Gastroenterol J. 2018;6(1):63-72.

63. Bakker OJ et al. N Engl J Med. 2014;371(21):1983-93.

64. Tse F et al. Cochrane Database Syst Rev. 2012(5):Cd009779.

65. Kaner EFS et al. Cochrane Database Syst Rev. 2007(2):Cd004148.

66. da Costa DW et al. Lancet. 2015;386(10000):1261-8.

67. Schepers NJ et al. Trials. 2016;17:5.

68. Vadala di Prampero SF et al. Eur J Gastroenterol Hepatol. 2016;28(12):1415-24.

69. Kubiliun NM et al. Clin Gastroenterol Hepatol. 2015;13(7):1231-9; quiz e70-1.

70. Wan J et al. BMC Gastroenterol. 2017;17(1):43.

71. Yang C et al. Pancreatology. 2017;17(5):681-8.

72. DiMagno MJ et al. Pancreas. 2014;43(4):642-7.

73. Sagi SV et al. J Gastroenterol Hepatol. 2014;29(6):1316-20.

74. Choi JH et al. Clin Gastroenterol Hepatol. 2017;15(1):86-92.e1.

75. Wu D et al. J Clin Gastroenterol. 2017;51(8):e68-e76.

76. Zhang ZF et al. J Clin Gastroenterol. 2017;51(3):e17-e26.

77. Park CH et al. Endoscopy 2018 Apr;50(4):378-85.

78. Mok SRS et al. Gastrointest Endosc. 2017;85(5):1005-13.

79. Smeets XJN et al. Trials. 2018;19(1):207.

80. Elmunzer BJ et al. Trials. 2016;17(1):120.

 

Introduction

Acute pancreatitis (AP) is a major clinical and financial burden in the United States. Several major clinical guidelines provide evidence-based recommendations for the clinical management decisions in AP, including those from the American College of Gastroenterology (ACG; 2013),¹ and the International Association of Pancreatology (IAP; 2013).² More recently, the American Gastroenterological Association (AGA) released their own set of guidelines.^3,4 In this update on AP, we review these guidelines and reference recent literature focused on epidemiology, risk factors, etiology, diagnosis, risk stratification, and recent advances in the early medical management of AP. Regarding the latter, we review six treatment interventions (pain management, intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis) and four preventive interventions (alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis [PEP]). Updates on multidisciplinary management of (infected) pancreatic necrosis is beyond the scope of this review. Table 1 summarizes the concepts discussed in this article.

Recent advances in epidemiology and evaluation of AP

Epidemiology

AP is the third most common cause of gastrointestinal-related hospitalizations and fourth most common cause of readmission in 2014.⁵ Recent epidemiologic studies show conflicting trends for the incidence of AP, both increasing⁶ and decreasing,⁷ likely attributable to significant differences in study designs. Importantly, multiple studies have demonstrated that hospital length of stay, costs, and mortality have declined since 2009.^6,8-10

Persistent organ failure (POF), defined as organ failure lasting more than 48 hours, is the major cause of death in AP. POF, if only a single organ during AP, is associated with 27%-36% mortality; if it is multiorgan, it is associated with 47% mortality.^1,11 Other factors associated with increased hospital mortality include infected pancreatic necrosis,^12-14 diabetes mellitus,¹⁵ hospital-acquired infection,¹⁶ advanced age (70 years and older),¹⁷ and obesity.¹⁸ Predictive factors of 1-year mortality include readmission within 30 days, higher Charlson Comorbidity Index, and longer hospitalization.¹⁹

Risk factors

We briefly highlight recent insights into risk factors for AP (Table 1) and refer to a recent review for further discussion.²⁰ Current and former tobacco use are independent risk factors for AP.²¹ The dose-response relationship of alcohol to the risk of pancreatitis is complex,²² but five standard drinks per day for 5 years is a commonly used cut-off.^1,23 New evidence suggests that the relationship between the dose of alcohol and risk of AP differs by sex, linearly in men but nonlinearly (J-shaped) in women.²⁴ Risk of AP in women was decreased with alcohol consumption of up to 40 g/day (one standard drink contains 14 g of alcohol) and increased above this amount. Cannabis is a possible risk factor for toxin-induced AP and abstinence appears to abolish risk of recurrent attacks.²⁵

Patients with inflammatory bowel disease (IBD) have a 2.9-fold higher risk for AP versus non-IBD cohorts²⁶ with the most common etiologies are from gallstones and medications.²⁷ In patients with end-stage renal disease (ESRD), the risk of AP is higher in those who receive peritoneal dialysis, compared with hemodialysis^28-33 and who are women, older, or have cholelithiasis or liver disease.³⁴As recently reviewed,³⁵ pancreatic cancer appears to be associated with first-attack pancreatitis with few exceptions.³⁶ In this setting, the overall incidence of pancreatic cancer is low (1.5%). The risk is greatest within the first year of the attack of AP, negligible below age 40 years but steadily rising through the fifth to eighth decades.³⁷ Pancreatic cancer screening is a conditional recommendation of the ACG guidelines in patients with unexplained AP, particularly those aged 40 years or older.¹

Etiology and diagnosis

Alcohol and gallstones remain the most prevalent etiologies for AP.¹ While hypertriglyceridemia accounted for 9% of AP in a systematic review of acute pancreatitis in 15 different countries,³⁸ it is the second most common cause of acute pancreatitis in Asia (especially China).³⁹ Figure 1 provides a breakdown of the etiologies and risk factors of pancreatitis. Importantly, it remains challenging to assign several toxic-metabolic etiologies as either a cause or risk factor for AP, particularly with regards to alcohol, smoking, and cannabis to name a few.

Guidelines and recent studies of AP raise questions about the threshold above which hypertriglyceridemia causes or poses as an important cofactor for AP. American and European societies define the threshold for triglycerides at 885-1,000 mg/dL.^1,42,43 Pedersen et al. provide evidence of a graded risk of AP with hypertriglyceridemia: In multivariable analysis, adjusted hazard ratios for AP were much higher with nonfasting mild to moderately elevated plasma triglycerides (177-885 mg/dL), compared with normal values (below 89 mg/dL).⁴⁴ Moreover, the risk of severe AP (developing POF) increases in proportion to triglyceride value, independent of the underlying cause of AP.⁴⁵

Vidyard Video

Diagnosis of AP is derived from the revised Atlanta classification.⁴⁶ The recommended timing and indications for offering cross-sectional imaging are after 48-72 hours in patients with no improvement to initial care.¹ Endoscopic ultrasonography (EUS) has better diagnostic accuracy and sensitivity, compared with magnetic resonance cholangiopancreatography (MRCP) for choledocholithiasis, and has comparable specificity.^47,48 Among noninvasive imaging modalities, MRCP is more sensitive than computed tomography (CT) for diagnosing choledocholithiasis.⁴⁹ Despite guideline recommendations for more selective use of pancreatic imaging in the early assessment of AP, utilization of early CT or MRCP imaging (within the first 24 hours of care) remained high during 2014-2015, compared with 2006-2007.⁵⁰

ERCP is not recommended as a pure diagnostic tool, owing to the availability of other diagnostic tests and a complication rate of 5%-10% with risks involving PEP, cholangitis, perforation, and hemorrhage.⁵¹ A recent systematic review of EUS and ERCP in acute biliary pancreatitis concluded that EUS had lower failure rates and had no complications, and the use of EUS avoided ERCP in 71.2% of cases.⁵²

 

 

 

Risk stratification

The goals of using risk stratification tools in AP are to identify patients at risk for developing major outcomes, including POF, infected pancreatic necrosis, and death, and to ensure timely triaging of patients to an appropriate level of care. Existing prediction models have only moderate predictive value.^53,54 Examples include simple risk stratification tools such as blood urea nitrogen (BUN) and hemoconcentration,^55,56 disease-modifying patient variables (age, obesity, etc.), biomarkers (i.e., angiopoietin 2),⁵⁷ and more complex clinical scoring systems such as Acute Physiology and Chronic Health Evaluation II (APACHE II), BISAP (BUN, impaired mental status, SIRS criteria, age, pleural effusion) score, early warning system (EWS), Glasgow-Imrie score, Japanese severity score, and recently the Pancreatitis Activity Scoring System (PASS).⁵⁸ Two recent guidelines affirmed the importance of predicting the severity of AP, using one or more predictive tools.^1,2 The recent 2018 AGA technical review does not debate this commonsense approach, but does highlight that there is no published observational study or randomized, controlled trial (RCT) investigating whether prediction tools affect clinical outcomes.⁴

Recent advances in early treatment of AP

Literature review and definitions

The AP literature contains heterogeneous definitions of severe AP and of what constitutes a major outcome in AP. Based on definitions of the 2013 revised Atlanta Criteria, the 2018 AGA technical review and clinical guidelines emphasized precise definitions of primary outcomes of clinical importance in AP, including death, persistent single organ failure, or persistent multiple organ failure, each requiring a duration of more than 48 hours, and infected pancreatic or peripancreatic necrosis or both (Table 2).^3,4

 

Pain management

Management of pain in AP is complex and requires a detailed discussion beyond the scope of this review, but recent clinical and translational studies raise questions about the current practice of using opioids for pain management in AP. A provocative, multicenter, retrospective cohort study reported lower 30-day mortality among critically ill patients who received epidural analgesia versus standard care without epidural analgesia.⁵⁹ The possible mechanism of protection and the drugs administered are unclear. An interesting hypothesis is that the epidural cohort may have received lower exposure to morphine, which may increase gut permeability, the risk of infectious complications, and severity of AP, based on a translational study in mice.⁶⁰

Intravenous fluid administration

Supportive care with the use of IV fluid hydration is a mainstay of treatment for AP in the first 12-24 hours. Table 3 summarizes the guidelines in regards to IV fluid administration as delineated by the ACG and AGA guidelines on the management of pancreatitis.^1,3 Guidelines advocate for early fluid resuscitation to correct intravascular depletion in order to reduce morbidity and mortality associated with AP.^1,2,4 The 2018 AGA guidelines endorse a conditional recommendation for using goal-directed therapy for initial fluid management,³ do not recommend for or against normal saline versus lactated Ringer’s (LR), but do advise against the use of hydroxyethyl starch fluids.³ Consistent with these recommendations, two recent RCTs published subsequent to the prespecified time periods of the AGA technical review and guideline, observed no significant differences between LR and normal saline on clinically meaningful outcomes.^61,62 The AGA guidelines acknowledge that evidence was of very-low quality in support of goal-directed therapy,^3,4 which has not been shown to have a significant reduction in persistent multiple organ failure, mortality, or pancreatic necrosis, compared with usual care. As the authors noted, interpretation of the data was limited by the absence of other critical outcomes in these trials (infected pancreatic necrosis), lack of uniformity of specific outcomes and definitions of transient and POF, few trials, and risk of bias. There is a clear need for a large RCT to provide evidence to guide decision making with fluid resuscitation in AP, particularly in regard to fluid type, volume, rate, duration, endpoints, and clinical outcomes.

 

 

Feeding

More recently, the focus of nutrition in the management of AP has shifted away from patients remaining nil per os (NPO). Current guidelines advocate for early oral feeding (within 24 hours) in mild AP,^3,4 in order to protect the gut-mucosal barrier. Remaining NPO when compared with early oral feeding has a 2.5-fold higher risk for interventions for necrosis.⁴ The recently published AGA technical review identified no significant impact on outcomes of early versus delayed oral feeding, which is consistent with observations of a landmark Dutch PYTHON trial entitled “Early versus on-demand nasoenteric tube feeding in acute pancreatitis.”^4,63 There is no clear cutoff point for initiating feeding for those with severe AP. A suggested practical approach is to initiate feeding within 24-72 hours and offer enteral nutrition for those intolerant to oral feeds. In severe AP and moderately severe AP, enteral nutrition is recommended over parenteral nutrition.^3,4 Enteral nutrition significantly reduces the risk of infected peripancreatic necrosis, single organ failure, and multiorgan failure.⁴ Finally, the AGA guidelines provide a conditional recommendation for providing enteral nutrition support through either the nasogastric or nasoenteric route.³ Further studies are required to determine the optimal timing, rate, and formulation of enteral nutrition in severe AP.

 

Antibiotics and probiotics

Current guidelines do not support the use of prophylactic antibiotics to prevent infection in necrotizing AP and severe AP.^1-3 The AGA technical review reported that prophylactic antibiotics did not reduce infected pancreatic or peripancreatic necrosis, persistent single organ failure, or mortality.⁴ Guidelines advocate against the use of probiotics for severe AP, because of increased mortality risk.¹

Timing of ERCP in acute biliary pancreatitis

There is universal agreement for offering urgent ERCP (within 24 hours) in biliary AP complicated by cholangitis.^1-3,64 Figure 2 demonstrates an example of a cholangiogram completed within 24 hours of presentation of biliary AP complicated by cholangitis.

In the absence of cholangitis, the timing of ERCP for AP with persistent biliary obstruction is less clear.^1-3 In line with recent guidelines, the 2018 AGA guidelines advocate against routine use of urgent ERCP for biliary AP without cholangitis,³ a conditional recommendation with overall low quality of data.⁴ The AGA technical review found that urgent ERCP, compared with conservative management in acute biliary pancreatitis without cholangitis had no significant effect on mortality, organ failure, infected pancreatic necrosis, and total necrotizing pancreatitis, but did significantly shorten hospital length of stay.⁴ There are limited data to guide decision making of when nonurgent ERCP should be performed in hospitalized patients with biliary AP with persistent obstruction and no cholangitis.^3,64

 

 

Alcohol and smoking cessation

The AGA technical review advocates for brief alcohol intervention during hospitalization for alcohol-induced AP on the basis of one RCT that addresses the impact of alcohol counseling on recurrent bouts of AP⁴ plus evidence from a Cochrane review of alcohol-reduction strategies in primary care populations.⁶⁵ Cessation of smoking – an established independent risk factor of AP – recurrent AP and chronic pancreatitis, should also be recommended as part of the management of AP.

Cholecystectomy

Evidence supports same-admission cholecystectomy for mild gallstone AP, a strong recommendation of published AGA guidelines.³ When compared with delayed cholecystectomy, same-admission cholecystectomy significantly reduced gallstone-related complications, readmissions for recurrent pancreatitis, and pancreaticobiliary complications, without having a significant impact on mortality during a 6-month follow-up period.⁶⁶ Delaying cholecystectomy 6 weeks in patients with moderate-severe gallstone AP appears to reduce morbidity, including the development of infected collections, and mortality.⁴ An ongoing RCT, the APEC trial, aims to determine whether early ERCP with biliary sphincterotomy reduces major complications or death when compared with no intervention for biliary AP in patients at high risk of complications.⁶⁷

Chemoprevention and IV fluid management of post-ERCP pancreatitis

Accumulating data support the effectiveness of chemoprevention, pancreatic stent placement, and fluid administration to prevent post-ERCP pancreatitis. Multiple RCTs, meta-analyses, and systematic reviews indicate that rectal NSAIDs) reduce post-ERCP pancreatitis onset^68-71 and moderate-severe post-ERCP pancreatitis. Additionally, placement of a pancreatic duct stent may decrease the risk of severe post-ERCP pancreatitis in high-risk patients.³ Guidelines do not comment on fluid administrations for prevention of post-ERCP pancreatitis, but studies have shown that greater periprocedural IV fluid was an independent protective factor against moderate to severe PEP⁷² and was associated with shorter hospital length of stay.⁷³ Recent meta-analyses and RCTs support using LR prior to ERCP to prevent PEP.^74-77 Interestingly, a recent RCT shows that the combination of rectal indomethacin and LR, compared with combination placebo and normal saline reduced the risk of PEP in high-risk patients.⁷⁸

Two ongoing multicenter RCTs will clarify the role of combination therapy. The Dutch FLUYT RCT aims to determine the optimal combination of rectal NSAIDs and periprocedural infusion of IV fluids to reduce the incidence of PEP and moderate-severe PEP⁷⁹ and the Stent vs. Indomethacin (SVI) trial aims to determine the whether combination pancreatic stent placement plus rectal indomethacin is superior to monotherapy indomethacin for preventing post-ERCP pancreatitis in high-risk cases.⁸⁰

Implications for clinical practice

The diagnosis and optimal management of AP require a systematic approach with multidisciplinary decision making. Morbidity and mortality in AP are driven by early or late POF, and the latter often is triggered by infected necrosis. Risk stratification of these patients at the point of contact is a commonsense approach to enable triaging of patients to the appropriate level of care. Regardless of pancreatitis severity, recommended treatment interventions include goal-directed IV fluid resuscitation, early feeding by mouth or enteral tube when necessary, avoidance of prophylactic antibiotics, avoidance of probiotics, and urgent ERCP for patients with acute biliary pancreatitis complicated by cholangitis. Key measures for preventing hospital readmission and pancreatitis include same-admission cholecystectomy for acute biliary pancreatitis and alcohol and smoking cessation. Preventive measures for post-ERCP pancreatitis in patients undergoing ERCP include rectal indomethacin, prophylactic pancreatic duct stent placement, and periprocedural fluid resuscitation.

Dr. Mandalia is a fellow, gastroenterology, department of internal medicine, division of gastroenterology, Michigan Medicine, Ann Arbor; Dr. DiMagno is associate professor of medicine, director, comprehensive pancreas program, department of internal medicine, division of gastroenterology, University of Michigan, Ann Arbor. Dr. Mandalia reports no conflicts of interest.

 

 

References

1. Tenner S et al. Am J Gastroenterol. 2013;108:1400.

2. Besseline M et al. Pancreatology. 2013;13(4, Supplement 2):e1-15.

3. Crockett SD et al. Gastroenterology. 2018;154(4):1096-101.

4. Vege SS et al. Gastroenterology. 2018;154(4):1103-39.

5. Peery AF et al. Gastroenterology. 2019 Jan;156(1):254-72.e11.

6. Krishna SG et al. Pancreas. 2017;46(4):482-8.

7. Sellers ZM et al. Gastroenterology. 2018;155(2):469-78.e1.

8. Brown A et al. JOP. 2008;9(4):408-14.

9. Fagenholz PJ et al. Ann Epidemiol. 2007;17(7):491.e1-.e8.

10. McNabb-Baltar J et al. Pancreas. 2014;43(5):687-91.

11. Johnson CD et al. Gut. 2004;53(9):1340-4.

12. Dellinger EP et al. Ann Surg. 2012;256(6):875-80.

13. Petrov MS et al. Gastroenterology. 2010;139(3):813-20.

14. Sternby H et al. Ann Surg. Apr 18. doi: 10.1097/SLA.0000000000002766.

15. Huh JH et al. J Clin Gastroenterol. 2018;52(2):178-83.

16. Wu BU et al. Gastroenterology. 2008;135(3):816-20.

17. Gardner TB et al. Clin Gastroenterol Hepatol. 2008;6(10):1070-6.

18. Krishna SG et al. Am J Gastroenterol. 2015;110(11):1608-19.

19. Lee PJ et al. Pancreas. 2016;45(4):561-4.

20. Mandalia A et al. F1000Research. 2018 Jun 28;7.

21. Majumder S et al. Pancreas. 2015;44(4):540-6.

22. DiMagno MJ. Clin Gastroenterol Hepatol. 2011;9(11):920-2.

23. Yadav D, Whitcomb DC. Nature Rev Gastroenterol Hepatol. 2010;7(3):131-45.

24. Samokhvalov AV et al. EBioMedicine. 2015;2(12):1996-2002.

25. Barkin JA et al. Pancreas. 2017;46(8):1035-8.

26. Chen Y-T et al. J Gastroenterol Hepatol. 2016;31(4):782-7.

27. Ramos LR et al. J Crohns Colitis. 2016;10(1):95-104.

28. Avram MM. Nephron. 1977;18(1):68-71.

29. Lankisch PG et al. Nephrol Dial Transplant. 2008;23(4):1401-5.

30. Owyang C et al. Mayo Clin Proc. 1979;54(12):769-73.

31. Owyang Cet al. Gut. 1982;23(5):357-61.

32. Quraishi ER et al. Am J Gastroenterol. 2005;100:2288.

33. Vaziri ND et al. Nephron. 1987;46(4):347-9.

34. Chen HJ et al. Nephrol Dial Transplant. 2017;32(10):1731-6.

35. Kirkegard J et al. Gastroenterology. 2018;May;154(6):1729-36.

36. Karlson BM, et al. Gastroenterology. 1997;113(2):587-92.

37. Munigala S et al. Clin Gastroenterol Hepatol. 2014;12(7):1143-50.e1.

38. Carr RA et al. Pancreatology. 2016;16(4):469-76.

39. Li X et al. BMC Gastroenterol. 2018;18(1):89.

40. Ahmed AU et al. Clin Gastroenterol Hepatol. 2016;14(5):738-46.

41. Sankaran SJ et al. Gastroenterology. 2015;149(6):1490-500.e1.

42. Berglund L et al. J Clin Endocrinol Metab. 2012;97(9):2969-89.

43. Catapano AL et al. Atherosclerosis. 2011;217(1):3-46.

44. Pedersen SB et al. JAMA Intern Med. 2016;176(12):1834-42.

45. Nawaz H et al. Am J Gastroenterol. 2015;110(10):1497-503.

46. Banks PA et al. Gut. 2013;62(1):102-11.

47. Kondo S et al. Eur J Radiol. 2005;54(2):271-5.

48. Meeralam Y et al. Gastrointest Endosc. 2017;86(6):986-93.

49. Stimac D et al. Am J Gastroenterol. 2007;102(5):997-1004.

50. Jin DX et al. Dig Dis Sci. 2017;62(10):2894-9.

51. Freeman ML. Gastrointest Endosc Clin N Am. 2012;22(3):567-86.

52. De Lisi S et al. Eur J Gastroenterol Hepatol. 2011;23(5):367-74.

53. Di MY et al. Ann Int Med. 2016;165(7):482-90.

54. Mounzer R et al. Gastroenterology. 2012;142(7):1476-82; quiz e15-6.

55. Koutroumpakis E et al. Am J Gastroenterol. 2015;110(12):1707-16.

56. Wu BU et al. Gastroenterology. 2009;137(1):129-35.

57. Buddingh KT et al. J Am Coll Surg. 2014;218(1):26-32.

58. Buxbaum J et al. Am J Gastroenterol. 2018;113(5):755-64.

59. Jabaudon M et al. Crit Car Med. 2018;46(3):e198-e205.

60. Barlass U et al. Gut. 2018;67(4):600-2.

61. Buxbaum JL et al. Am J Gastroenterol. 2017;112(5):797-803.

62. de-Madaria E et al. United Eur Gastroenterol J. 2018;6(1):63-72.

63. Bakker OJ et al. N Engl J Med. 2014;371(21):1983-93.

64. Tse F et al. Cochrane Database Syst Rev. 2012(5):Cd009779.

65. Kaner EFS et al. Cochrane Database Syst Rev. 2007(2):Cd004148.

66. da Costa DW et al. Lancet. 2015;386(10000):1261-8.

67. Schepers NJ et al. Trials. 2016;17:5.

68. Vadala di Prampero SF et al. Eur J Gastroenterol Hepatol. 2016;28(12):1415-24.

69. Kubiliun NM et al. Clin Gastroenterol Hepatol. 2015;13(7):1231-9; quiz e70-1.

70. Wan J et al. BMC Gastroenterol. 2017;17(1):43.

71. Yang C et al. Pancreatology. 2017;17(5):681-8.

72. DiMagno MJ et al. Pancreas. 2014;43(4):642-7.

73. Sagi SV et al. J Gastroenterol Hepatol. 2014;29(6):1316-20.

74. Choi JH et al. Clin Gastroenterol Hepatol. 2017;15(1):86-92.e1.

75. Wu D et al. J Clin Gastroenterol. 2017;51(8):e68-e76.

76. Zhang ZF et al. J Clin Gastroenterol. 2017;51(3):e17-e26.

77. Park CH et al. Endoscopy 2018 Apr;50(4):378-85.

78. Mok SRS et al. Gastrointest Endosc. 2017;85(5):1005-13.

79. Smeets XJN et al. Trials. 2018;19(1):207.

80. Elmunzer BJ et al. Trials. 2016;17(1):120.

 

Introduction

Acute pancreatitis (AP) is a major clinical and financial burden in the United States. Several major clinical guidelines provide evidence-based recommendations for the clinical management decisions in AP, including those from the American College of Gastroenterology (ACG; 2013),¹ and the International Association of Pancreatology (IAP; 2013).² More recently, the American Gastroenterological Association (AGA) released their own set of guidelines.^3,4 In this update on AP, we review these guidelines and reference recent literature focused on epidemiology, risk factors, etiology, diagnosis, risk stratification, and recent advances in the early medical management of AP. Regarding the latter, we review six treatment interventions (pain management, intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis) and four preventive interventions (alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis [PEP]). Updates on multidisciplinary management of (infected) pancreatic necrosis is beyond the scope of this review. Table 1 summarizes the concepts discussed in this article.

Recent advances in epidemiology and evaluation of AP

Epidemiology

AP is the third most common cause of gastrointestinal-related hospitalizations and fourth most common cause of readmission in 2014.⁵ Recent epidemiologic studies show conflicting trends for the incidence of AP, both increasing⁶ and decreasing,⁷ likely attributable to significant differences in study designs. Importantly, multiple studies have demonstrated that hospital length of stay, costs, and mortality have declined since 2009.^6,8-10

Persistent organ failure (POF), defined as organ failure lasting more than 48 hours, is the major cause of death in AP. POF, if only a single organ during AP, is associated with 27%-36% mortality; if it is multiorgan, it is associated with 47% mortality.^1,11 Other factors associated with increased hospital mortality include infected pancreatic necrosis,^12-14 diabetes mellitus,¹⁵ hospital-acquired infection,¹⁶ advanced age (70 years and older),¹⁷ and obesity.¹⁸ Predictive factors of 1-year mortality include readmission within 30 days, higher Charlson Comorbidity Index, and longer hospitalization.¹⁹

Risk factors

We briefly highlight recent insights into risk factors for AP (Table 1) and refer to a recent review for further discussion.²⁰ Current and former tobacco use are independent risk factors for AP.²¹ The dose-response relationship of alcohol to the risk of pancreatitis is complex,²² but five standard drinks per day for 5 years is a commonly used cut-off.^1,23 New evidence suggests that the relationship between the dose of alcohol and risk of AP differs by sex, linearly in men but nonlinearly (J-shaped) in women.²⁴ Risk of AP in women was decreased with alcohol consumption of up to 40 g/day (one standard drink contains 14 g of alcohol) and increased above this amount. Cannabis is a possible risk factor for toxin-induced AP and abstinence appears to abolish risk of recurrent attacks.²⁵

Patients with inflammatory bowel disease (IBD) have a 2.9-fold higher risk for AP versus non-IBD cohorts²⁶ with the most common etiologies are from gallstones and medications.²⁷ In patients with end-stage renal disease (ESRD), the risk of AP is higher in those who receive peritoneal dialysis, compared with hemodialysis^28-33 and who are women, older, or have cholelithiasis or liver disease.³⁴As recently reviewed,³⁵ pancreatic cancer appears to be associated with first-attack pancreatitis with few exceptions.³⁶ In this setting, the overall incidence of pancreatic cancer is low (1.5%). The risk is greatest within the first year of the attack of AP, negligible below age 40 years but steadily rising through the fifth to eighth decades.³⁷ Pancreatic cancer screening is a conditional recommendation of the ACG guidelines in patients with unexplained AP, particularly those aged 40 years or older.¹

Etiology and diagnosis

Alcohol and gallstones remain the most prevalent etiologies for AP.¹ While hypertriglyceridemia accounted for 9% of AP in a systematic review of acute pancreatitis in 15 different countries,³⁸ it is the second most common cause of acute pancreatitis in Asia (especially China).³⁹ Figure 1 provides a breakdown of the etiologies and risk factors of pancreatitis. Importantly, it remains challenging to assign several toxic-metabolic etiologies as either a cause or risk factor for AP, particularly with regards to alcohol, smoking, and cannabis to name a few.

Guidelines and recent studies of AP raise questions about the threshold above which hypertriglyceridemia causes or poses as an important cofactor for AP. American and European societies define the threshold for triglycerides at 885-1,000 mg/dL.^1,42,43 Pedersen et al. provide evidence of a graded risk of AP with hypertriglyceridemia: In multivariable analysis, adjusted hazard ratios for AP were much higher with nonfasting mild to moderately elevated plasma triglycerides (177-885 mg/dL), compared with normal values (below 89 mg/dL).⁴⁴ Moreover, the risk of severe AP (developing POF) increases in proportion to triglyceride value, independent of the underlying cause of AP.⁴⁵

Vidyard Video

Diagnosis of AP is derived from the revised Atlanta classification.⁴⁶ The recommended timing and indications for offering cross-sectional imaging are after 48-72 hours in patients with no improvement to initial care.¹ Endoscopic ultrasonography (EUS) has better diagnostic accuracy and sensitivity, compared with magnetic resonance cholangiopancreatography (MRCP) for choledocholithiasis, and has comparable specificity.^47,48 Among noninvasive imaging modalities, MRCP is more sensitive than computed tomography (CT) for diagnosing choledocholithiasis.⁴⁹ Despite guideline recommendations for more selective use of pancreatic imaging in the early assessment of AP, utilization of early CT or MRCP imaging (within the first 24 hours of care) remained high during 2014-2015, compared with 2006-2007.⁵⁰

ERCP is not recommended as a pure diagnostic tool, owing to the availability of other diagnostic tests and a complication rate of 5%-10% with risks involving PEP, cholangitis, perforation, and hemorrhage.⁵¹ A recent systematic review of EUS and ERCP in acute biliary pancreatitis concluded that EUS had lower failure rates and had no complications, and the use of EUS avoided ERCP in 71.2% of cases.⁵²

 

 

 

Risk stratification

The goals of using risk stratification tools in AP are to identify patients at risk for developing major outcomes, including POF, infected pancreatic necrosis, and death, and to ensure timely triaging of patients to an appropriate level of care. Existing prediction models have only moderate predictive value.^53,54 Examples include simple risk stratification tools such as blood urea nitrogen (BUN) and hemoconcentration,^55,56 disease-modifying patient variables (age, obesity, etc.), biomarkers (i.e., angiopoietin 2),⁵⁷ and more complex clinical scoring systems such as Acute Physiology and Chronic Health Evaluation II (APACHE II), BISAP (BUN, impaired mental status, SIRS criteria, age, pleural effusion) score, early warning system (EWS), Glasgow-Imrie score, Japanese severity score, and recently the Pancreatitis Activity Scoring System (PASS).⁵⁸ Two recent guidelines affirmed the importance of predicting the severity of AP, using one or more predictive tools.^1,2 The recent 2018 AGA technical review does not debate this commonsense approach, but does highlight that there is no published observational study or randomized, controlled trial (RCT) investigating whether prediction tools affect clinical outcomes.⁴

Recent advances in early treatment of AP

Literature review and definitions

The AP literature contains heterogeneous definitions of severe AP and of what constitutes a major outcome in AP. Based on definitions of the 2013 revised Atlanta Criteria, the 2018 AGA technical review and clinical guidelines emphasized precise definitions of primary outcomes of clinical importance in AP, including death, persistent single organ failure, or persistent multiple organ failure, each requiring a duration of more than 48 hours, and infected pancreatic or peripancreatic necrosis or both (Table 2).^3,4

 

Pain management

Management of pain in AP is complex and requires a detailed discussion beyond the scope of this review, but recent clinical and translational studies raise questions about the current practice of using opioids for pain management in AP. A provocative, multicenter, retrospective cohort study reported lower 30-day mortality among critically ill patients who received epidural analgesia versus standard care without epidural analgesia.⁵⁹ The possible mechanism of protection and the drugs administered are unclear. An interesting hypothesis is that the epidural cohort may have received lower exposure to morphine, which may increase gut permeability, the risk of infectious complications, and severity of AP, based on a translational study in mice.⁶⁰

Intravenous fluid administration

Supportive care with the use of IV fluid hydration is a mainstay of treatment for AP in the first 12-24 hours. Table 3 summarizes the guidelines in regards to IV fluid administration as delineated by the ACG and AGA guidelines on the management of pancreatitis.^1,3 Guidelines advocate for early fluid resuscitation to correct intravascular depletion in order to reduce morbidity and mortality associated with AP.^1,2,4 The 2018 AGA guidelines endorse a conditional recommendation for using goal-directed therapy for initial fluid management,³ do not recommend for or against normal saline versus lactated Ringer’s (LR), but do advise against the use of hydroxyethyl starch fluids.³ Consistent with these recommendations, two recent RCTs published subsequent to the prespecified time periods of the AGA technical review and guideline, observed no significant differences between LR and normal saline on clinically meaningful outcomes.^61,62 The AGA guidelines acknowledge that evidence was of very-low quality in support of goal-directed therapy,^3,4 which has not been shown to have a significant reduction in persistent multiple organ failure, mortality, or pancreatic necrosis, compared with usual care. As the authors noted, interpretation of the data was limited by the absence of other critical outcomes in these trials (infected pancreatic necrosis), lack of uniformity of specific outcomes and definitions of transient and POF, few trials, and risk of bias. There is a clear need for a large RCT to provide evidence to guide decision making with fluid resuscitation in AP, particularly in regard to fluid type, volume, rate, duration, endpoints, and clinical outcomes.

 

 

Feeding

More recently, the focus of nutrition in the management of AP has shifted away from patients remaining nil per os (NPO). Current guidelines advocate for early oral feeding (within 24 hours) in mild AP,^3,4 in order to protect the gut-mucosal barrier. Remaining NPO when compared with early oral feeding has a 2.5-fold higher risk for interventions for necrosis.⁴ The recently published AGA technical review identified no significant impact on outcomes of early versus delayed oral feeding, which is consistent with observations of a landmark Dutch PYTHON trial entitled “Early versus on-demand nasoenteric tube feeding in acute pancreatitis.”^4,63 There is no clear cutoff point for initiating feeding for those with severe AP. A suggested practical approach is to initiate feeding within 24-72 hours and offer enteral nutrition for those intolerant to oral feeds. In severe AP and moderately severe AP, enteral nutrition is recommended over parenteral nutrition.^3,4 Enteral nutrition significantly reduces the risk of infected peripancreatic necrosis, single organ failure, and multiorgan failure.⁴ Finally, the AGA guidelines provide a conditional recommendation for providing enteral nutrition support through either the nasogastric or nasoenteric route.³ Further studies are required to determine the optimal timing, rate, and formulation of enteral nutrition in severe AP.

 

Antibiotics and probiotics

Current guidelines do not support the use of prophylactic antibiotics to prevent infection in necrotizing AP and severe AP.^1-3 The AGA technical review reported that prophylactic antibiotics did not reduce infected pancreatic or peripancreatic necrosis, persistent single organ failure, or mortality.⁴ Guidelines advocate against the use of probiotics for severe AP, because of increased mortality risk.¹

Timing of ERCP in acute biliary pancreatitis

There is universal agreement for offering urgent ERCP (within 24 hours) in biliary AP complicated by cholangitis.^1-3,64 Figure 2 demonstrates an example of a cholangiogram completed within 24 hours of presentation of biliary AP complicated by cholangitis.

In the absence of cholangitis, the timing of ERCP for AP with persistent biliary obstruction is less clear.^1-3 In line with recent guidelines, the 2018 AGA guidelines advocate against routine use of urgent ERCP for biliary AP without cholangitis,³ a conditional recommendation with overall low quality of data.⁴ The AGA technical review found that urgent ERCP, compared with conservative management in acute biliary pancreatitis without cholangitis had no significant effect on mortality, organ failure, infected pancreatic necrosis, and total necrotizing pancreatitis, but did significantly shorten hospital length of stay.⁴ There are limited data to guide decision making of when nonurgent ERCP should be performed in hospitalized patients with biliary AP with persistent obstruction and no cholangitis.^3,64

 

 

Alcohol and smoking cessation

The AGA technical review advocates for brief alcohol intervention during hospitalization for alcohol-induced AP on the basis of one RCT that addresses the impact of alcohol counseling on recurrent bouts of AP⁴ plus evidence from a Cochrane review of alcohol-reduction strategies in primary care populations.⁶⁵ Cessation of smoking – an established independent risk factor of AP – recurrent AP and chronic pancreatitis, should also be recommended as part of the management of AP.

Cholecystectomy

Evidence supports same-admission cholecystectomy for mild gallstone AP, a strong recommendation of published AGA guidelines.³ When compared with delayed cholecystectomy, same-admission cholecystectomy significantly reduced gallstone-related complications, readmissions for recurrent pancreatitis, and pancreaticobiliary complications, without having a significant impact on mortality during a 6-month follow-up period.⁶⁶ Delaying cholecystectomy 6 weeks in patients with moderate-severe gallstone AP appears to reduce morbidity, including the development of infected collections, and mortality.⁴ An ongoing RCT, the APEC trial, aims to determine whether early ERCP with biliary sphincterotomy reduces major complications or death when compared with no intervention for biliary AP in patients at high risk of complications.⁶⁷

Chemoprevention and IV fluid management of post-ERCP pancreatitis

Accumulating data support the effectiveness of chemoprevention, pancreatic stent placement, and fluid administration to prevent post-ERCP pancreatitis. Multiple RCTs, meta-analyses, and systematic reviews indicate that rectal NSAIDs) reduce post-ERCP pancreatitis onset^68-71 and moderate-severe post-ERCP pancreatitis. Additionally, placement of a pancreatic duct stent may decrease the risk of severe post-ERCP pancreatitis in high-risk patients.³ Guidelines do not comment on fluid administrations for prevention of post-ERCP pancreatitis, but studies have shown that greater periprocedural IV fluid was an independent protective factor against moderate to severe PEP⁷² and was associated with shorter hospital length of stay.⁷³ Recent meta-analyses and RCTs support using LR prior to ERCP to prevent PEP.^74-77 Interestingly, a recent RCT shows that the combination of rectal indomethacin and LR, compared with combination placebo and normal saline reduced the risk of PEP in high-risk patients.⁷⁸

Two ongoing multicenter RCTs will clarify the role of combination therapy. The Dutch FLUYT RCT aims to determine the optimal combination of rectal NSAIDs and periprocedural infusion of IV fluids to reduce the incidence of PEP and moderate-severe PEP⁷⁹ and the Stent vs. Indomethacin (SVI) trial aims to determine the whether combination pancreatic stent placement plus rectal indomethacin is superior to monotherapy indomethacin for preventing post-ERCP pancreatitis in high-risk cases.⁸⁰

Implications for clinical practice

The diagnosis and optimal management of AP require a systematic approach with multidisciplinary decision making. Morbidity and mortality in AP are driven by early or late POF, and the latter often is triggered by infected necrosis. Risk stratification of these patients at the point of contact is a commonsense approach to enable triaging of patients to the appropriate level of care. Regardless of pancreatitis severity, recommended treatment interventions include goal-directed IV fluid resuscitation, early feeding by mouth or enteral tube when necessary, avoidance of prophylactic antibiotics, avoidance of probiotics, and urgent ERCP for patients with acute biliary pancreatitis complicated by cholangitis. Key measures for preventing hospital readmission and pancreatitis include same-admission cholecystectomy for acute biliary pancreatitis and alcohol and smoking cessation. Preventive measures for post-ERCP pancreatitis in patients undergoing ERCP include rectal indomethacin, prophylactic pancreatic duct stent placement, and periprocedural fluid resuscitation.

Dr. Mandalia is a fellow, gastroenterology, department of internal medicine, division of gastroenterology, Michigan Medicine, Ann Arbor; Dr. DiMagno is associate professor of medicine, director, comprehensive pancreas program, department of internal medicine, division of gastroenterology, University of Michigan, Ann Arbor. Dr. Mandalia reports no conflicts of interest.

 

 

References

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2. Besseline M et al. Pancreatology. 2013;13(4, Supplement 2):e1-15.

3. Crockett SD et al. Gastroenterology. 2018;154(4):1096-101.

4. Vege SS et al. Gastroenterology. 2018;154(4):1103-39.

5. Peery AF et al. Gastroenterology. 2019 Jan;156(1):254-72.e11.

6. Krishna SG et al. Pancreas. 2017;46(4):482-8.

7. Sellers ZM et al. Gastroenterology. 2018;155(2):469-78.e1.

8. Brown A et al. JOP. 2008;9(4):408-14.

9. Fagenholz PJ et al. Ann Epidemiol. 2007;17(7):491.e1-.e8.

10. McNabb-Baltar J et al. Pancreas. 2014;43(5):687-91.

11. Johnson CD et al. Gut. 2004;53(9):1340-4.

12. Dellinger EP et al. Ann Surg. 2012;256(6):875-80.

13. Petrov MS et al. Gastroenterology. 2010;139(3):813-20.

14. Sternby H et al. Ann Surg. Apr 18. doi: 10.1097/SLA.0000000000002766.

15. Huh JH et al. J Clin Gastroenterol. 2018;52(2):178-83.

16. Wu BU et al. Gastroenterology. 2008;135(3):816-20.

17. Gardner TB et al. Clin Gastroenterol Hepatol. 2008;6(10):1070-6.

18. Krishna SG et al. Am J Gastroenterol. 2015;110(11):1608-19.

19. Lee PJ et al. Pancreas. 2016;45(4):561-4.

20. Mandalia A et al. F1000Research. 2018 Jun 28;7.

21. Majumder S et al. Pancreas. 2015;44(4):540-6.

22. DiMagno MJ. Clin Gastroenterol Hepatol. 2011;9(11):920-2.

23. Yadav D, Whitcomb DC. Nature Rev Gastroenterol Hepatol. 2010;7(3):131-45.

24. Samokhvalov AV et al. EBioMedicine. 2015;2(12):1996-2002.

25. Barkin JA et al. Pancreas. 2017;46(8):1035-8.

26. Chen Y-T et al. J Gastroenterol Hepatol. 2016;31(4):782-7.

27. Ramos LR et al. J Crohns Colitis. 2016;10(1):95-104.

28. Avram MM. Nephron. 1977;18(1):68-71.

29. Lankisch PG et al. Nephrol Dial Transplant. 2008;23(4):1401-5.

30. Owyang C et al. Mayo Clin Proc. 1979;54(12):769-73.

31. Owyang Cet al. Gut. 1982;23(5):357-61.

32. Quraishi ER et al. Am J Gastroenterol. 2005;100:2288.

33. Vaziri ND et al. Nephron. 1987;46(4):347-9.

34. Chen HJ et al. Nephrol Dial Transplant. 2017;32(10):1731-6.

35. Kirkegard J et al. Gastroenterology. 2018;May;154(6):1729-36.

36. Karlson BM, et al. Gastroenterology. 1997;113(2):587-92.

37. Munigala S et al. Clin Gastroenterol Hepatol. 2014;12(7):1143-50.e1.

38. Carr RA et al. Pancreatology. 2016;16(4):469-76.

39. Li X et al. BMC Gastroenterol. 2018;18(1):89.

40. Ahmed AU et al. Clin Gastroenterol Hepatol. 2016;14(5):738-46.

41. Sankaran SJ et al. Gastroenterology. 2015;149(6):1490-500.e1.

42. Berglund L et al. J Clin Endocrinol Metab. 2012;97(9):2969-89.

43. Catapano AL et al. Atherosclerosis. 2011;217(1):3-46.

44. Pedersen SB et al. JAMA Intern Med. 2016;176(12):1834-42.

45. Nawaz H et al. Am J Gastroenterol. 2015;110(10):1497-503.

46. Banks PA et al. Gut. 2013;62(1):102-11.

47. Kondo S et al. Eur J Radiol. 2005;54(2):271-5.

48. Meeralam Y et al. Gastrointest Endosc. 2017;86(6):986-93.

49. Stimac D et al. Am J Gastroenterol. 2007;102(5):997-1004.

50. Jin DX et al. Dig Dis Sci. 2017;62(10):2894-9.

51. Freeman ML. Gastrointest Endosc Clin N Am. 2012;22(3):567-86.

52. De Lisi S et al. Eur J Gastroenterol Hepatol. 2011;23(5):367-74.

53. Di MY et al. Ann Int Med. 2016;165(7):482-90.

54. Mounzer R et al. Gastroenterology. 2012;142(7):1476-82; quiz e15-6.

55. Koutroumpakis E et al. Am J Gastroenterol. 2015;110(12):1707-16.

56. Wu BU et al. Gastroenterology. 2009;137(1):129-35.

57. Buddingh KT et al. J Am Coll Surg. 2014;218(1):26-32.

58. Buxbaum J et al. Am J Gastroenterol. 2018;113(5):755-64.

59. Jabaudon M et al. Crit Car Med. 2018;46(3):e198-e205.

60. Barlass U et al. Gut. 2018;67(4):600-2.

61. Buxbaum JL et al. Am J Gastroenterol. 2017;112(5):797-803.

62. de-Madaria E et al. United Eur Gastroenterol J. 2018;6(1):63-72.

63. Bakker OJ et al. N Engl J Med. 2014;371(21):1983-93.

64. Tse F et al. Cochrane Database Syst Rev. 2012(5):Cd009779.

65. Kaner EFS et al. Cochrane Database Syst Rev. 2007(2):Cd004148.

66. da Costa DW et al. Lancet. 2015;386(10000):1261-8.

67. Schepers NJ et al. Trials. 2016;17:5.

68. Vadala di Prampero SF et al. Eur J Gastroenterol Hepatol. 2016;28(12):1415-24.

69. Kubiliun NM et al. Clin Gastroenterol Hepatol. 2015;13(7):1231-9; quiz e70-1.

70. Wan J et al. BMC Gastroenterol. 2017;17(1):43.

71. Yang C et al. Pancreatology. 2017;17(5):681-8.

72. DiMagno MJ et al. Pancreas. 2014;43(4):642-7.

73. Sagi SV et al. J Gastroenterol Hepatol. 2014;29(6):1316-20.

74. Choi JH et al. Clin Gastroenterol Hepatol. 2017;15(1):86-92.e1.

75. Wu D et al. J Clin Gastroenterol. 2017;51(8):e68-e76.

76. Zhang ZF et al. J Clin Gastroenterol. 2017;51(3):e17-e26.

77. Park CH et al. Endoscopy 2018 Apr;50(4):378-85.

78. Mok SRS et al. Gastrointest Endosc. 2017;85(5):1005-13.

79. Smeets XJN et al. Trials. 2018;19(1):207.

80. Elmunzer BJ et al. Trials. 2016;17(1):120.

 

You have run your experiments, analyzed your data, and finished your manuscript, but now you are asked to write a cover letter for journal submission. How do you effectively convey your message in a cover letter? To understand how to gain the editors’ support for your paper, let us first discuss the role of this letter.

The cover letter is your first communication with the editors. As this serves as your first impression, you want to send a clear and concise message that highlights the novelty, validity, and significance of your manuscript. You also want to state why your manuscript would be a good fit for the journal. Keeping this letter concise and ideally to one page allows the editors to quickly review the highlights of your manuscript. Here are 10 steps we believe are important to follow when writing an effective cover letter (Table 1). We have listed examples to accompany each step; note that our examples are for illustrative purposes only.
 

1) Address the editor(s) formally by name in your cover letter

This information is found on the journal’s website and in the journal. Common mistakes we have seen is reporting the wrong editor(s) for submission or omitting an introduction. Though this cover letter is not published, it reflects poorly on the authors if there are incorrect editors listed or misspelled words.

Example:
Richard M. Peek, Jr., MD, and Douglas A. Corley, MD, PhD, MPH
Editors in Chief, Gastroenterology

Dear Drs. Peek and Corley:

2) Manuscript title and authors

Bolding your manuscript and listing the authors are essential parts of the cover letter.

3) Methods

We recommend dedicating one sentence to your methods. Take this time to highlight key features if appropriate, such as novel techniques, prospective enrollment, and randomized, controlled studies, which are all generally viewed as stronger study designs than retrospective studies. Make sure you are truthful in your claims. Mistakes we have seen include making claims the group is the “first” or the “largest,” but our review of the literature disproves these statements. These are false claims and raise flags regarding the integrity of the science.

4) Results and key findings

We recommend dedicating a sentence to the key finding of this study. This allows the editors in chief to identify which associate editor should handle the manuscript and highlights the importance of the study, which will determine whether the associate editor will send your paper for external review.

Example:
We found that combined endoscopic dilation and oral steroid therapy at index food impaction improved quality of life and need for repeat dilation measured at 1-year follow-up, compared with sham dilation and placebo.
 

5) Novelty

The editors want to know the degree to which your paper is unique among other publications in the field. We recommend emphasizing the novelty of your study as compared with other published work. The focus of this should be how your manuscript adds to the literature and serves to advance the science in this field.

Example:
Our study is unique because we enrolled patients in a pragmatic fashion at time of admission for food impaction to the emergency department. This design allows implementation of our intervention in most clinical settings, where we expect our findings to translate broadly into reduced hospital admissions and repeat endoscopic interventions, as well as improved quality of life as documented by patient-reported outcomes.

6) Submission to other journals

Certain manuscripts are only part of the entire study, which can be because of interim results or prespecified secondary endpoints. It is important to state whether this manuscript or any part has been published elsewhere or parts of the study are in submission elsewhere.

Example:
Neither the entire paper nor any part of its content has been published or has been accepted elsewhere. This work has not been submitted to any other journal, and in case of acceptance of the manuscript, the copyright is transferred to Gastroenterology.

7) Journal fit

Not all journals have the same readership or focus. When submitting to the journals, please highlight why this manuscript fits this journal and its readership. When able, also recommend what section of the journal this manuscript should go to for review. This allows for expedited review process and shows you understand the journal’s readership and categories.

Example:
We believe our study will be of great interest to readers of Gastroenterology and suggest the manuscript section: “Clinical: Alimentary Tract.”

8) Influence of sponsors and conflicts of interest

Given the concern for potential conflict of interests in study design, data collection, or analysis, we recommend listing any important conflicts of interest or study sponsors. The entire list of conflicts of interest is typically included elsewhere, but a sponsored study or direct conflict should be listed to prevent any perceived influence from sponsors that may limit data integrity.

Example:
The study was supported by RDN-Gastro, a nonprofit private organization aimed to promote clinical and translational research in eosinophilic esophagitis. The RDN-Gastro organization receives support from the National Institutes of Health and the Emergency Department Eosinophilic Esophagitis Association.

9) Suggestions for editors and reviewers

It is helpful to suggest potential associate editors to handle your manuscript. Similarly, suggesting potential reviewers (and providing their email addresses) who are experts in the field and understand your research topic can enhance the quality of reviews. Soliciting reviewers who you know may seem like a recipe for friendly reviews; however, this is a flawed assumption because sometimes these reviewers are more rigorous in their comments.

Example:
Preferred Associate Editor: John M. Inadomi.
Preferred Reviewer: Rishi Naik ([email protected]); expertise in esophageal motility.

10) Do Not Review list (optional)

Unfortunately, not all review processes for all journals are created equal. For particular topics, you may wish to ensure your data are not compromised through the review process. Some journals will have the option for selecting reviewers who you prefer not review your manuscript and this request should be respected in the review process.

Example:
Nonpreferred reviewers: Rishi D. Naik (Nashville, TN).

In summary, the cover letter should be viewed as an opportunity to highlight the significance of your manuscript and reasons why your manuscript should be published in the journal. Highlighting the innovation, validity, and importance of your manuscript using this systematic approach will allow the editors and reviewers to more effectively evaluate your paper. Being truthful about potential conflicts of interest and sponsorships will also be appreciated by the editors. Good luck with your future submissions!
 

Dr. Naik is a gastroenterology fellow, department of gastroenterology, Vanderbilt University, Nashville, Tenn., as well as fellow editor of Gastroenterology. Dr. Inadomi is the Cyrus E. Rubin Chair, professor of medicine and head, division of gastroenterology, University of Washington, Seattle, as well as associate editor of Gastroenterology. Dr. Naik and Dr. Inadomi have no conflicts of interest to disclose.
 

You have run your experiments, analyzed your data, and finished your manuscript, but now you are asked to write a cover letter for journal submission. How do you effectively convey your message in a cover letter? To understand how to gain the editors’ support for your paper, let us first discuss the role of this letter.

The cover letter is your first communication with the editors. As this serves as your first impression, you want to send a clear and concise message that highlights the novelty, validity, and significance of your manuscript. You also want to state why your manuscript would be a good fit for the journal. Keeping this letter concise and ideally to one page allows the editors to quickly review the highlights of your manuscript. Here are 10 steps we believe are important to follow when writing an effective cover letter (Table 1). We have listed examples to accompany each step; note that our examples are for illustrative purposes only.
 

1) Address the editor(s) formally by name in your cover letter

This information is found on the journal’s website and in the journal. Common mistakes we have seen is reporting the wrong editor(s) for submission or omitting an introduction. Though this cover letter is not published, it reflects poorly on the authors if there are incorrect editors listed or misspelled words.

Example:
Richard M. Peek, Jr., MD, and Douglas A. Corley, MD, PhD, MPH
Editors in Chief, Gastroenterology

Dear Drs. Peek and Corley:

2) Manuscript title and authors

Bolding your manuscript and listing the authors are essential parts of the cover letter.

3) Methods

We recommend dedicating one sentence to your methods. Take this time to highlight key features if appropriate, such as novel techniques, prospective enrollment, and randomized, controlled studies, which are all generally viewed as stronger study designs than retrospective studies. Make sure you are truthful in your claims. Mistakes we have seen include making claims the group is the “first” or the “largest,” but our review of the literature disproves these statements. These are false claims and raise flags regarding the integrity of the science.

4) Results and key findings

We recommend dedicating a sentence to the key finding of this study. This allows the editors in chief to identify which associate editor should handle the manuscript and highlights the importance of the study, which will determine whether the associate editor will send your paper for external review.

Example:
We found that combined endoscopic dilation and oral steroid therapy at index food impaction improved quality of life and need for repeat dilation measured at 1-year follow-up, compared with sham dilation and placebo.
 

5) Novelty

The editors want to know the degree to which your paper is unique among other publications in the field. We recommend emphasizing the novelty of your study as compared with other published work. The focus of this should be how your manuscript adds to the literature and serves to advance the science in this field.

Example:
Our study is unique because we enrolled patients in a pragmatic fashion at time of admission for food impaction to the emergency department. This design allows implementation of our intervention in most clinical settings, where we expect our findings to translate broadly into reduced hospital admissions and repeat endoscopic interventions, as well as improved quality of life as documented by patient-reported outcomes.

6) Submission to other journals

Certain manuscripts are only part of the entire study, which can be because of interim results or prespecified secondary endpoints. It is important to state whether this manuscript or any part has been published elsewhere or parts of the study are in submission elsewhere.

Example:
Neither the entire paper nor any part of its content has been published or has been accepted elsewhere. This work has not been submitted to any other journal, and in case of acceptance of the manuscript, the copyright is transferred to Gastroenterology.

7) Journal fit

Not all journals have the same readership or focus. When submitting to the journals, please highlight why this manuscript fits this journal and its readership. When able, also recommend what section of the journal this manuscript should go to for review. This allows for expedited review process and shows you understand the journal’s readership and categories.

Example:
We believe our study will be of great interest to readers of Gastroenterology and suggest the manuscript section: “Clinical: Alimentary Tract.”

8) Influence of sponsors and conflicts of interest

Given the concern for potential conflict of interests in study design, data collection, or analysis, we recommend listing any important conflicts of interest or study sponsors. The entire list of conflicts of interest is typically included elsewhere, but a sponsored study or direct conflict should be listed to prevent any perceived influence from sponsors that may limit data integrity.

Example:
The study was supported by RDN-Gastro, a nonprofit private organization aimed to promote clinical and translational research in eosinophilic esophagitis. The RDN-Gastro organization receives support from the National Institutes of Health and the Emergency Department Eosinophilic Esophagitis Association.

9) Suggestions for editors and reviewers

It is helpful to suggest potential associate editors to handle your manuscript. Similarly, suggesting potential reviewers (and providing their email addresses) who are experts in the field and understand your research topic can enhance the quality of reviews. Soliciting reviewers who you know may seem like a recipe for friendly reviews; however, this is a flawed assumption because sometimes these reviewers are more rigorous in their comments.

Example:
Preferred Associate Editor: John M. Inadomi.
Preferred Reviewer: Rishi Naik ([email protected]); expertise in esophageal motility.

10) Do Not Review list (optional)

Unfortunately, not all review processes for all journals are created equal. For particular topics, you may wish to ensure your data are not compromised through the review process. Some journals will have the option for selecting reviewers who you prefer not review your manuscript and this request should be respected in the review process.

Example:
Nonpreferred reviewers: Rishi D. Naik (Nashville, TN).

In summary, the cover letter should be viewed as an opportunity to highlight the significance of your manuscript and reasons why your manuscript should be published in the journal. Highlighting the innovation, validity, and importance of your manuscript using this systematic approach will allow the editors and reviewers to more effectively evaluate your paper. Being truthful about potential conflicts of interest and sponsorships will also be appreciated by the editors. Good luck with your future submissions!
 

Dr. Naik is a gastroenterology fellow, department of gastroenterology, Vanderbilt University, Nashville, Tenn., as well as fellow editor of Gastroenterology. Dr. Inadomi is the Cyrus E. Rubin Chair, professor of medicine and head, division of gastroenterology, University of Washington, Seattle, as well as associate editor of Gastroenterology. Dr. Naik and Dr. Inadomi have no conflicts of interest to disclose.
 

You have run your experiments, analyzed your data, and finished your manuscript, but now you are asked to write a cover letter for journal submission. How do you effectively convey your message in a cover letter? To understand how to gain the editors’ support for your paper, let us first discuss the role of this letter.

The cover letter is your first communication with the editors. As this serves as your first impression, you want to send a clear and concise message that highlights the novelty, validity, and significance of your manuscript. You also want to state why your manuscript would be a good fit for the journal. Keeping this letter concise and ideally to one page allows the editors to quickly review the highlights of your manuscript. Here are 10 steps we believe are important to follow when writing an effective cover letter (Table 1). We have listed examples to accompany each step; note that our examples are for illustrative purposes only.
 

1) Address the editor(s) formally by name in your cover letter

This information is found on the journal’s website and in the journal. Common mistakes we have seen is reporting the wrong editor(s) for submission or omitting an introduction. Though this cover letter is not published, it reflects poorly on the authors if there are incorrect editors listed or misspelled words.

Example:
Richard M. Peek, Jr., MD, and Douglas A. Corley, MD, PhD, MPH
Editors in Chief, Gastroenterology

Dear Drs. Peek and Corley:

2) Manuscript title and authors

Bolding your manuscript and listing the authors are essential parts of the cover letter.

3) Methods

We recommend dedicating one sentence to your methods. Take this time to highlight key features if appropriate, such as novel techniques, prospective enrollment, and randomized, controlled studies, which are all generally viewed as stronger study designs than retrospective studies. Make sure you are truthful in your claims. Mistakes we have seen include making claims the group is the “first” or the “largest,” but our review of the literature disproves these statements. These are false claims and raise flags regarding the integrity of the science.

4) Results and key findings

We recommend dedicating a sentence to the key finding of this study. This allows the editors in chief to identify which associate editor should handle the manuscript and highlights the importance of the study, which will determine whether the associate editor will send your paper for external review.

Example:
We found that combined endoscopic dilation and oral steroid therapy at index food impaction improved quality of life and need for repeat dilation measured at 1-year follow-up, compared with sham dilation and placebo.
 

5) Novelty

The editors want to know the degree to which your paper is unique among other publications in the field. We recommend emphasizing the novelty of your study as compared with other published work. The focus of this should be how your manuscript adds to the literature and serves to advance the science in this field.

Example:
Our study is unique because we enrolled patients in a pragmatic fashion at time of admission for food impaction to the emergency department. This design allows implementation of our intervention in most clinical settings, where we expect our findings to translate broadly into reduced hospital admissions and repeat endoscopic interventions, as well as improved quality of life as documented by patient-reported outcomes.

6) Submission to other journals

Certain manuscripts are only part of the entire study, which can be because of interim results or prespecified secondary endpoints. It is important to state whether this manuscript or any part has been published elsewhere or parts of the study are in submission elsewhere.

Example:
Neither the entire paper nor any part of its content has been published or has been accepted elsewhere. This work has not been submitted to any other journal, and in case of acceptance of the manuscript, the copyright is transferred to Gastroenterology.

7) Journal fit

Not all journals have the same readership or focus. When submitting to the journals, please highlight why this manuscript fits this journal and its readership. When able, also recommend what section of the journal this manuscript should go to for review. This allows for expedited review process and shows you understand the journal’s readership and categories.

Example:
We believe our study will be of great interest to readers of Gastroenterology and suggest the manuscript section: “Clinical: Alimentary Tract.”

8) Influence of sponsors and conflicts of interest

Given the concern for potential conflict of interests in study design, data collection, or analysis, we recommend listing any important conflicts of interest or study sponsors. The entire list of conflicts of interest is typically included elsewhere, but a sponsored study or direct conflict should be listed to prevent any perceived influence from sponsors that may limit data integrity.

Example:
The study was supported by RDN-Gastro, a nonprofit private organization aimed to promote clinical and translational research in eosinophilic esophagitis. The RDN-Gastro organization receives support from the National Institutes of Health and the Emergency Department Eosinophilic Esophagitis Association.

9) Suggestions for editors and reviewers

It is helpful to suggest potential associate editors to handle your manuscript. Similarly, suggesting potential reviewers (and providing their email addresses) who are experts in the field and understand your research topic can enhance the quality of reviews. Soliciting reviewers who you know may seem like a recipe for friendly reviews; however, this is a flawed assumption because sometimes these reviewers are more rigorous in their comments.

Example:
Preferred Associate Editor: John M. Inadomi.
Preferred Reviewer: Rishi Naik ([email protected]); expertise in esophageal motility.

10) Do Not Review list (optional)

Unfortunately, not all review processes for all journals are created equal. For particular topics, you may wish to ensure your data are not compromised through the review process. Some journals will have the option for selecting reviewers who you prefer not review your manuscript and this request should be respected in the review process.

Example:
Nonpreferred reviewers: Rishi D. Naik (Nashville, TN).

In summary, the cover letter should be viewed as an opportunity to highlight the significance of your manuscript and reasons why your manuscript should be published in the journal. Highlighting the innovation, validity, and importance of your manuscript using this systematic approach will allow the editors and reviewers to more effectively evaluate your paper. Being truthful about potential conflicts of interest and sponsorships will also be appreciated by the editors. Good luck with your future submissions!
 

Dr. Naik is a gastroenterology fellow, department of gastroenterology, Vanderbilt University, Nashville, Tenn., as well as fellow editor of Gastroenterology. Dr. Inadomi is the Cyrus E. Rubin Chair, professor of medicine and head, division of gastroenterology, University of Washington, Seattle, as well as associate editor of Gastroenterology. Dr. Naik and Dr. Inadomi have no conflicts of interest to disclose.
 

AGA workshops/webcasts to give free advice on advancing your GI career

The free half-day workshops and webcasts in Columbus, Ohio, on Feb. 16, 2019, and in Boston on March 30, 2019, emphasize mastering basic business skills that can help advance your GI career.

Fellows and early-career GIs will have an opportunity to connect with seasoned GIs to gain real-world insights on successfully managing their careers at one of two upcoming American Gastroenterological Association’s Regional Practice Skills Workshops. Seasoned faculty will share their experiences and recommendations on:

• Measuring quality and delivering value-based care.
• Health care reform and the future of GI.
• Planning and managing finances, and much more.

Register and plan to join one of the upcoming workshops or webcasts:

• Columbus, Ohio - Feb. 16, 2019
• Boston - March 30, 2019

If you’re in the Columbus or Boston area, attending the workshop in person is a great opportunity to ask questions of presenters and to network with faculty and peers. If you are not able to attend in person, you may still benefit from the valuable information by registering for the live webcast.

Open to AGA members and nonmembers, the workshops have been a hit with recent attendees who have called them an “eye opener,” “amazing and very informative,” and “phenomenal.” Take advantage of this free learning opportunity and register for one or both events/webcasts today.

Registration for all workshops and webcasts is required.

Rising microbiome investigator: Lea Ann Chen, MD

Dr. Chen, of New York University, talks about her research on gastrointestinal illnesses and what motivated her to focus on the gut microbiome.

We spoke with Dr. Chen, the recipient of the AGA Research Foundation’s 2016 Research Scholar Award, to learn about her work on the gut microbiome and inflammatory bowel disease (IBD).

How would you sum up your research in one sentence?
I study longitudinal changes of the gut microbiome as it relates to gastrointestinal illnesses, particularly IBD.

What impact do you hope your research will have on patients?
I hope that my research will provide greater insights into the role of gut microbes in disease pathogenesis and activity to ultimately inform the development of new diagnostics and treatments.

What inspired you to focus your research career on the gut microbiome?
I’ve long been fascinated by ecological systems and host-microbe interactions. As technologies to study the gut microbiome became more readily available, I was eager, and somewhat relieved, to be able to combine my research interests with my clinical interest in gastroenterology.

What recent publication from your lab best represents your work, if anyone wants to learn more?
In this study, we show that gut bacterial disturbances are resolved after fecal transplantation in children without IBD but are only transiently resolved in those with IBD. 
Hourigan S et al. Aliment Pharmacol Ther. 2015;42:741-52.

You’re involved with several AGA initiatives, including the Future Leaders Program and the FMT National Registry. How has being an AGA member impacted your career?
AGA has provided key mentorship and training opportunities that have been instrumental in my career development. It has further helped me discover a diverse community of clinicians and scientists who are amazing role models, resources and colleagues. I really had no inkling what was in store when I first joined AGA as a trainee, but I feel very lucky that I did and am grateful for how AGA membership has really enriched my life as a gastroenterologist.

My experiences during AGA’s Advocacy Day: Facilitating change

BY YAMINI NATARAJAN, MD

The hospital is often the intersection between patients’ medical illness and their social and financial issues.

As physicians, it is important to recognize that patient care encompasses the prescribing of medications, the performing of procedures, as well as systems-based practice, and ensuring that social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by any one individual health care professional (HCP); they can only be improved by working with government representatives and policymakers to make systemic changes. For gastroenterologists, advocacy involves educating patients, HCPs, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all the patients who require it.

AGA, via the Government Affairs Committee, facilitates advocacy in several ways. These include policy briefs, position statements, and facilitating meetings with our representatives and senators in home districts and in Washington. AGA hosted Advocacy Day in Washington on Sept. 14, 2018. Seventeen AGA members from 11 states visited 26 congressional offices. I am an assistant professor at the Baylor College of Medicine in Houston. During Advocacy Day, I visited the office of my congressional representative, Rep. Pete Olsen (R-Tex.), as well as health policy advisors for Sen. Ted Cruz (R-Tex.) and Sen. John Cornyn (R-Tex.). For the visits to the senators’ offices, I was joined by my colleagues from Baylor, Avinash Ketwaroo, MD, and Richard Robbins, MD, as well as Thomas Kerr, MD, PhD, of University of Texas, Dallas. During these visits, we discussed National Institutes of Health funding and barriers to effective care in digestive diseases such as copays for colonoscopy.

Academic institutions share the aim of conducting high-quality research to further advances in medicine. These research projects are often funded through NIH grant programs. Unfortunately, these programs are also often the target of budget cuts, which can affect primary research and also downstream economic growth. An analysis by United for Medical Research found that, for every dollar spent in NIH grants, $2 of economic output is generated.¹ In 2016, these programs created 379,000 jobs and $64 billion in economic activity nationally. AGA calls for increased NIH funding to maintain pace with inflation.²

We also discussed how projects funded by NIH have led to important advances in gastroenterology in Texas. For example, NIH-funded research by Hashem El-Serag, MD, and Fasiha Kanwal, MD, has produced studies to evaluate biomarkers and improve screening techniques in hepatocellular carcinoma.^3,4 Dr. Kerr discussed his experiences as a physician-scientist and the importance of basic science research as a foundation for clinical advances.

After the Affordable Care Act was passed, deductibles and coinsurance fees were waived for colorectal cancer screening tests that received an “A” or “B” grade from the U.S. Preventive Services Task Force. However, once a polyp is found and removed during a screening colonoscopy, the procedure is reclassified as a therapeutic procedure, meaning the patient will have to pay the coinsurance.⁵

Coinsurance costs can be 20%-25% of the Medicare-approved amount. In essence, patients may go into a procedure with the expectation that it will be 100% covered by insurance only to find out that they will receive a larger bill because polyps were removed. It puts gastroenterologists in a difficult position because they know that polyp removal will increase the cost to the patient; however, waiting for a repeat procedure would be redundant and lead to possible loss of follow-up care. The Removing Barriers to Colorectal Cancer Screening Act would correct this by waiving the coinsurance for a screening colonoscopy even if polyps were removed.⁶ We discussed the importance of this legislation to removing barriers to screening.

Use of biologics has advanced the treatment of many diseases, including inflammatory bowel disease (IBD). However, mandates by insurance companies can make it difficult to use these medications without first “stepping” through other less costly medications. We spoke with staffers regarding the Restoring the Patient’s Voice Act, which would remove unneeded barriers to prescribing appropriate therapy. It would also streamline the prior authorization/appeals process by requiring insurance companies to respond in a timely manner. We discussed the effects IBD has on the quality of life of our patients and shared our experiences in obtaining timely therapy.

As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators, others members of Congress, and practicing gastroenterologists and GI fellows. AGA Advocacy Day is an important event to discuss our perspective as physicians and our experiences dealing with the health care system on a daily basis. Congressional staffers were very interested to hear our points of view as HCPs. They even shared their personal stories regarding friends and relatives with colon cancer and other digestive diseases. I strongly encourage other AGA members to take advantage of this important program. Other advocacy programs by AGA are discussed as follows.
 

Congressional Advocates Program
This is a grassroots program aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities that range from creating educational posts on social media to meeting with government representatives. Members are mentored by AGA leadership and staff for advocacy training. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.

AGA PAC
The AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA and is the only political action committee supported by a national gastroenterology society. Its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and support for federal funding of digestive disease research. If you are interested in learning more, contact AGA’s Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

GovPredict
AGA’s online advocacy platform allows members to contact their members of Congress with just a few clicks. AGA develops messages on key pieces of legislation, key efforts in Congress, or on issues being advanced by federal agencies that have great effects on gastroenterology. The platform also allows AGA to track legislation, key votes, a legislator’s priority issues, and other key legislative activity. AGA can also track member activity with a legislator and their staff, a key component in building and maintaining relationships with key legislators.

References

1. Ehrlich E. United for Medical Research. NIH’S role in sustaining the U.S. economy. http://www.unitedformedicalresearch.com/advocacy_reports/nihs-role-in-sustaining-the-u-s-economy-2017-update/nih-role-in-the-economy-fy2016-2/#.XD9RafZFy5t.
2. AGA. AGA position statement on research funding. http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag HB et al. Gastroenterology. 2014 May;146(5):1249-55.e1.
4. White DL et al. Gastroenterology. 2015 Dec;149(7):1986-7.
5. AGA. AGA position statement on patient cost sharing for screening colonoscopy. http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
6. Removing Barriers to Colorectal Cancer Screening Act of 2017. S. 479 U.S.C. (2017-2018).

Dr. Natarajan has received clinical trial support from Gilead and Allergan. Dr. Natarajan is a member of the AGA Government Affairs Committee. This feature originally appeared in AGA Perspectives.

AGA workshops/webcasts to give free advice on advancing your GI career

The free half-day workshops and webcasts in Columbus, Ohio, on Feb. 16, 2019, and in Boston on March 30, 2019, emphasize mastering basic business skills that can help advance your GI career.

Fellows and early-career GIs will have an opportunity to connect with seasoned GIs to gain real-world insights on successfully managing their careers at one of two upcoming American Gastroenterological Association’s Regional Practice Skills Workshops. Seasoned faculty will share their experiences and recommendations on:

• Measuring quality and delivering value-based care.
• Health care reform and the future of GI.
• Planning and managing finances, and much more.

Register and plan to join one of the upcoming workshops or webcasts:

• Columbus, Ohio - Feb. 16, 2019
• Boston - March 30, 2019

If you’re in the Columbus or Boston area, attending the workshop in person is a great opportunity to ask questions of presenters and to network with faculty and peers. If you are not able to attend in person, you may still benefit from the valuable information by registering for the live webcast.

Open to AGA members and nonmembers, the workshops have been a hit with recent attendees who have called them an “eye opener,” “amazing and very informative,” and “phenomenal.” Take advantage of this free learning opportunity and register for one or both events/webcasts today.

Registration for all workshops and webcasts is required.

Rising microbiome investigator: Lea Ann Chen, MD

Dr. Chen, of New York University, talks about her research on gastrointestinal illnesses and what motivated her to focus on the gut microbiome.

We spoke with Dr. Chen, the recipient of the AGA Research Foundation’s 2016 Research Scholar Award, to learn about her work on the gut microbiome and inflammatory bowel disease (IBD).

How would you sum up your research in one sentence?
I study longitudinal changes of the gut microbiome as it relates to gastrointestinal illnesses, particularly IBD.

What impact do you hope your research will have on patients?
I hope that my research will provide greater insights into the role of gut microbes in disease pathogenesis and activity to ultimately inform the development of new diagnostics and treatments.

What inspired you to focus your research career on the gut microbiome?
I’ve long been fascinated by ecological systems and host-microbe interactions. As technologies to study the gut microbiome became more readily available, I was eager, and somewhat relieved, to be able to combine my research interests with my clinical interest in gastroenterology.

What recent publication from your lab best represents your work, if anyone wants to learn more?
In this study, we show that gut bacterial disturbances are resolved after fecal transplantation in children without IBD but are only transiently resolved in those with IBD. 
Hourigan S et al. Aliment Pharmacol Ther. 2015;42:741-52.

You’re involved with several AGA initiatives, including the Future Leaders Program and the FMT National Registry. How has being an AGA member impacted your career?
AGA has provided key mentorship and training opportunities that have been instrumental in my career development. It has further helped me discover a diverse community of clinicians and scientists who are amazing role models, resources and colleagues. I really had no inkling what was in store when I first joined AGA as a trainee, but I feel very lucky that I did and am grateful for how AGA membership has really enriched my life as a gastroenterologist.

My experiences during AGA’s Advocacy Day: Facilitating change

BY YAMINI NATARAJAN, MD

The hospital is often the intersection between patients’ medical illness and their social and financial issues.

As physicians, it is important to recognize that patient care encompasses the prescribing of medications, the performing of procedures, as well as systems-based practice, and ensuring that social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by any one individual health care professional (HCP); they can only be improved by working with government representatives and policymakers to make systemic changes. For gastroenterologists, advocacy involves educating patients, HCPs, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all the patients who require it.

AGA, via the Government Affairs Committee, facilitates advocacy in several ways. These include policy briefs, position statements, and facilitating meetings with our representatives and senators in home districts and in Washington. AGA hosted Advocacy Day in Washington on Sept. 14, 2018. Seventeen AGA members from 11 states visited 26 congressional offices. I am an assistant professor at the Baylor College of Medicine in Houston. During Advocacy Day, I visited the office of my congressional representative, Rep. Pete Olsen (R-Tex.), as well as health policy advisors for Sen. Ted Cruz (R-Tex.) and Sen. John Cornyn (R-Tex.). For the visits to the senators’ offices, I was joined by my colleagues from Baylor, Avinash Ketwaroo, MD, and Richard Robbins, MD, as well as Thomas Kerr, MD, PhD, of University of Texas, Dallas. During these visits, we discussed National Institutes of Health funding and barriers to effective care in digestive diseases such as copays for colonoscopy.

Academic institutions share the aim of conducting high-quality research to further advances in medicine. These research projects are often funded through NIH grant programs. Unfortunately, these programs are also often the target of budget cuts, which can affect primary research and also downstream economic growth. An analysis by United for Medical Research found that, for every dollar spent in NIH grants, $2 of economic output is generated.¹ In 2016, these programs created 379,000 jobs and $64 billion in economic activity nationally. AGA calls for increased NIH funding to maintain pace with inflation.²

We also discussed how projects funded by NIH have led to important advances in gastroenterology in Texas. For example, NIH-funded research by Hashem El-Serag, MD, and Fasiha Kanwal, MD, has produced studies to evaluate biomarkers and improve screening techniques in hepatocellular carcinoma.^3,4 Dr. Kerr discussed his experiences as a physician-scientist and the importance of basic science research as a foundation for clinical advances.

After the Affordable Care Act was passed, deductibles and coinsurance fees were waived for colorectal cancer screening tests that received an “A” or “B” grade from the U.S. Preventive Services Task Force. However, once a polyp is found and removed during a screening colonoscopy, the procedure is reclassified as a therapeutic procedure, meaning the patient will have to pay the coinsurance.⁵

Coinsurance costs can be 20%-25% of the Medicare-approved amount. In essence, patients may go into a procedure with the expectation that it will be 100% covered by insurance only to find out that they will receive a larger bill because polyps were removed. It puts gastroenterologists in a difficult position because they know that polyp removal will increase the cost to the patient; however, waiting for a repeat procedure would be redundant and lead to possible loss of follow-up care. The Removing Barriers to Colorectal Cancer Screening Act would correct this by waiving the coinsurance for a screening colonoscopy even if polyps were removed.⁶ We discussed the importance of this legislation to removing barriers to screening.

Use of biologics has advanced the treatment of many diseases, including inflammatory bowel disease (IBD). However, mandates by insurance companies can make it difficult to use these medications without first “stepping” through other less costly medications. We spoke with staffers regarding the Restoring the Patient’s Voice Act, which would remove unneeded barriers to prescribing appropriate therapy. It would also streamline the prior authorization/appeals process by requiring insurance companies to respond in a timely manner. We discussed the effects IBD has on the quality of life of our patients and shared our experiences in obtaining timely therapy.

As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators, others members of Congress, and practicing gastroenterologists and GI fellows. AGA Advocacy Day is an important event to discuss our perspective as physicians and our experiences dealing with the health care system on a daily basis. Congressional staffers were very interested to hear our points of view as HCPs. They even shared their personal stories regarding friends and relatives with colon cancer and other digestive diseases. I strongly encourage other AGA members to take advantage of this important program. Other advocacy programs by AGA are discussed as follows.
 

Congressional Advocates Program
This is a grassroots program aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities that range from creating educational posts on social media to meeting with government representatives. Members are mentored by AGA leadership and staff for advocacy training. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.

AGA PAC
The AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA and is the only political action committee supported by a national gastroenterology society. Its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and support for federal funding of digestive disease research. If you are interested in learning more, contact AGA’s Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

GovPredict
AGA’s online advocacy platform allows members to contact their members of Congress with just a few clicks. AGA develops messages on key pieces of legislation, key efforts in Congress, or on issues being advanced by federal agencies that have great effects on gastroenterology. The platform also allows AGA to track legislation, key votes, a legislator’s priority issues, and other key legislative activity. AGA can also track member activity with a legislator and their staff, a key component in building and maintaining relationships with key legislators.

References

1. Ehrlich E. United for Medical Research. NIH’S role in sustaining the U.S. economy. http://www.unitedformedicalresearch.com/advocacy_reports/nihs-role-in-sustaining-the-u-s-economy-2017-update/nih-role-in-the-economy-fy2016-2/#.XD9RafZFy5t.
2. AGA. AGA position statement on research funding. http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag HB et al. Gastroenterology. 2014 May;146(5):1249-55.e1.
4. White DL et al. Gastroenterology. 2015 Dec;149(7):1986-7.
5. AGA. AGA position statement on patient cost sharing for screening colonoscopy. http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
6. Removing Barriers to Colorectal Cancer Screening Act of 2017. S. 479 U.S.C. (2017-2018).

Dr. Natarajan has received clinical trial support from Gilead and Allergan. Dr. Natarajan is a member of the AGA Government Affairs Committee. This feature originally appeared in AGA Perspectives.

AGA workshops/webcasts to give free advice on advancing your GI career

The free half-day workshops and webcasts in Columbus, Ohio, on Feb. 16, 2019, and in Boston on March 30, 2019, emphasize mastering basic business skills that can help advance your GI career.

Fellows and early-career GIs will have an opportunity to connect with seasoned GIs to gain real-world insights on successfully managing their careers at one of two upcoming American Gastroenterological Association’s Regional Practice Skills Workshops. Seasoned faculty will share their experiences and recommendations on:

• Measuring quality and delivering value-based care.
• Health care reform and the future of GI.
• Planning and managing finances, and much more.

Register and plan to join one of the upcoming workshops or webcasts:

• Columbus, Ohio - Feb. 16, 2019
• Boston - March 30, 2019

If you’re in the Columbus or Boston area, attending the workshop in person is a great opportunity to ask questions of presenters and to network with faculty and peers. If you are not able to attend in person, you may still benefit from the valuable information by registering for the live webcast.

Open to AGA members and nonmembers, the workshops have been a hit with recent attendees who have called them an “eye opener,” “amazing and very informative,” and “phenomenal.” Take advantage of this free learning opportunity and register for one or both events/webcasts today.

Registration for all workshops and webcasts is required.

Rising microbiome investigator: Lea Ann Chen, MD

Dr. Chen, of New York University, talks about her research on gastrointestinal illnesses and what motivated her to focus on the gut microbiome.

We spoke with Dr. Chen, the recipient of the AGA Research Foundation’s 2016 Research Scholar Award, to learn about her work on the gut microbiome and inflammatory bowel disease (IBD).

How would you sum up your research in one sentence?
I study longitudinal changes of the gut microbiome as it relates to gastrointestinal illnesses, particularly IBD.

What impact do you hope your research will have on patients?
I hope that my research will provide greater insights into the role of gut microbes in disease pathogenesis and activity to ultimately inform the development of new diagnostics and treatments.

What inspired you to focus your research career on the gut microbiome?
I’ve long been fascinated by ecological systems and host-microbe interactions. As technologies to study the gut microbiome became more readily available, I was eager, and somewhat relieved, to be able to combine my research interests with my clinical interest in gastroenterology.

What recent publication from your lab best represents your work, if anyone wants to learn more?
In this study, we show that gut bacterial disturbances are resolved after fecal transplantation in children without IBD but are only transiently resolved in those with IBD. 
Hourigan S et al. Aliment Pharmacol Ther. 2015;42:741-52.

You’re involved with several AGA initiatives, including the Future Leaders Program and the FMT National Registry. How has being an AGA member impacted your career?
AGA has provided key mentorship and training opportunities that have been instrumental in my career development. It has further helped me discover a diverse community of clinicians and scientists who are amazing role models, resources and colleagues. I really had no inkling what was in store when I first joined AGA as a trainee, but I feel very lucky that I did and am grateful for how AGA membership has really enriched my life as a gastroenterologist.

My experiences during AGA’s Advocacy Day: Facilitating change

BY YAMINI NATARAJAN, MD

The hospital is often the intersection between patients’ medical illness and their social and financial issues.

As physicians, it is important to recognize that patient care encompasses the prescribing of medications, the performing of procedures, as well as systems-based practice, and ensuring that social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by any one individual health care professional (HCP); they can only be improved by working with government representatives and policymakers to make systemic changes. For gastroenterologists, advocacy involves educating patients, HCPs, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all the patients who require it.

AGA, via the Government Affairs Committee, facilitates advocacy in several ways. These include policy briefs, position statements, and facilitating meetings with our representatives and senators in home districts and in Washington. AGA hosted Advocacy Day in Washington on Sept. 14, 2018. Seventeen AGA members from 11 states visited 26 congressional offices. I am an assistant professor at the Baylor College of Medicine in Houston. During Advocacy Day, I visited the office of my congressional representative, Rep. Pete Olsen (R-Tex.), as well as health policy advisors for Sen. Ted Cruz (R-Tex.) and Sen. John Cornyn (R-Tex.). For the visits to the senators’ offices, I was joined by my colleagues from Baylor, Avinash Ketwaroo, MD, and Richard Robbins, MD, as well as Thomas Kerr, MD, PhD, of University of Texas, Dallas. During these visits, we discussed National Institutes of Health funding and barriers to effective care in digestive diseases such as copays for colonoscopy.

Academic institutions share the aim of conducting high-quality research to further advances in medicine. These research projects are often funded through NIH grant programs. Unfortunately, these programs are also often the target of budget cuts, which can affect primary research and also downstream economic growth. An analysis by United for Medical Research found that, for every dollar spent in NIH grants, $2 of economic output is generated.¹ In 2016, these programs created 379,000 jobs and $64 billion in economic activity nationally. AGA calls for increased NIH funding to maintain pace with inflation.²

We also discussed how projects funded by NIH have led to important advances in gastroenterology in Texas. For example, NIH-funded research by Hashem El-Serag, MD, and Fasiha Kanwal, MD, has produced studies to evaluate biomarkers and improve screening techniques in hepatocellular carcinoma.^3,4 Dr. Kerr discussed his experiences as a physician-scientist and the importance of basic science research as a foundation for clinical advances.

After the Affordable Care Act was passed, deductibles and coinsurance fees were waived for colorectal cancer screening tests that received an “A” or “B” grade from the U.S. Preventive Services Task Force. However, once a polyp is found and removed during a screening colonoscopy, the procedure is reclassified as a therapeutic procedure, meaning the patient will have to pay the coinsurance.⁵

Coinsurance costs can be 20%-25% of the Medicare-approved amount. In essence, patients may go into a procedure with the expectation that it will be 100% covered by insurance only to find out that they will receive a larger bill because polyps were removed. It puts gastroenterologists in a difficult position because they know that polyp removal will increase the cost to the patient; however, waiting for a repeat procedure would be redundant and lead to possible loss of follow-up care. The Removing Barriers to Colorectal Cancer Screening Act would correct this by waiving the coinsurance for a screening colonoscopy even if polyps were removed.⁶ We discussed the importance of this legislation to removing barriers to screening.

Use of biologics has advanced the treatment of many diseases, including inflammatory bowel disease (IBD). However, mandates by insurance companies can make it difficult to use these medications without first “stepping” through other less costly medications. We spoke with staffers regarding the Restoring the Patient’s Voice Act, which would remove unneeded barriers to prescribing appropriate therapy. It would also streamline the prior authorization/appeals process by requiring insurance companies to respond in a timely manner. We discussed the effects IBD has on the quality of life of our patients and shared our experiences in obtaining timely therapy.

As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators, others members of Congress, and practicing gastroenterologists and GI fellows. AGA Advocacy Day is an important event to discuss our perspective as physicians and our experiences dealing with the health care system on a daily basis. Congressional staffers were very interested to hear our points of view as HCPs. They even shared their personal stories regarding friends and relatives with colon cancer and other digestive diseases. I strongly encourage other AGA members to take advantage of this important program. Other advocacy programs by AGA are discussed as follows.
 

Congressional Advocates Program
This is a grassroots program aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities that range from creating educational posts on social media to meeting with government representatives. Members are mentored by AGA leadership and staff for advocacy training. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.

AGA PAC
The AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA and is the only political action committee supported by a national gastroenterology society. Its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and support for federal funding of digestive disease research. If you are interested in learning more, contact AGA’s Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

GovPredict
AGA’s online advocacy platform allows members to contact their members of Congress with just a few clicks. AGA develops messages on key pieces of legislation, key efforts in Congress, or on issues being advanced by federal agencies that have great effects on gastroenterology. The platform also allows AGA to track legislation, key votes, a legislator’s priority issues, and other key legislative activity. AGA can also track member activity with a legislator and their staff, a key component in building and maintaining relationships with key legislators.

References

1. Ehrlich E. United for Medical Research. NIH’S role in sustaining the U.S. economy. http://www.unitedformedicalresearch.com/advocacy_reports/nihs-role-in-sustaining-the-u-s-economy-2017-update/nih-role-in-the-economy-fy2016-2/#.XD9RafZFy5t.
2. AGA. AGA position statement on research funding. http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag HB et al. Gastroenterology. 2014 May;146(5):1249-55.e1.
4. White DL et al. Gastroenterology. 2015 Dec;149(7):1986-7.
5. AGA. AGA position statement on patient cost sharing for screening colonoscopy. http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
6. Removing Barriers to Colorectal Cancer Screening Act of 2017. S. 479 U.S.C. (2017-2018).

Dr. Natarajan has received clinical trial support from Gilead and Allergan. Dr. Natarajan is a member of the AGA Government Affairs Committee. This feature originally appeared in AGA Perspectives.

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Feb. 16, 2019
AGA Regional Practice Skills Workshop – Ohio
The workshop provides fellows with insights on life in private practice, life in academia, and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy, and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Columbus, OH

Feb. 20-21, 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Hartford, CT

Feb. 21, 2019
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Richmond, VA

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth, and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching, and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World SummitThe 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

March 30, 2019
AGA Regional Practice Skills Workshop – Massachusetts
The workshop provides fellows with insights on life in private practice, life in academia and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Boston, MA

April 10-12, 2019
2019 AGA Tech Summit
By bringing together and fostering collaboration among innovators, entrepreneurs, clinicians, MedTech companies,regulatory agency representatives and venture capitalists, the Tech Summit helps ensure a pipeline of GI innovation that ultimately will improve delivery of care and patient outcomes.
San Francisco, CA

May 18-21, 2019
Digestive Disease Week (DDW)®
DDW^® is the world’s leading educational forum for academicians, clinicians, researchers, students and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD, or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students, or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Dec. 16, 2019

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Feb. 16, 2019
AGA Regional Practice Skills Workshop – Ohio
The workshop provides fellows with insights on life in private practice, life in academia, and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy, and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Columbus, OH

Feb. 20-21, 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Hartford, CT

Feb. 21, 2019
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Richmond, VA

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth, and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching, and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World SummitThe 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

March 30, 2019
AGA Regional Practice Skills Workshop – Massachusetts
The workshop provides fellows with insights on life in private practice, life in academia and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Boston, MA

April 10-12, 2019
2019 AGA Tech Summit
By bringing together and fostering collaboration among innovators, entrepreneurs, clinicians, MedTech companies,regulatory agency representatives and venture capitalists, the Tech Summit helps ensure a pipeline of GI innovation that ultimately will improve delivery of care and patient outcomes.
San Francisco, CA

May 18-21, 2019
Digestive Disease Week (DDW)®
DDW^® is the world’s leading educational forum for academicians, clinicians, researchers, students and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD, or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students, or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Dec. 16, 2019

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Feb. 16, 2019
AGA Regional Practice Skills Workshop – Ohio
The workshop provides fellows with insights on life in private practice, life in academia, and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy, and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Columbus, OH

Feb. 20-21, 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Hartford, CT

Feb. 21, 2019
Coding and Reimbursement Solutions by McVey Associates, Inc.
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
Richmond, VA

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth, and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching, and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World SummitThe 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

March 30, 2019
AGA Regional Practice Skills Workshop – Massachusetts
The workshop provides fellows with insights on life in private practice, life in academia and other career opportunities. Attendees will also gain practical knowledge on key topics such as contract negotiations, billing/coding, health care policy and other topics that can help to enhance their career. Work/life balance and financial management as an early career professional are also addressed.
Boston, MA

April 10-12, 2019
2019 AGA Tech Summit
By bringing together and fostering collaboration among innovators, entrepreneurs, clinicians, MedTech companies,regulatory agency representatives and venture capitalists, the Tech Summit helps ensure a pipeline of GI innovation that ultimately will improve delivery of care and patient outcomes.
San Francisco, CA

May 18-21, 2019
Digestive Disease Week (DDW)®
DDW^® is the world’s leading educational forum for academicians, clinicians, researchers, students and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery and related fields. Whether you work in patient care, research, education or administration, the DDW program offers something for you. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD, or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students, or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate, or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Dec. 16, 2019

Gastroenterology

How to approach a patient with refractory or recurrent benign esophageal stricture. Siersema PD. 2019 Jan;156(1):7-10. doi.org/10.1053/j.gastro.2018.11.040

How to approach a patient with ampullary lesion. Kandler J; Neuhaus H. 2018 Dec;155(6):1670-6. doi.org/10.1053/j.gastro.2018.11.010

How to promote the academic success of junior faculty physicians in gastroenterology. Shaheen NJ; Sandler RS. 2018 Nov;155(5):1293-7. doi.org/10.1053/j.gastro.2018.10.006

Clin Gastro Hepatol

Screening and surveillance of varices in patients with cirrhosis. Jakab SS; Garcia-Tsao G. 2019 Jan;17(1):26-9. doi.org/10.1016/j.cgh.2018.03.012

Common gastrostomy feeding tube complications and troubleshooting. Sealock RJ; Munot K. 2018 Dec;16(12):1864-9. doi.org/10.1016/j.cgh.2018.07.037

Endobariatrics: A primer. Storm AC; Abu Dayyeh BK; Topazian M. 2018 Nov;16(11):1701-4. doi.org/10.1016/j.cgh.2018.03.009

AGA Perspectives

My experiences during AGA’s Advocacy Day: Facilitating change
Published on 12/05/2018 by Yamini Natarajan, MD.

Lessons learned from the AGA Future Leaders Program
Published on 12/05/2018 by Jennifer Weiss, MD, MS, AGAF.

Gastroenterology

How to approach a patient with refractory or recurrent benign esophageal stricture. Siersema PD. 2019 Jan;156(1):7-10. doi.org/10.1053/j.gastro.2018.11.040

How to approach a patient with ampullary lesion. Kandler J; Neuhaus H. 2018 Dec;155(6):1670-6. doi.org/10.1053/j.gastro.2018.11.010

How to promote the academic success of junior faculty physicians in gastroenterology. Shaheen NJ; Sandler RS. 2018 Nov;155(5):1293-7. doi.org/10.1053/j.gastro.2018.10.006

Clin Gastro Hepatol

Screening and surveillance of varices in patients with cirrhosis. Jakab SS; Garcia-Tsao G. 2019 Jan;17(1):26-9. doi.org/10.1016/j.cgh.2018.03.012

Common gastrostomy feeding tube complications and troubleshooting. Sealock RJ; Munot K. 2018 Dec;16(12):1864-9. doi.org/10.1016/j.cgh.2018.07.037

Endobariatrics: A primer. Storm AC; Abu Dayyeh BK; Topazian M. 2018 Nov;16(11):1701-4. doi.org/10.1016/j.cgh.2018.03.009

AGA Perspectives

My experiences during AGA’s Advocacy Day: Facilitating change
Published on 12/05/2018 by Yamini Natarajan, MD.

Lessons learned from the AGA Future Leaders Program
Published on 12/05/2018 by Jennifer Weiss, MD, MS, AGAF.

Gastroenterology

How to approach a patient with refractory or recurrent benign esophageal stricture. Siersema PD. 2019 Jan;156(1):7-10. doi.org/10.1053/j.gastro.2018.11.040

How to approach a patient with ampullary lesion. Kandler J; Neuhaus H. 2018 Dec;155(6):1670-6. doi.org/10.1053/j.gastro.2018.11.010

How to promote the academic success of junior faculty physicians in gastroenterology. Shaheen NJ; Sandler RS. 2018 Nov;155(5):1293-7. doi.org/10.1053/j.gastro.2018.10.006

Clin Gastro Hepatol

Screening and surveillance of varices in patients with cirrhosis. Jakab SS; Garcia-Tsao G. 2019 Jan;17(1):26-9. doi.org/10.1016/j.cgh.2018.03.012

Common gastrostomy feeding tube complications and troubleshooting. Sealock RJ; Munot K. 2018 Dec;16(12):1864-9. doi.org/10.1016/j.cgh.2018.07.037

Endobariatrics: A primer. Storm AC; Abu Dayyeh BK; Topazian M. 2018 Nov;16(11):1701-4. doi.org/10.1016/j.cgh.2018.03.009

AGA Perspectives

My experiences during AGA’s Advocacy Day: Facilitating change
Published on 12/05/2018 by Yamini Natarajan, MD.

Lessons learned from the AGA Future Leaders Program
Published on 12/05/2018 by Jennifer Weiss, MD, MS, AGAF.

Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.

Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.

Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.

In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.

When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.

Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.

Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.

Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.

Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.

In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.

When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.

Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.

Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.

Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.

Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.

In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.

When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.

Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.