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March 2020 Volume 14 / Number 3

INSIDE GALAD score FROM THE AGA JOURNALS predicts USMSTF publishes polypectomy guidance Recommendations aim to NASH-HCC improve complete endoscopic resection More than a year in advance rates. • 6 enter

C BY WILL PASS sensitivity of ultrasound, Task force on CRC MDedge News reported lead author Jan ediCal updates colonoscopy M Best, MD, of the University follow-up guidance inai or patients with Hospital Magdeburg (Ger- -s Few, small adenomas can nonalcoholic steato- many), and colleagues. be treated like none. • 7 edars C Fhepatitis (NASH), the “The limitations of ul- Dr. Gil Y. Melmed reported on a quality improvement initiative that GALAD score may accu- trasound surveillance LIVER DISEASE also reduced hospitalizations and opioid use. rately predict hepatocel- alone for early detection Serum keratin 18 lular carcinoma (HCC) as of HCC are particularly early as 560 days before evident in patients with shows injury in AAH IBD quality initiative diagnosis, according to in- NASH,” the investigators Biomarker outperforms vestigators. wrote in Clinical Gastroen- MELD, other measures. The GALAD score, terology and Hepatology. • 18 slashes ED utilization which combines sex, age, “Serum-based biomarkers PRACTICE alpha-fetoprotein-L3 might be more effective, BY RICHARD MARK KIRKNER ment visit rates decline from (AFP-L3), alpha-fetopro- with or without ultra- MANAGEMENT MDedge News 18% to 14%, a 22% relative tein, and des-gamma-car- sound surveillance, for Toolbox: E/M changes decrease, Gil Y. Melmed, MD, boxyprothrombin (DCP), HCC surveillance in NASH coming for 2021 REPORTING FROM CROHN’S & COLITIS CONGRESS AGAF, of Cedars-Sinai Medi- could improve cancer sur- patients, although data in AGA outlines the coding cal Center, Los Angeles, said. veillance among NASH pa- this patient population are updates. • 21 AUSTIN, TEX. – A quality Additionally, the study doc- tients whose obesity limits See NASH-HCC · page 3 improvement initiative aimed umented a similar decrease in the rate of hospitalization, bowel disease (IBD) has re- declining from 14% to 11%, IBD: Inpatient opioids linked ducedat patients emergency with inflammatory department while narcotic utilization visits and hospitalizations by rates declined from 8% to with outpatient use by IBD patients 20% or more and slashed opi- 4%. “We also found decreases oid use by half, according to in special-cause variation in BY WILL PASS rospective analysis of more en’s Hospital, Boston, and study results presented at the other measures of interest, MDedge News than 800 patients. colleagues. Crohn’s & Colitis Congress®, including CT scan utilization Awareness of this “Recent evidence has a partnership of the Crohn’s as well as corticosteroid use, - dose-dependent relation- demonstrated that opi- & Colitis Foundation and the which was reduced 29% Pmatory bowel disease ship and IBD-related risks of oid use is associated with American Gastroenterological during the course of the pro- (IBD)atients who withreceive inflam opioids opioid use should encourage severe infections and in- Association. gram,” he said. while hospitalized are physicians to consider alter- creased mortality among After 15 months, the qual- The quality initiative three times as likely to be native analgesics, according IBD patients,” the inves- ity improvement program was conducted through prescribed opioids after to lead author Rahul S. Dalal, tigators wrote in Clinical showed emergency depart- See Quality · page 13 discharge, based on a ret- MD, of Brigham and Wom- See Opioids · page 13

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01_3_4_5_11_12_13_GIHEP20_3.indd 1 2/21/20 3:15 PM †NEWS LETTER FROM THE EDITOR: Crohn’s & Colitis Congress has passed, DDW ahead Quick quiz guidance. In our practice manage- Q1. A 45-year-old man has monitoring of the ALT and HBV n late January, the Crohn’s & Coli- ment section, we provide a step-by- recently been diagnosed with DNA. tis Foundation teamed with AGA step guide to changes in evaluation leukemia. The chemotherapeutic to present the Crohn’s & Colitis and management (E/M) coding regimen will include rituximab Q2. An 18-year-old woman I ® Congress in Austin, Tex. Each year, – these changes are the most im- and high-dose steroids. He is presents for evaluation of chronic this is the premier gath- pactful since the Medicare a former IV drug user but has diarrhea, fatigue, and abdominal ering for IBD experts and E/M documentation speci- been sober for 20 years. His lab cramping. She was recently in the rest of us to catch work is as follows: ALT 25 U/L, Puerto Rico for 6 months visiting up on the substantial We have 2 months left HAV total antibody positive, HBs family and returned a few weeks progress we are making beforefications Digestive first appeared. Disease antibody positive, HBs antigen in treating patients with Week® (DDW). Each negative, HBc total positive, HCV a hemoglobin of 11 g/L with an IBD. This month, we year, DDW marks the antibody positive, HCV RNA un- MCVago. Her of 109 labs fL. are Her significant albumin foris 3.6 highlight a number of ar- end of our AGA Institute detected. g/dL. She had stool studies which ticles from the Congress, President’s term and the ruled out infection, including including results show- beginning of another’s Which of the following is true? parasites. TtG IgA and total IgA ing how a focused IBD Dr. Allen epoch. Hashem B. El-Se- A. The patient is at risk of HCV were within normal limits. EGD quality initiative reduced rag will pass the gavel to reactivation because of prior with multiple duodenal biopsies emergency department visits, an Bishr Omary – both great friends exposure. showed villous blunting with article about the effects of IBD on and great gastroenterologists. I B. The patient should receive increased intraepithelial lympho- fertility, and the link between stress am happy to see that Gail Hecht prophylaxis against HBV re- cytes. follows me as this year’s AGA Ju- verse seroconversion through these articles are worth reading, lius Friedenwald Medal recipient his chemotherapy. What is the preferred treatment sinceand ulcerative they can helpcolitis our flares. care All of pa-of (AGA’s highest honor). She, too, is C. The patient should receive pro- for this patient? tients. On agau.gastro.org, you can a great friend and role model for phylaxis against HBV reverse A. Gluten-free diet access slides from the Congress. me and many others. DDW returns seroconversion through his B. Ceftriaxone IV followed by Bac- Several more articles deserve to Chicago in early May, and once chemotherapy and for 12-18 trim PO mention. Three articles from the again will be the world’s best gath- months afterward. C. Low FODMAP diet AGA journals highlight new infor- ering of physicians and scientists D. The HBV reactivation is not a D. Tetracycline and folic acid mation about colorectal cancer pre- dedicated to digestive diseases. concern in this patient. E. Rifaxmin vention and the U.S. Multi-Society E. A watchful waiting approach Task Force on Colorectal Cancer John I. Allen, MD, MBA, AGAF is reasonable with q 3-month The answers are on page 6. has updated colonoscopy follow-up Editor in Chief

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Editor in ChiEf, Gi & hEpatoloGy nEws Gi & hEpatoloGy nEws is the official newspaper of the American frontlinE mEdiCal CommuniCations soCiEty partnErs John I. Allen, MD, MBA, AGAF Gastroenterological Association (AGA) Institute and provides the Executive Editor Kathy Scarbeck Editor in ChiEf, thE nEw GastroEntEroloGist gastroenterologist with timely and relevant news and commentary about Editor Lora T. McGlade Vijaya L. Rao, MD clinical developments and about the impact of health care policy. Content for Creative Director Louise A. Koenig assoCiatE Editors Gi & hEpatoloGy nEws is developed through a partnership of the newspaper’s Megan A. Adams, MD, JD, MSc medical board of editors (Editor in Chief and Associate Editors), Frontline Director, Production/Manufacturing Rebecca Slebodnik Ziad Gellad, MD, MPH, AGAF Medical Communications Inc. and the AGA Institute Staff. “News from the National Account Manager Artie Krivopal, 973-290-8218, Kim L. Isaacs, MD, PhD, AGAF AGA” is provided exclusively by the AGA, AGA Institute, and AGA Research cell 973-202-5402, [email protected] Gyanprakash A. Ketwaroo, MD, MSc Foundation. All content is reviewed by the medical board of editors for Digital Account Manager Rey Valdivia, 973-206-8094, Larry R. Kosinski, MD, MBA, AGAF accuracy, timeliness, and pertinence. To add clarity and context to important [email protected] Sonia S. Kupfer, MD developments in the field, select content is reviewed by and commented on by Wajahat Mehal, MD, PhD external experts selected by the board of editors. Senior Director of Classified Sales Tim LaPella, 484-921-5001, [email protected] The ideas and opinions expressed in Gi & hEpatoloGy nEws do not Editors EmEritus, Gi & hEpatoloGy nEws necessarily reflect those of the AGA Institute or the Publisher. The AGA Advertising Offices 7 Century Drive, Suite 302, Parsippany, Colin W. Howden, MD, AGAF Institute and Frontline Medical Communications Inc. will not assume NJ 07054-4609 973-206-3434, fax 973-206-9378 Charles J. Lightdale, MD, AGAF responsibility for damages, loss, or claims of any kind arising from or related Editorial Offices 2275 Research Blvd, Suite 400, Rockville, MD 20850, Editor EmEritus, thE nEw GastroEntEroloGist Bryson Katona, MD, PhD to the information contained in this publication, including any claims related 240-221-2400, fax 240-221-2548 to the products, drugs, or services mentioned herein. Advertisements do aGa institutE staff not constitute endorsement of products on the part of the AGA Institute or Managing Editor, GI & HepatoloGy News, Brook A. Simpson Frontline Medical Communications Inc. Managing Editor, tHe New GastroeNteroloGIst, Ryan A. Farrell POSTMASTER Send changes of address (with old mailing label) to GI & Senior Publications Coordinator Jillian L. Schweitzer Hepatology News, Subscription Service, 10255 W Higgins Road, Suite 280, FRONTLINE MEDICAL COMMUNICATIONS Director of Publications Lindsey M. Brounstein Rosemont, IL 60018-9914. Corporate Vice President of Publications Erin C. Landis RECIPIENT To change your address, contact Subscription Services at 1-800-430- VP, Sales Mike Guire offiCErs of thE aGa institutE 5450. For paid subscriptions, single issue purchases, and missing issue claims, VP, Digital Content & Strategy Amy Pfeiffer President Hashem B. El-Serag, MD, MPH, AGAF call Customer Service at 1-833-836-2705 or e-mail custsvc.gihep@ President, Custom Solutions JoAnn Wahl President-Elect M. Bishr Omary, MD, PhD, AGAF fulcoinc.com VP, Human Resources & Facility Operations Carolyn Caccavelli Vice President John M. Inadomi, MD, AGAF The AGA Institute headquarters is located at 4930 Del Ray Avenue, Circulation Director Jared Sonners Secretary/Treasurer Lawrence S. Kim, MD, AGAF Bethesda, MD 20814, [email protected]. Director, Custom Programs Patrick Finnegan Gi & hEpatoloGy nEws (ISSN 1934-3450) is published monthly for ©2020 by the AGA Institute. All rights reserved. No part of this publication $230.00 per year by Frontline Medical Communications Inc., Scan this QR In affiliation with Global Academy for Medical Education, LLC may be reproduced or transmitted in any form or by any means, electronic or 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609. Code to visit President David J. Small, MBA mechanical, including photocopy, recording, or any information storage and Phone 973-206-3434, fax 973-206-9378 mdedge.com/ retrieval system, without permission in writing from the publisher. gihepnews

2 March 2020 / GI & Hepatology News

02_6_7_8_9_10_GIHEP20_3.indd 2 2/21/20 3:15 PM †FROM THE AGA JOURNALS Detects HCC separate from cirrhosis here has been increasing ingly accounts for HCC cases in NASH-HCC from page 1 Trecognition that ultra- the Western world but has been sound-based HCC sur- underrepresented in currently lacking. The current study any-stage and early-stage HCC veillance in patients assessed the performance of the – remained high regardless of with cirrhosis has it is reassuring to know GALAD score for early HCC detec- cirrhosis status. Among patients suboptimal sensitivi- thatprior GALAD studies. appears Therefore, to tion in patients with NASH-related have high sensitivity and liver disease.” The study consisted of two parts: forwith early-stage cirrhosis, theHCC. AUC For for patients any- particularlyty and specificity when for stage HCC was 0.93, and 0.85 appliedearly HCC to detection,those with specificity in this patient nonalcoholic steato- group. However, while prospectivefirst, a retrospective trial that case-control implemented without cirrhosis, GALAD was - hepatitis (NASH). thesethe data results by Best in larger et al. are theanalysis, GALAD and score second, in a areal-world phase 3 tionslightly of any-stage more predictive, and early- based on These data highlight Dr. Singal cohortpromising, studies validation is needed of population. AUC’s of 0.98 and 0.94 for detec the critical need for before routine adoption The retrospective component these accuracy values significantly novel biomarkers to improve of the study involved 126 NASH stageoutmatched HCC, respectively. each serum Again,measure- early HCC detection and reduce - ment in isolation. in clinical practice. Fortunately, NASH patients without HCC (con- “These data on NASH-HCC pa- and colleagues evaluated a maturationDetection Research of phase Network 3 biomark patients with HCC (cases) and 231 tients demonstrate that GALAD can mortality. The study by Dr. Best er cohorts, including the Early eight centers in Germany. The me- detect HCC independent of cirrhosis trols), all of whom were treated at andblood-based found that biomarker it was able panel, to de- Hepatocellular Early Detection higher among NASH patients with - tectGALAD, HCC in at patients an early with stage NASH with a thisStrategy evaluation (EDRN in HEDS) the near and fu- Texas dian GALAD score was significantly rhoticor stage NASH-HCC of HCC,” the seems investigators clearly sep- tureHCC andConsortium, will hopefully will facilitate translate P less than .001). At wrote. “Indeed, even early noncir - promising biomarkers into clini- HCC than in those without (2.93 small groups resulted in robust sensitivity of 68% and specificity cal practice. GALADvs. –3.96; score predicted HCC with performance.”arable from NASH controls, as even abdominalof 95% – performance ultrasound. compaIn an aan sensitivity optimal cutoff of 91.2% of –1.334, and a thespec- The prospective component of rable,accompanying if not superior, pilot prospective to that of Amit G. Singal, MD, is an associ- ate professor of medicine, med- of the GALAD score aligned with patients with NASH at a single found GALAD may detect HCC ical director of the liver tumor ificity of 95.2%. Each component treatmentthe study involved center in screening Japan. From 392 morecohort than study, 1 year the authorsprior to alsodiag- program, and chief of hepatology patients with HCC were predom- nosis. Although earlier studies at UT Southwestern Medical Cen- inantlypreviously older published men with findings, elevated as HCC after a median of 10.1 years. had similarly demonstrated high ter, Dallas. He has served as a Manythis cohort, patients 28 inpatients this group developed had performance of GALAD for early consultant for Wako Diagnostics, a closer look at the data showed - Glycotest, Exact Sciences, Roche thatserum the AFP-L3, GALAD AFP, score and more DCP. accu- But - Diagnostics, and TARGET Phar- rately predicted HCC than any of significantly higher GALAD scores NASHHCC detection, – a cohort this that study increas- spe masolutions. its constituent serum measure- sharplyfor 5 or inmore the yearsmonths before preceding being di cifically examined patients with ments in isolation. For any stage diagnosis.agnosed with Depending HCC, and on scores selected rose - or to individual serum markers The study was funded by Deutche - of HCC, GALAD had an area under priorcutoff to value, diagnosis. the GALAD score pre independent of tumor stage or the curve (AUC) of 0.96, compared dicted HCC from 200 to 560 days for detection of HCC in NASH, Werner Forschungsgemeinschaft, Jackstaedt Foundation. the Wil The with significantly lower values for “The findings suggest that GALAD helm-Laupitz Foundation, and the AFP (0.88), AFP-L3 (0.86), and DCP “While this specific result has to- shouldcirrhosis,” be investigatedthe investigators as a po-wrote. of interest. (0.87). Similarly, for early-stage - tionbe confirmed for potential in further use of GALADprospective as tential tool for screening of NASH investigators [email protected] no conflicts HCC, GALAD score AUC was 0.92, studies, it is a promising observa individuals to detect HCC at a compared with significantly low the investigators wrote. resectable stage in a sufficiently SOURCE: Best J et al. Clin Gastro erThe values accuracy for AFP of (0.77), the GALAD AFP-L3 a screening tool in NASH patients,” large prospective study to identify Hepatol. 2019 Nov 8. doi: 10.1016/j. score(0.74), – and for detectionDCP (0.87). of both that the GALAD score is superi- a cutoff.” cgh.2019.11.012. “In conclusion, our data confirm Mailed fecal tests may catch more cancer than endoscopic testing

BY WILL PASS ing programs over multiple rounds with long- MDedge News term follow-up.” researchterdam, the has Netherlands, shown that andsuccessful colleagues. FIT screen- - ingIn depends addition upon to high continued participation, adherence previous to the screening-naive people in the Netherlands to Ohistochemical tests (FITs) may catch more To this end, the investigators invited 30,052 casesn ofa populationadvanced neoplasia level, mailed than fecal endoscopic immuno Clinical Gastroenterology and Hepatology. They was for one of three groups: once-only colo- screening program, the investigators wrote in participate in the present study. Each invitation - of FIT were needed to outperform endoscopic four rounds of FIT. All individuals received an ticipate.methods, based on a Dutch screening study noted that, in the present study, just two rounds noscopy, once-only flexible sigmoidoscopy, or thatThe invited relative more success than of 30,000mailed FITpeople screening to par later by a more substantial information kit (and - methods,“No literature and that is availablethese comparative on the comparison findings advanced notification by mail followed 2 weeks betweenare a first endoscopic for the field. screening strategies and was largely due a participation rate of 73%, com - weeksfirst FIT later. test when applicable). If these steps pared with participation rates between 24% and gators wrote. “It is of key importance for policy receivedParticipants no response, in the FIT a reminder group received was sent one 6 test 31% among those invited to undergo endoscopic- makersmultiple to rounds know ofthe FIT impact screening,” of different the investi screen- Continued on following page screening, reported lead author Esmée J. Grobbee, MD,MDedge.com/gihepnews of Erasmus University Medical / March Centre 2020 in Rot 3

01_3_4_5_11_12_13_GIHEP20_3.indd 3 2/21/20 3:15 PM †FROM THE AGA JOURNALS Large study probes colonoscopy surveillance intervals

BY WILL PASS MDedge News Tadults into high- and low-risk groups based adenoma risk, individuals with serrated polyps ompared with patients who he current CRC surveillance paradigm stratifies tection rates. However, to examine conventional have normal baseline colo- postcolonoscopy CRC incidence to support this ap- is unclear. Since New Hampshire Colonoscopy C proach.on index Lee findings. et al. provided However, valuable there are long-term few data dataon wereRegistry excluded data demonstrate and thus the a impact higher ofrisk these of meta- lesions low-risk adenomas may not have in their retrospective analysis of data from chronous advanced adenomas for those elevatednoscopy risks offindings, colorectal those cancer with an integrated health organization. While with both sessile serrated polyps and (CRC) or CRC-related death, based high-risk adenomas, long-term CRC data on a retrospective analysis of more with an increased CRC risk, compared with for serrated polyps is crucial. In addition, than 64,000 patients. noindex adenomas, high-risk low-risk adenomas adenomas were associated (LRA; data from short-term studies suggest that In contrast, patients with high- 1-2 tubular adenomas less than 1 cm) had there may be heterogeneity in risk for risk adenomas at baseline had no increased risk. A lower CRC mortality in LRAs, a higher risk for an 8-mm lesion those with LRAs decreased the likelihood than a 3-mm one. Thus, we await more CRC and CRC-related death, report- that CRCs resulted from overdiagnosis long-term studies to address these and edsignificantly lead author elevated Jeffrey ratesK. Lee, of MD,both of or lead time bias caused by differences other issues. Kaiser Permanente San Francisco Dr. Anderson and colleagues. subsequent surveillance colonoscopies, a Joseph C. Anderson, MD, MHCDS, is an as- With additional research, these incommon exposure issue among in long-term the three studies. groups Theseto data add sociate professor of medicine at White River Junction to growing evidence, such as that from the Prostate, VAMC, Dartmouth College, Hanover, N.H., and the surveillance intervals, the investiga- Lung, Colorectal and Ovarian Cancer Trial, that sup- University of Connecticut Health Center, Farmington, torsfindings wrote may in influenceGastroenterology. colonoscopy port lengthening current surveillance intervals for Conn. The contents of this work do not represent the “Current guidelines recommend LRAs. views of the Department of Veterans Affairs or the that patients with a low-risk ade- Study strengths include a large sample and in- United States Government. He has no relevant con- clusion of quality measures such as adenoma de- flicts of interest. colonoscopy in 5-10 years, although innoma practice, finding clinicians ... receive often surveillance use even more frequent surveillance ... in this trials evaluating optimal postpolyp- patients remained. Among these After a median follow-up of 8.1 low-risk group,” they wrote. “The ectomy surveillance intervals.” patients, the mean age was 61.6 years, 117 patients who had normal rationale for continued support of To alleviate this knowledge gap, years, with a slight female major- shorter-than-recommended sur- the investigators began by screen- ity (54.3%). Almost three out of CRC, 22 of whom died from the dis- veillance intervals for patients with ing data from 186,046 patients who four patients (71.2%) had normal ease.colonoscopy In comparison, findings the developed low-risk low-risk adenomas is unclear, but underwent baseline colonoscopy adenoma group had 37 cases of could stem from a lack of long-term between 2004 and 2010 at 21 med- by smaller proportions who were CRC and 3 instances of CRC-related population-based studies assessing ical centers in California. Following diagnosedcolonoscopy with findings, low-risk followed adenoma death, whereas the high-risk adeno- colorectal cancer incidence and (17.0%) or high-risk adenoma ma group had 60 cases of CRC and related deaths following low-risk confounding gastrointestinal dis- (11.7%), based on United States 13 instances of CRC-related death. adenoma removal or randomized eases,exclusions and incompletebased on family data, history, 64,422 Multi-Society Task Force guidelines. Continued on following page

Continued from previous page of CRC than either of the other two groups (0.6% every 2 years. Patients who had a positive FIT vs. 0.2% for both). In contrast, colonoscopy and “Comparing CRC detection rates of FIT and (hemoglobin concentration of at least 10 mcg sigmoidoscopy had higher detection rates for findings require careful interpretation.… because CRCs Hb/g feces) were scheduled for a colonoscopy. nonadvanced adenomas, at 5.6% and 3.7%, re- detected in FIT screening could in theory have Similarly, colonoscopies were performed in pa- spectively, compared with 3.2% for FIT, although beenendoscopic prevented screening in a once-only is complex colonoscopy by the investigators noted that nonadvanced adeno- the removal of adenomas,” they wrote. sigmoidoscopy (e.g., sessile serrated adenoma). Still, the key takeaway of the study – that FIT Thistients sequential who had concerningsystem reduced findings the onrelative flexible screening was the most effective strategy – may number of colonoscopies in these two groups; At a population level, FIT screening have practical implications on a global scale, ac- had the highest advanced neoplasia cording to the investigators. sigmoidoscopy group were 13% and 3%, respec- “Because many countries are considering im- tively,colonoscopy compared rates with in the the FIT 24% group participation and flexible rate detection rate, at 4.5%. in the colonoscopy group. this study aid in deciding on choice of screening At a population level, FIT screening had the plementing screening programs, the findings of- highest advanced neoplasia detection rate, at 4.5%, mas are “of uncertain clinical importance.” Ses- ed participation rates and available colonoscopy compared with 2.3% and 2.2% for screening by sile adenoma detection rates were similar across resources,”strategies worldwide, they wrote. which is based on expect sigmoidoscopy and colonoscopy, respectively. all three groups. The study was funded by the Netherlands “In the intention-to-screen analysis, FIT al- The as-screened analysis revealed higher Organization for Health Research and Develop- - detection rates of advanced neoplasia for colo- plasia and colorectal cancer (CRC) after only 2 noscopy (9.1%), compared with sigmoidoscopy interest. roundsready detected of FIT, and significantly this difference more increasedadvanced overneo (7.4%) and FIT (6.1%). In the same analysis, ment. The investigators [email protected] no conflicts of rounds,” the investigators noted. detection rates of colorectal cancer were compa- Again in the intention-to-screen population, rable across all three groups. SOURCE: Grobbee EJ et al. Clin Gastro Hepatol. 2019 Aug mailed FIT detected three times as many cases According to the investigators, the CRC-related 13. doi: 10.1016/j.cgh.2019.08.015.

4 March 2020 / GI & Hepatology News

01_3_4_5_11_12_13_GIHEP20_3.indd 4 2/25/20 10:49 AM Continued from previous page comparable cancer incidence and “Additional studies, potentially National Cancer Institute and the In the no-adenoma and low-risk including randomized trials, on the American Gastroenterological Asso- groups, trends in age-adjusted groups,” they wrote. natural history of low-risk adenoma ciation. The investigators disclosed CRC incidence rates were similar; mortalityStill, the benefits investigators for these noted two - in both cohorts, CRC incidence in- that study limitations – such as vening surveillance exams before [email protected] creased gradually over the decade disparate rates of subsequent colo- 10and years normal are findings needed withoutto help guide inter no conflicts of interest. following colonoscopy, with each noscopy between groups – make future surveillance practices,” they SOURCE: Lee JK et al. Gastroenterol- group reaching approximately 50 - concluded. ogy. 2019 Oct 4. doi: 10.1053/j.gas- cases per 100,000 person-years by tice-changingRHTC180 conclusions. Pre-launch 1pg Journal Ad GIHepNewsThe studyFINAL 111719.pdf was supported 1 11/17/19 by the 7:53 AMtro.2019.09.039. year 10. In contrast, CRC incidence it difficult to draw definitive, prac climbed rapidly in the high-risk adenoma group, ultimately peaking a decade later at almost 220 cases per 100,000 person-years. Aver- age incidence rates per 100,000 It's time for a different approach person-years were similar among patients with no adenoma (31.1) to combat H. pylori and low-risk adenoma (38.8), but markedly higher among those with high-risk adenoma (90.8). At the end of the 14-year follow-up pe-

Average incidence rates per 100,000 person-years were The FDA classifies similar among patients with no H. pylori as a potential adenoma (31.1) and low-risk 1 adenoma (38.8). In contrast, CRC public health threat incidence climbed rapidly in the high-risk adenoma group, ultimately peaking a decade later at almost 220 cases 90% per 100,000 person-years. of noncardia gastric cancers are H. pylori-related2 riod, absolute risks of CRC among patients with no adenoma, low-risk adenoma, and high-risk adenoma were 0.51%, 0.57%, and 2.03%, re- spectively. Based on covariate-adjusted Cox regression models, patients with >30% low-risk adenoma did not have a resistance found in a 2016 U.S. multicenter study analysis CRC-related death than did patients of H. pylori strains3 withsignificantly no adenoma. higher In risk contrast, of CRC pa- or tients with high-risk adenoma had

(hazard ratio, 2.61) and CRC-relat- edsignificantly death (HR, higher 3.94). risks of CRC recommendations for intensive ≈ colonoscopy“These findings surveillance support in guideline [pa- 3x tients with high-risk adenomas at likelihood of treatment failure baseline],” the investigators wrote. of clarithromycin triple therapy Considering similar risks between with clarithromycin-resistant patients with low-risk adenomas strains3

investigators suggested that longer surveillanceand those with intervals normal may findings, be ac- the ceptable for both of these patient populations. 1. U.S. Food & Drug Administration. CFR—Code of Federal Regulations Title 21. Section 21CFR317.2. 2. Moss S. The “Guidelines recommending com- clinical evidence linking Helicobacter pylori to gastric cancer. Cell Mol Gastroenterol Hepatol. 2017;3(2):183-191. 3. Park JY, Dunbar KB, Mitui M, et al. Helicobacter pylori clarithromycin resistance and treatment failure are common in the USA. parable follow-up for low-risk ad- Dig Dis Sci. 2016;61:2373-2380. enomas and normal examinations, ©2019 RedHill Biopharma Ltd. All rights reserved. DS/0002 10/2019 such as lengthening the surveil- lance interval to more than 5 years and possibly 10 years, may provide

MDedge.com/gihepnews / March 2020 5

01_3_4_5_11_12_13_GIHEP20_3.indd 5 2/21/20 3:15 PM †FROM THE AGA JOURNALS U.S. Multi-Society Task Force publishes polypectomy guidance Quick quiz BY WILL PASS For nonpedunculated lesions between 10 MDedge News and 19 mm, guidance is minimal. The panelists answers recommended cold or hot snare polypectomy, he U.S. Multi-Society Task Force (USMSTF) although this statement was conditional and Q1. Correct answer: C on Colorectal Cancer recently published Trecommendations for endoscopic removal Recommendations were more extensive for Rationale of precancerous colorectal lesions. largebased nonpedunculated on low-quality evidence. lesions (at least 20 mm). This patient has been exposed to HBV in According to lead author Tonya Kaltenbach, For such lesions, the panelists strongly recom- the past and has cleared the virus. The MD, of the University of California, San Francis- mended endoscopic mucosal resection (EMR). HBVcore total Ab is indicative of prior expo- co, and fellow panelists, the publication aims They emphasized that large lesions should be re- sure while the HBV surface Ab is detectable to improve complete resection rates, which can moved in the fewest possible pieces by an appro- and gives immunity against reinfection un- vary widely between endoscopists; almost one priately experienced endoscopist during a single der most routine clinical scenarios. Patients out of four lesions (22.7%) may be incompletely colonoscopy session. The panelists recommended who have been exposed to HBV still have removed by some practitioners, leading to high- the use of a viscous injection solution with a con- HBV ccc DNA within their hepatocytes that er rates of colorectal cancer. trast agent and adjuvant thermal ablation of the is dormant, but under extreme combined “[A]lthough the majority (50%) of postcolo- post-EMR margin. They recommended against B- and T-cell immunosuppression, the pa- noscopy colon cancers [are] likely due to missed the use of tattoo as a submucosal injection solu- tients are at risk for reverse seroconversion tion, and ablation of residual lesion tissue that where they can lose HBV surface Ab and [are] related to incomplete resection,” the pan- is endoscopically visible. Additional recommen- manifest HBV surface antigen and present elistslesions, wrote close in to Gastroenterology, one-fifth of incident referring cancers to a dations for large lesions, including prophylactic as an acute HBV infection. Prophylaxis is pooled analysis of eight surveillance studies. closure of resection defects and coagulation tech- The panelists’ recommendations, which were 12-18 months after therapy because of the based on both evidence and clinical experience, For pedunculated lesions greater than 10 mm, long-lastingrequired during effects therapy of anti–B and cellfor atmonoclo- least theniques, panelists were basedrecommended on low-quality hot snare evidence. polyp- nal antibodies like rituximab. Reactivation ectomy. For pedunculated lesions with a head of HCV in HCV Ab–positive, RNA-negative ofrange polypectomies. from specific Each polyp statement removal istechniques described to greater than 20 mm or a stalk thickness greater patients has not been reported. byguidance both strength for institution-wide of recommendation quality assuranceand level than 5 mm, they recommended prophylactic me- of evidence, the latter of which was determined chanical ligation. Reference by Grading of Recommendations, Assessment, Beyond lesion assessment and removal, rec- 1. Pauly MP, Tucker LY, Szpakowski JL, et al. Incidence of hepati- tis B virus reactivation and hepatotoxicity in patients receiving Development, and Evaluation Ratings of Evidence - long-term treatment with tumor necrosis factor antagonists. (GRADE) criteria. Recommendations were writ- Clin Gastroenterol Hepatol. 2018 Apr 24. doi: 10.1016/j. ten by a panel of nine experts and approved by ommendations addressed lesion marking, equip cgh.2018.04.033. the governing boards of the three societies they ment, surveillance, and quality of polypectomy.- represented – the American College of Gastro- anceConcerning program quality,that documents the panelists adverse recommended events, Q2. Correct answer: D enterology, the American Gastroenterological thatand thatendoscopists institutions participate use standardized in a quality polypecto- assur Association, and the American Society for Gastro- my competency assessments, such as Cold Snare Rationale intestinal Endoscopy. The recommendations were Polypectomy Competency Assessment Tool and/ This patient has tropical sprue based on copublished in the March issues of the American or Direct Observation of Polypectomy Skills. her travel to an endemic country, negative Journal of Gastroenterology, Gastroenterology, “Focused teaching is needed to ensure the celiac serologies, labs revealing a macrocyt- and Gastrointestinal Endoscopy. optimal endoscopic management of colorectal ic anemia and low albumin, and character- Central to the publication are recommended pol- lesions,” the panelists wrote. They went on to istic histology (villous blunting, increased suggest that “development and implementation intraepithelial lymphocytes). Treatment is - - with tetracycline and folate. Diagnosis of ypectomycal practice,” techniques the panelists for specific wrote. “Theytypes ofare lesions. often sary to optimize practice and outcomes.” driven“Polypectomy by physician techniques preference vary based widely on in how clini they of “Forpolypectomy example, qualitythe type metrics of resection may be method neces a response to treatment. A gluten-free diet were taught and on trial and error, due to the lack used for the colorectal lesion removal in the pro- istropical not appropriate, sprue is ultimately as the patient confirmed does bynot of standardized training and the paucity of pub- cedure report should be documented, and the lished evidence. In the past decade, evidence has celiac serologies. Ceftriaxone IV followed byhave Bactrim celiac disease,PO is the confirmed correct treatment by normal programsinclusion ofshould adequate be considered,” resection technique they wrote. as a for Whipple’s disease. A diet low in fer- evolved on the superiority of specific methods.” “Adversequality indicator events, includingin colorectal bleeding, cancer perfora- screening mentable oligo-, di-, and monosaccharides lesion“Optimal characteristics, techniques including encompass location, effectiveness, size, tion, hospital admissions, and the number of - safety, and efficiency,” they wrote. “Colorectal benign colorectal lesions referred for surgical ment in some patients with IBS with ab- removal method.” management, should be measured and reported. dominaland polyols bloating (FODMAPs) or pain. is Rifaximin beneficial is treat the morphology,For lesions andup to histology, 9 mm, the influence panelists the recom- optimal Finally, standards for pathology preparation and correct treatment for small-intestine bacte- mended cold snare polypectomy “due to high reporting of lesions suspicious for submucosal rial overgrowth or IBS-D. invasion should be in place to provide accurate contrast, they recommended against both cold staging and management.” References andcomplete hot biopsy resection forceps, rates which and safety have beenprofile.” associ- In The investigators reported relationships with 1. Brown IS, Bettington A, Bettington M, Rosty C. Tropical sprue: revisiting an underrecognized disease. Am J Surg Pathol. ated with higher rates of incomplete resection. Covidien, Ironwood, Medtronic, and others. 2014;38:666. Furthermore, they cautioned that hot biopsy [email protected] 2. Shah VH, Rotterdam H, Kotler DP, et al. All that scallops is not forceps may increase risks of complications and celiac disease. Gastrointest Endosc. 2000;51:717. - SOURCE: Kaltenbach T et al. Gastroenterology. 2020 Jan [email protected] thology. 18. doi: 10.1053/j.gastro.2019.12.018. produce inadequate tissue samples for histopa 6 March 2020 / GI & Hepatology News

02_6_7_8_9_10_GIHEP20_3.indd 6 2/21/20 3:15 PM †FROM THE AGA JOURNALS CRC task force updates colonoscopy follow-up guidance

BY WILL PASS mendation made at the time of the hyperplastic polyps less than 10 mm new/incident growth, incomplete MDedge News prior colonoscopy,” the task force that were located in the rectum or baseline resection, and missed neo- wrote. plasia; each of these potential causes he U.S. Multi-Society Task The most prominent recommen- recommendations are strong and may require different interventions Force on Colorectal Cancer dations of this kind concern patients basedsigmoid on colon. moderate Incidentally, evidence, these where- two for improvement.” T(CRC) recently updated rec- who undergo removal of tubular as the remaining recommendations The task force also suggested that ommendations for patient follow-up adenomas less than 10 mm in size. for serrated polyps are weak and some questions beyond risk strat- after colonoscopy and polypectomy. For patients who have one or two of based on very-low-quality evidence. The new guidance was based on these adenomas removed, the task Because of such knowledge gaps, as the impact of surveillance on CRC advancements in both research and force now recommends follow-up the investigators emphasized the incidenceification remain and mortality. unanswered, such technology since the last recommen- need for more data. The publication - dations were published in 2012, re- includes extensive discussion of gation include age-related analyses ported lead author Samir Gupta, MD, ‘Importantly, the observed risk pressing research topics and appro- thatOther incorporate suggested procedural topics of investirisk, AGAF, of the University of California, priate methods of investigation. cost-effectiveness studies, and com- San Diego, and colleagues. for fatal CRC among individuals parisons of nonendoscopic methods “[Since 2012,] a number of arti- with 1-10 adenomas less than opportunities for research to clarify of surveillance, such as fecal immu- cles have been published on risk of 10 mm is lower than average “Our review highlights several nochemical testing. of patients post-polypectomy,” the The study was funded by the Na- and patient characteristics, as well for the general population.’ risk stratification and management- asCRC the based potential on colonoscopy impact of screening findings mize risk-reduction strategies, the Department of Veterans Affairs. The and surveillance colonoscopy on mechanismstask force wrote. driving “In ordermetachronous to opti investigatorstional Institutes reported of Health relationships and the outcomes, such as incident CRC and after 7-10 years, instead of the pre- advanced neoplasia after baseline pol- polyps,” the investigators wrote in viously recommended interval of ypectomy and their relative frequency and others. Gastroenterology. “Further, recent 5-10 years. need to be better understood through with Covidien, Ironwood,[email protected] Medtronic, - “[This decision was] based on studies that include large numbers of ern era of colonoscopy with more the growing body of evidence to patients with interval cancers and/or SOURCE: Gupta S et al. Gastroenterol- awarenessstudies increasingly of the importance reflect the of mod support low risk for metachronous advanced neoplasia after baseline pol- ogy. 2020 Feb 7. doi: 10.1053/j.gas- quality factors (e.g., adequate bowel advanced neoplasia,” the task force ypectomy. Mechanisms may include tro.2019.10.026. preparation, cecal intubation, ade- quate adenoma detection, and com- for metachronous advanced neopla- plete polyp resection), and utilization siawrote. is similar “In this to population, that for individuals the risk of state of the art technologies (e.g., observed risk for fatal CRC among The task force, which comprised the individualswith no adenoma. with 1-10 Importantly, adenomas the high-definitionAmerican College colonoscopes).” of Gastroenterology, less than 10 mm is lower than aver- May 2–5, 2020 Exhibit Dates: May 3–5 the American Gastroenterological age for the general population.” McCormick Place, Chicago, IL Association, and the American Society Along similar lines, patients who www.ddw.org for Gastrointestinal Endoscopy, iden- undergo removal of three to four small adenomas now have a rec- Register by March 18 intervention, comparison, and out- ommended 3-5 year follow-up win- and save at least $85. come)tified key questions topics using before PICO conducting (patient, a dow, instead of the previously strict comprehensive literature review that recommendation for follow-up at 3 included 136 articles. Based on these years. - But not all of the new guidance is erated recommendations that were less stringent. While the task force findings, two task force members gen previously recommended a follow-up discussion. The recommendations period of less than 3 years after re- werefurther copublished refined through in the consensus March issues moval of more than 10 adenomas, AASLD, AGA, ASGE and Jan. 15, 2020 SSAT members-only of the American Journal of Gastroen- they now recommend follow-up at registration opens. General registration terology, Gastroenterology, and Gas- 1 year. This change was made to Jan. 22, 2020 opens. trointestinal Endoscopy. simplify guidance, the investigators Join us in Chicago for Digestive Disease DDW On Demand Week® (DDW), the world’s largest is Included with According to Dr. Gupta and col- wrote, noting that the evidence base registration! gathering of professionals working in the leagues, some of the new recom- in this area “has not been markedly Get access to the online fi elds of gastroenterology, hepatology, digital presentations mendations, particularly those that strengthened” since 2012. from DDW 2020 so you endoscopy and gastrointestinal surgery. advise less stringent follow-up, may Compared with the old guidance, don’t miss a session. encounter resistance. the updated publication offers more Register online at detailed recommendations for fol- www.ddw.org/registration and colonoscopists may have con- low-up after removal of serrated cerns“Patients, about primarylengthening care a physicians, previously - recommended interval, and will need narios are presented, with follow-up to engage in shared decision making polyps.ranging On from this 6 topic,months 10 after clinical piece- sce regarding whether to lengthen the meal resection of a sessile serrated follow-up interval based upon the polyp greater than 20 mm to 10 guidance here or utilize the recom- years after removal of 20 or fewer

MDedge.com/gihepnews / March 2020 7

02_6_7_8_9_10_GIHEP20_3.indd 7 2/21/20 3:15 PM NEWS FROM THE AGA GI leaders honored by AGA’s prestigious recognition prizes

GA has announced the 2020 lows, as well as faculty members via have also stimulated young learners recipients of the annual Rec- understanding of the pathogenesis his clear, concise, and well-organized to pursue careers in science. Dr. Aognition Prizes, given in hon- have significantly contributed to the lectures and presentations. Dr. Fon- Merchant is professor and chief of or of outstanding contributions and (IBD). Dr. Sartor’s seminal observa- tana is a professor of medicine, med- gastroenterology and hepatology at achievements in gastroenterology. tionsof inflammatory throughout bowel his career diseases helped ical director of liver transplantation, the University of Arizona, Tucson. “AGA Recognition Prizes allow launch the area of inquiry that led to and director of transplant hepatol- members to honor their colleagues the recognition that the microbiome ogy fellowship ACGME-accredited Research Service Award and peers for outstanding contribu- is a key to metabolic disease, IBD, training program at the University of AGA honors Peter Perrin, PhD, with - intestinal neoplasia, and hepatic Michigan, Ann Arbor. the Research Service Award, which ogy,” said Hashem B. El-Serag, MD, disorders. Dr. Sartor is the Margaret recognizes individuals whose work MPH,tions toAGAF, the fieldpresident of gastroenterol of the AGA In- W. and Lorimer W. Midgett Distin- Distinguished - stitute. “The 2020 AGA Recognition guished Professor and a professor, Clinician Awards enterological science and research. Prize winners are just a few of the departments of medicine, microbiol- The AGA Distinguished Clinician Ashas a significantly program director advanced at the gastro Na- distinguished and talented members ogy and immunology, University of Awards recognize members of the tional Institute of Diabetes, Diges- who help make AGA such an accom- North Carolina, Chapel Hill. practicing community who, by ex- tive and Kidney Diseases (NIDDK), plished organization. We are hon- ample, combine the art of medicine National Institutes of Health (NIH), ored that such esteemed individuals William Beaumont Prize with the skills demanded by the sci- Bethesda, Md., Dr. Perrin has had a are representatives of AGA.” AGA honors two individuals with huge impact on NIH-funded diges- The AGA Recognition Prizes will the William Beaumont Prize in to their patients. tive diseases research. At NIDDK, he be presented during Digestive Dis- Gastroenterology, which recognizes entificAGA presentsbody of knowledge the Distinguished in service has the largest portfolio of grants ease Week® 2020, May 1-5, 2020, in individuals who have made unique, Clinician Award in Private Practice to that have high impact in digestive Chicago, Ill. outstanding contributions of major Kimberly Persley, MD, AGAF. Dr. Per- diseases, in topics including im- - sley made a huge impact on patient munology, microbiology, infectious Julius Friedenwald Medal terology. diseases, and IBD, barrier and AGA bequeaths its highest honor, importanceDennis Ahnen, to the MD, field AGAF, of gastroen had IBD-specialty trained private practice transport functions, and AIDS/HIV. the Julius Friedenwald Medal, to made many contributions to the gastroenterologistcare in her community in the as Dallas-Fort the first Gail Hecht, MD, MS, AGAF, for her Worth, Tex., region. She was sought Outstanding Service Award out by gastroenterologists and pa- AGA honors the Funderburg fam- of gastroenterology and AGA. The patientsfield of gastroenterology through clinical andthat trans-have tients throughout the region for her ily with the Outstanding Service Juliussubstantial Friedenwald contributions Medal, to presented the field lationalsignificantly research advanced into the the pathobi- care of thorough, kind and holistic care. Dr. Award, which was created in 1972 annually since 1941, recognizes a ology of colorectal cancer and its Persley is a partner at Texas Digestive to honor an individual(s) who has physician for lifelong contributions prevention. Dr. Ahnen, has provided Disease Consultants and assistant - exemplary service to AGA. He is clinical professor of medicine at the ety’s health and welfare. The family, Dr. Hecht is internationally re- director of genetics at Gastroenter- University of Texas Southwestern whichcontributed includes significantly Rob and Cathy, to soci Alex nownedto the field for of her gastroenterology. pivotal contributions ology of the Rockies and Professor Medical School, Dallas, Tex. and Patty, and Hugh and Gail, has to the understanding of the import- Emeritus of medicine at the Univer- AGA is honored to present the ant diarrheal pathogen, enteropatho- sity of Colorado Anschutz Medical Distinguished Clinician Award in Research Foundation through their genic E. coli. She is also a passionate Campus School of Medicine, Aurora. Clinical Academic Practice, to Gary personalsignificantly philanthropy. contributed Their to the parents AGA advocate for the science and practice Peter Kahrilas, MD, AGAF, has Lichtenstein, MD, AGAF. Dr. Lichten- established the AGA – R. Robert and of gastroenterology, including serv- worked tirelessly and creatively to stein is a renowned physician, edu- Sally Funderburg Research Award in ing as AGA Institute President. Dr. characterize the function and patho- cator, and investigator whose local, Gastric Cancer in 1992. In total, the Hecht’s collegial and generous spirit, physiology of the esophagus and regional, and national prominence is family has given $3 million and with her past and continued leadership has written the esophageal papers remarkable. Patients and physicians their most recent gift, they have per- roles in AGA, her passion for and upon which a large portion of current throughout the country seek his manently endowed their research contributions to science and clin- research is based. Dr. Kahrilas has consultation and advice in IBD. Dr. award in gastric cancer. ical medicine, and her dedication also dedicated many years of service Lichtenstein is a professor of medi- The family encourages collabora- to both her patients and trainees to AGA and is currently the Gilbert cine and director of the IBD Center at tion and communication between have strengthened the specialty of H. Marquardt Professor of Medicine the University of Pennsylvania, Phila- and among the Funderburg recipi- gastroenterology, and also inspired in the division of gastroenterology delphia. ents and as a result, AGA established and shaped the next generation of at the Feinberg School of Medicine, the annual Funderburg Symposium investigators and gastroenterologists. Northwestern University, Chicago, Ill. Distinguished Mentor Award at DDW. This symposium allows Dr. Hecht is currently assistant dean, AGA bestows the Distinguished medical student research and profes- Distinguished Educator Award Mentor Award to Juanita Merchant, many of whom are past Funderburg sor of medicine and microbiology/ AGA honors Robert Fontana, MD, MD, PhD. This award recognizes an recipients,leaders in the to come gastric together cancer andfield, immunology at Loyola University Chi- with the Distinguished Educator individual who has made a lifelong learn about the latest advances and cago Stritch School of Medicine, and Award, which recognizes an indi- effort dedicated to the mentoring of a staff physician at Hines VA Medical vidual who has made outstanding - Center, Chicago, Ill. contributions as an educator in ology and for achievements as out- Youngfindings Investigatorin gastric cancer Awards research. gastroenterology on both local and standingtrainees inmentors the field throughout of gastroenter their The AGA Young Investigator Awards Distinguished Achievement national levels. Dr. Fontana’s great- careers. Dr. Merchant is an excep- recognize two young investigators, Award in Basic Science est teaching impact has been the tional mentor, providing guidance one in basic science and one in AGA recognizes R. Balfour Sartor, establishment of one of the most to multiple learners to jump start, clinical science, for outstanding re- MD, with the AGA Distinguished highly successful transplant hepatol- enhance, and guide their careers search achievements. Achievement Award in Basic Sci- ogy fellowship training programs in as scientists in gastroenterology. AGA honors Jennifer Lai, MD, ence, for his major accomplishments the country. He has taught countless Many of her trainees are faculty in MBA, with the Young Investigator in basic science research, which medical students, residents, and fel- institutions around the world who Continued on following page

8 March 2020 / GI & Hepatology News

02_6_7_8_9_10_GIHEP20_3.indd 8 2/21/20 3:15 PM NEWS FROM THE AGA Now open: Registration AGA honors today’s luminaries for DDW® 2020 and the in gastroenterology AGA Postgraduate Course elebrate with the AGA Research Rodger A. Liddle, MD igestive Disease and consolidate its repu- Foundation. David A. Lieberman, MD, AGAF Week® (DDW) is tation as the meeting that C To honor the lifelong contribu- Pankaj J. Pasricha, MD Dtaking place May 2-5, brings the brightest ideas tions and achievements of some of our Chung Owyang, MD, AGAF 2020, at McCormick Place in and breakthroughs in diges- most esteemed members, we are pleased Jean-Pierre Raufman, MD Chicago, Ill. Featuring clini- tive disease. Prepare to be to present the AGA Research Foundation’s Don C. Rockey, MD, AGAF cal care updates – presented blown away in the Windy newest program, AGA Honors: Celebrating Anil K. Rustgi, MD, AGAF nowhere else during DDW City by all that DDW has to Difference Makers in Our Field. Robert S. Sandler, MD, MPH, AGAF – the AGA Postgraduate offer: Our honorees have been chosen for their Michael L. Weinstein, MD Course will be held in con- More than 400 scientif- pivotal role in shaping the future of gas- junction with DDW on May ic sessions, organized by troenterology and hepatology. Honorees 2 and 3. You can register for educational tracks and span the gamut from mentors and C. Mel Wilcox, MD both together. Visit DDW.org presented in a wide range researchers to administrators and and AGA University, agau. of session formats. New ses- clinicians and educators across a gastro.org, to learn more sions include an AGA Clini- myriad of disciplines: about each. cal Plenary, Topic-Focused Workshops on hypnosis John I. Allen, MD, MBA, AGAF Improve patient care techniques and nutrition, C. Richard Boland, MD, AGAF The AGA Postgraduate Martin Brotman, MD, AGAF Course is a comprehensive in the DDW Trainee and Michael Camilleri, MD, AGAF We invite you to learn more about our 1.5-day program highlighting Earlyand expanded Career Lounge. programming Eugene B. Chang, MD, AGAF honorees and to celebrate their contribu- ground-breaking advances Opportunities to connect Sheila Crowe, MD, AGAF in the delivery of high-qual- with over 14,000 attendees Francis M. Giardiello, MD, AGAF the AGA Research Foundation. Visit our ity, patient-centered GI care. from around the world, in- Fred S. Gorelick, MD tionswebsite to theat http://foundation.gastro.org/ field by making a donation to Attendees will participate in Gail A. Hecht, MD, AGAF aga-honors-celebrating/. dynamic case-based sessions, Continuing Conversation Wayne I. Lencer, MD, AGAF [email protected] learning lunches, and panel blocks,cluding immediatelytop GI experts. follow- New discussions, and will walk ing select invited-speaker away with best practices for sessions, allow you time to treating a variety of disease network with presenters Diversify GI: Mayra Sanchez states and digestive disorders. and fellow attendees. - e’re celebrating diversity in our “The practice of gastroenterology allows The brightest ideas ing new innovations and W me to understand mind-body interactions and breakthroughs technologiesAn Exhibit Hallthat spotlightyou can members of the AGA Diversity Commit- and to appreciate how each person’s life in digestive disease implement in your practice. tee andfield AGA with FORWARD a new series Program. spotlighting - DDW continues to improve [email protected] Born and raised in Cuba, Mayra San- tributes to her or his digestive health.” chez, MD, came to this country as an experiences and emotional well-being con adult, with little money in her pocket Let’s get personal Continued from previous page ology and hepatology, at the and no recognition of her previous med- What are you most proud of in your ca- Award in Clinical Science. University of California, San reer? “I am proud that I built a very large, Dr. Lai has pioneered a re- Francisco. her story is not uncommon. very busy, state-of-the-art motility prac- search program in frailty in AGA honors Nobuhiko ical training. Unfortunately, she explains,- tice at Yale University. Despite the fact hepatology that is changing Kamada, PhD, with the sity Committee to ensure there is recogni- that we have one of the biggest motility the way that gastroenter- Young Investigator Award in “I first got involved with the AGA Diver practices on the East Coast, we also pride ologists and hepatologists Basic Science. Dr. Kamada nontraditional paths such as this.” ourselves on our dedication to patient manage patients with liver is known for his innovation tionHer of professional those who come hero tois ourDr. Guadalupe field from care and patient satisfaction.” disease. She has carved out - Garcia-Tsao, a senior hepatologist at Yale. ... In your personal life? “In my personal a niche at the junction of ag- ing the microbiota and the “She is inspiring as an engaging teacher life, I am proud to have two beautiful chil- ing and hepatology research immunecombining system fields in examin IBD, and as a role model for practicing cut- dren and a wonderful husband who serve that is particularly timely - ting-edge medicine, but she also is my as constant reminders of the importance - tween diet, commensal and hero because she was able to rise to a of life outside of the workplace.” tients with cirrhosis being pathogenicspecifically, microbes,the interplay and be leadership position despite the challenges What’s your favorite part of your job? seengiven in the clinical influx practice, of older paas the immune system. He has of being a minority.” “Making a difference in people’s lives, espe- well as the rapid rise in cir- An issue affecting underrepresented cially when others have not been able to.” rhotic patients with multiple that have been highly cited minorities at the top of her radar is the What do you know now that you wish co-morbidities and frailty withinpublished short stellar periods findings of time need for more mentorship. someone told you when you started your seeking liver transplanta- because of their innovation. While serving on the committee, she career? “The importance of persistence tion. Dr. Lai is an associate Dr. Kamada is an assistant also wants to stimulate a deeper under- cannot be overstated.” professor of medicine in professor in the division of standing among colleagues of the value If I weren’t in gastroenterology, I would residence and director of gastroenterology at the Uni- people bring by virtue of their different be ... “a writer.” the Advancing Research in versity of Michigan Medical backgrounds, both in the gastroenter- In my free time I like to ... “travel with Clinical Hepatology Group in School, Ann Arbor. the division of gastroenter- [email protected] patients. ginews@gastro ology and hepatology fields, and in GI my family to experience new cultures.” MDedge.com/gihepnews / March 2020 9

02_6_7_8_9_10_GIHEP20_3.indd 9 2/25/20 10:53 AM NEWS FROM THE AGA AGA congressional champion Phil Roe announces retirement

Top AGA - Long-term AGA congressional - constituents and his colleagues in champion and fierce physi the House of Representatives as Community cian-community advocate Con a valued and respected leader- on gressman Phil Roe (R, Tenn.), MD, health care issues. He currently patient cases announced that he will not seek serves as the top-ranking Re re-election in the upcoming 2020 publican on the Veteran’s Affairs election. Following his retirement Committee and as co-chair of announcement, Congressman Roe both the House Doctor’s Caucus - communicated to AGA and fellow - and the Congressional Academic Physicians with difficult patient- health care organizations that he is Medicine Caucus. His primary fo scenarios regularly bring their still committed to ensuring the suc cus as a member of Congress has questions to the AGA Com cess of the prior authorization bill, always been on health care issues munity (https://community.gastro.- H.R.Congressman 3107, before Roe leaving served Congress. both his – many of which include AGA’s org) to seek advice from colleagues constituents and his colleagues topGI winspolicy with priorities. Roe about therapy and disease manage

ment options, best practices, and in the House of Representatives - domain

diagnoses. In case you missed it, as a valued and respected Sustainable Growth Rate (SGR). public here are the most popular clinical Congressman Roe was an instru / discussions shared in the forum leader on health care issues. mental figure in the bipartisan -

recently: victory to repeal the flawed oakridge -

Medicare physician payment for- doe 1. Adherence to noninvasive mula, in 2015. Throughout the Congressman Phil Roe CRC screening (http:// Congressman Roe, who was deliberation of SGR repeal legis - ow.ly/6eng30qfUKq). first elected to Congress in 2008 lation, he stayed in close contact 2. eQ&A with Guideline authors: and is currently serving his sixth with physician groups and active Management of gastric intestinal term, is an OBGYN by trade who ly whipped House members for advocacy on the issue. - metaplasia (GIM) (http://ow.ly/ practiced for thirty years before support. Through AGA PAC, AGA staff was Cxsl30qfUYm). running for office. He originally - Independent Payment Advisory afforded the opportunity to culti 3. IBD patient: Crohn’s colitis ran for Congress on a platform - Board (IPAB). Congressman Roe vate a strong working relationship- (http://ow.ly/DsOg30qfUNt). touting his experience as a prac was a key ally in the fight to repeal over the years with Congressman- 4. Patient with intractable ticing physician to drive and pos the IPAB, which was created under Roe and his staff. While his leader abdominal pain (http://ow.ly/ itively impact health care policy. the Affordable Care Act and which- ship and commitment to pro-pa EPFi30qfUsi). Upon entering Congress, he did AGA and all of organized medicine tient, pro-physician policies will 5. IBD patient: Ulcerative colitis just that – focusing his legislative- long opposed since its sole pur be missed following his retirement- (http://ow.ly/d6e730qfUVZ). attention and efforts on policies pose was to make budgetary cuts - from Congress, AGA staff looks that protect patients, ease ad to Medicare if it reached a certain- forward to working with Congress Access these clinical cases and ministrative burdens, and protect threshold of spending. Largely be man Roe through the remainder of more discussions at https:// fair reimbursements for specialty cause of Congressman Roe’s lead his term on issues [email protected] impact our community.gastro.org/discussions. physicians. Throughout his tenure, ership on this issue, the IPAB was patients and our practice. Congressman Roe served both his successfully repealed after years of †IBD AND AND INTESTINAL DISORDERS FDA approves fidaxomicin for treatment of C. difficile– associated diarrhea in children

BY LUCAS FRANKI - MDedge News conclusion of treatment was similar in both years“C. difficile and seemed to be related to other co groups (77.6% for fidaxomicin vs. 70.5% for morbidities. - T vancomycin), and fidaxomicin had a superior is an important cause of health he Food andClostridioides Drug Administration difficile– has sustained response 30 days after the conclusion care– and community-associated diarrheal ill approved fidaxomicin (Dificid) for the of treatment (68.4% vs. 50.0%). ness in children, and sustained cure is difficult- treatment of associated- The safety of fidaxomicin was assessed in- a to achieve in someC. difficile patients. The fidaxomicin diarrhea in children aged 6 months and older. pair of clinical trials involving 136 patients; pediatric trial was the first randomized, con Approval was based on results from SUN the most common adverse events were py trolled trial of infection treatment SHINE, a phase 3, multicenter, investigator- rexia, abdominal pain, vomiting, diarrhea, - in children,” Larry K. Kociolek, MD, associate blind, randomized, parallel-groupC. difficile study in 142 constipation, increased aminotransferases, medical director of infection prevention and pediatric patients aged between 6 months and and rash. Four patients discontinued fidaxomi control at Ann & Robert H. Lurie Children’s 18 years with confirmed infection cin treatment because of adverse events, and Hospital of Chicago, said in [email protected] press release who received either fidaxomicin or vancomycin four patients died during the trials, though all from Merck, manufacturer of fidaxomicin. for10 10 days. Clinical response 2 days after the deaths were in patients aged younger than 2 March 2020 / GI & Hepatology News

02_6_7_8_9_10_GIHEP20_3.indd 10 2/21/20 3:15 PM †IBD AND INTESTINAL DISORDERS No biopsy to diagnose most pediatric celiac disease

BY ERIK GREB term health complications. Although more than half of all children being tively treated for celiac disease. It is MDedge News celiac disease is easy to detect and investigated for celiac disease will scandalous that so many children go treat, 10-13 years may elapse be- no longer need to have an invasive so long, often up to 10 years, without n most cases, a biopsy is no longer tween symptom onset and the time biopsy,” said Luisa Mearin Manrique, diagnosis. ” required to diagnose celiac disease of diagnosis. The new guidelines are MD, PhD, professor of pediatrics at - Iin children, according to new guid- intended to facilitate diagnosis and Leiden (the Netherlands) University ported. ance from the European Society for increase its accuracy, thus enabling and senior author of the guidelines, No conflicts of [email protected] were re Pediatric Gastroenterology, Hepatol- earlier diagnosis and improved de- in a press release. “This is a big step ogy, and Nutrition (ESPGHAN). The tection, according to ESPGHAN. forward in our mission to ensure that SOURCE: Husby S et al. J Pediatr Gastroen- authors recommend that the diagno- “These new guidelines mean that children can be diagnosed and effec- terol Nutr. 2020;70(1):141-56. sis be established with a two-stage blood test instead of an endoscopy,

The guidance was published in the Journalwhich children of Pediatric often Gastroenterology find distressing. and Nutrition. The document is an 2020 AGA update of ESPGHAN’s 2012 guidance. Postgraduate Course About half of children with sus- pected celiac disease undergo a bi- Knowledge gained. Knowledge shared. reduction of the number of biopsies, May 2-3, 2020 / Chicago, Illinois andopsy the to confirmanesthesia the required diagnosis. to Withper- The 2020 AGA Postgraduate Course is the GI clinician’s premier event for form them, the new guidelines could ground-breaking advances and effective tools for optimizing clinical care. reduce European health care costs. Held over 1.5 days during Digestive Disease Week®, attendees learn from — Steffen Husby, MD, of Odense and network with — luminaries in the field. (Denmark) University Hospital, and colleagues recommend testing for Why join us in Chicago? total IgA and anti-intestinal transglu- Hear about cutting-edge research and newly taminase 2 (TGA-IgA) antibodies as approved therapeutics in the treatment pipeline. initial screening in children with sus- pected celiac disease. An IgG-based Receive practical takeways that will help you remain a leader test is indicated only when total IgA in the field with a free abstract book, CME and MOC credits. is low or undetectable, according to the authors. Physicians should refer children with positive results to a pe- Early bird pricing ends March 18! For course diatric gastroenterologist. If the level details and registration visit pgcourse.gastro.org. of TGA-IgA is 10 or more times the EDU19-132 upper limit of normal, and the family agrees, the physician may diagnose celiac disease without a biopsy, pro- vided that endomysial antibodies test positive in a second blood sample, according to the guidance. For chil- dren with a positive TGA-IgA level of less than 10 times the upper limit of normal, however, at least four biop- sies from the distal duodenum and at ® least one from the bulb are required Build your career at DDW to establish the diagnosis. Physicians can diagnose celiac 2020 AGA Trainee & Early Career GI Sessions disease in children with no symp- AGA Reviewer Training Program The Paths to Partnership, toms without the need for a biopsy Saturday, May 2, 8–9:30 a.m. Academic Promotion and Research Productivity: How to Advance as an using the same criteria as they use AGA Postgraduate Course Early Career Gastroenterologist for symptomatic children, wrote Dr. Saturday, May 2, 8:15 a.m.–5:30 p.m., & Sunday May 3, 4-5:30 p.m. Husby and colleagues. Clinicians, par- Sunday, May 3, 8:30 a.m.–12:35 p.m. Pathways to Leadership: ents, and, when appropriate, children AGA Networking Hour Critical Success Factors should participate in the decision Sunday, May 3, 2-3 p.m. Monday, May 4, 10-11:30 a.m. Advancing Clinical Practice: AGA Board Review Course about whether to perform a biopsy. GI-Fellow-Directed Quality- Monday, May 4, 1:30-5:30 p.m. Improvement Projects Celiac disease is the most preva- Nutrition Bootcamp for Trainees Sunday, May 3, 4-5:30 p.m. lent food-related chronic disease in Tuesday, May 5, 1:30-5:30 p.m. European children, but as much as 80% of children with celiac disease With the exception of the postgraduate course, all of the sessions are undiagnosed. The prevalence of are free, but you must be registered for DDW to attend. celiac disease is increasing, and un- Member trainees, residents and students can register for DDW for free until March 18, 2020. diagnosed children with this disease Learn more at www.gastro.org/traineesessions. are at risk of nutritional and devel- EDU20-004 opmental problems, as well as long-

MDedge.com/gihepnews / March 2020 11

01_3_4_5_11_12_13_GIHEP20_3.indd 11 2/25/20 10:51 AM †IBD AND INTESTINAL DISORDERS ERAS takes its place in IBD surgery

BY RICHARD MARK KIRKNER partnership of the Crohn’s & Colitis MDedge News - troenterological Association. forbody IBD weight, patients, and the sarcopenia latter an are inde- J Gastro Hep. 2018;30:997-1002). - REPORTING FROM THE CROHN’S & COLITIS CONGRESS Foundation and the American Gas pendentpredictors predictor of surgical in patients complications aged teralGastroenterologists nutrition (TPN) perioperative- should not be - lyafraid in these of implementing patients, Ms. totalIssokson paren AUSTIN, TEX. – Enhanced recov- “It’s really important that we The ERAS protocol involves opti- - ery after surgery (ERAS) protocols goingimplement to have strategies on our perioperative to help miti 40 years and older. - have been around for decades, but gate the impact that malnutrition is ative nutrition, she said. It has been said. “This can really help to im typically excluded patients having do that is by using an ERAS or en- mizing preoperative and postoper prove outcomes and quality of life hancedpatients, recovery and one after of the surgery ways we pro- elective colorectal surgery (World J in our patients, and it’s something tocol,” said Kelly Issokson, MS, RD, linked with improved outcomes), although in that we really should not shy away surgery for inflammatory bowel of Cedars-Sinai Medical Center, Los the evidence in IBD isn’t as robust. from,” she added in an interview. “If disease (IBD). However, recent Angeles. She noted that patients Surg.She cited 2014;38:1531-41 a retrospective study our patients are malnourished and presurgerystudies have carbohydrate shown strategies loading to - meet the criteria for TPN, then we andoptimize early thesepostsurgery patients, feeding, including can gestive Disease Week® of patients should really not be withholding with IBD are five times more likely reported at the 2019 annual Di it.” Patients with severe IBD who to be malnourished than non-IBD- - are not absorbing from their gut theimprove Crohn’s outcomes, & Colitis according Congress to®, a patients, and those with fistulizing with Crohn’s disease that found no and can’t meet 60% of their needs a review of evidence presented at Crohn’s disease and bowel resec ERASdifference and standard-carein readmissions, patients. compli studyby mouth that arereported prime thatcandidates preop- for tions are at greatest risk (Inflamm cations, or reoperations between - TPN, she said, referencing a 2019 Bowel Dis. 2008;14:1139-46). patients resulted in a rate of overall “I constantly see patients who are Preoperative nutrition optimiza erative TPN in malnourished IBD kept NPO [nothing by mouth] 12- tion in ERAS involves anemia and - nately,”or 24 hours she said. before “We surgery, should maybe really Europeanfluid management, Society for oral Clinical nutrition Nutri- noninfectious complications half even longer sometimes, unfortu supplementation, and – based on that of no-TPN). patients: 8.3% ver guidelines – delaying the operation susCarbohydrate 16.8% (Gastroenterol loading before Rep. 2019 surgerybe minimizing has on thatour patientsNPO to help and tion and Metabolism (ESPEN) 2017- surgeryApr;7:107-14 is a big part of ERAS in mitigate the catabolic effect that these patients. “Surgery has a huge To screen surgery patients for preoperativewhere possible nutrition if the patient support is mal

ews nutritionhelp them risk, recover Ms. Issoksonmore quickly.” said nourished. “Patients who receive patient,” Ms. Issokson said. “It’s N that gastroenterologists can ask - impact on the catabolic state of a edge

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R registered dietician. Malnutrition, support versus 60% for those on Kelly Issokson either question merits referral to a standard care; in those on enteral - nutrition, the disparity was more 100 g of carbohydrates the night weight loss of 5%-10% of total pronounced: 21% versus 73% (Eur before and 50 g 2 hours before sur gery in the form of a clear-liquid beverage, along with permitting a light meal up to 6 hours before, Welcome to the newest surgery.with exceptions in gastroparesis, motility disorders, and emergency member of our family in IBD is early postoperative feed- Another key component of ERAS Techniques and Innovations feed our patients as soon as pos- in Gastrointestinal Endoscopy sible,”ing. “Postoperatively Ms. Issokson said. we wantESPEN to guidelines call for feeding patients TIGE cuts through the noise with quarterly updates on ground- breaking advances in GI endoscopy and answers to “what’s next” - in diagnostic techniques and disease management, featuring: with new nondiverted colorectal anastomosis within 4 hours. “Stud Original research for high-impact innovations in endoscopic ies show that patients aren’t able- procedures. to eat enough calories to help them- Topical reviews from international experts on hot-button issues. recover postoperatively, so imple added.menting an oral nutrition supple Practical “how-to” strategies for the diagnosis and treatment of TIGE supports clinicians and mentMs. mightIssokson be helpfulis a Crohn’s there,” & Colitisshe digestive diseases. researchers improving digestive - health worldwide. Explore our new Orgain,Foundation RMEI, board and member,Medscape. and dis journal at www.tigejournal.org. closed financial [email protected] with

SOURCE: Issokson K et al. Crohn’s & Coli- tis Congress 2020, Session Sp83.

12 March 2020 / GI & Hepatology News

01_3_4_5_11_12_13_GIHEP20_3.indd 12 2/21/20 3:15 PM 144751.graphic †IBD AND INTESTINAL DISORDERS Headline for a Bar Graphic Changes in outcome measures after quality initiative IMNG Print Colors Provides quick care improvement If a deck headline is needed, use this style.

Quality from page 1 Outcome measure Baseline rate Final rate Relative Label style and size (February 2018) (April 2019) change Axes number style and size the Crohn’s & Colitis Foundation weekly “huddle” to review high-risk Clinical remission 42% 45% +7% as an outgrowth of its IBD Qorus patients, and patient education on Note: Trade Gothic Medium, 8/11 ush left quality improvement program. The using urgent care. Perceived need for urgent care in 26% 21% –19% prior 6 months Source: Trade Gothic Medium, 8/11 ush left 15-month study involved 20,392 One of the drivers of the program Emergency room use 18% 14% –22% patient visits at 15 academic and 11 was to provide immediate care im- Style Guide: Hospitalization 14% 11% –22% private/community practices from provement to patients, Dr. Melmed Keep the background white. January 2018 to April 2019. “This said in the interview. “As opposed to CT-scan use 22% 18% –18% Use the IMNG colors. - investments into the cure of IBD that Corticosteroid use 14% 10% –29% we need, but which can take years to Move the entire graph to align the bar labels left at the blue guide bar.

Narcotic use 8% 4% –50% ews

N (Resizing may need to be done on the graph to €t in the space.) specific project within Qorus is fo develop, this research has immediate, >4 phone calls to clinic in prior month 11% 10% –9% If a deeper or shorter template is needed, adjust in Window > Artboards.

practical applicability for patients edge Proportion of patients with “high risk” 14% 6% –57% D M today.” MDedge News (Standard, as shown here, is 28 picas x 20 picas.) “The fact that we were able to To create the dotted lines if they change, use the clear arrow tool, click demonstrate reduction in emer- Note: Based on data for 20,392 patient visits at 26 practices. on the line that needs to be changed, use the eyedropper tool, then gency room utilization and hospi- Source: Dr. Melmed click on the dotted rule provided on the side of the template. talization, steroid use, and narcotic use has really energized the work added, “An enormous amount of see how they compared with others

ews that we were doing. We can now money is spent on clinical trials of anonymously, Dr. Melmed said. “Using N show that very-low-cost process expensive biologics which have revo- the data, we called out high-perform- edge

D changes at a site level lead to robust lutionized treatment, yet the human- ing sites to teach the rest of us what /M r improvement in patient outcomes. they were doing that enabled them to kne r i These changes are potentially imple- great of an impact. In this study, each improve, so that all of us could learn K

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R Maria T. Abreu, MD, AGAF, director of learn from each other. The very plat- cessful interventions, with the plan to Dr. Gil Y. Melmed the Crohn’s and Colitis Center at the formOne size they did used not to fit conduct all, yet theythe study could present the latter at Digestive Disease University of Miami, asked about the is a model for all of us.” Week® and use them to develop a cost of the interventions. Dr. Melmed Corey A. Siegel, MD, of the Dart- toolkit practices can use. of improving access during times of said the costs were nominal, such mouth-Hitchcock Medical Center, urgentcused specifically care need,” around Dr. Melmed the concept told as paying for a new phone line for a Lebanon, N.H., and Dr. Melmed’s co– relationships with AbbVie, Boehring- this news organization. The goal was patient hotline. “But overall the cost principal investigator on Qorus, said er-Ingelheim,Dr. Melmed Celgene,disclosed GSK, financial Janssen, to identify practice changes that can really involved in the program was the quality initiative now includes 49 drive improvement. the time that it took to review the GI practices across the country with Takeda, and Techlab; IBD Qorus re- The intervention consisted of 19 high-risk list on a weekly basis with plans to grow to 60 by the end of the ceivesMedtronic, support Pfizer, from Samsung Abbvie, Bioepis, AMAG, different strategies, called a “Change the team, and that is essentially a year. “We have created this ‘collabo- Helmsley Charitable Trust, Janssen, Package,” and participating sites 15-minute huddle,” he said. ratory’ for providers from across the could choose to test and implement Later, Dr. Abreu said in an inter- country to work together to learn UCB. one or more of them, Dr. Melmed how to best deliver high-quality care Nephoroceuticals, Pfizer,[email protected] Takeda, and said. Some examples included desig- example of how measuring outcomes for patients with IBD,” he said. nating urgent care slots in the clinic viewand sharing that the ideas program can make was “a huge terrific Another feature of the quality ini- SOURCE: Melmed GY et al. Crohn’s & Coli- schedule, installing a nurse hotline, a impacts in the lives of patients.” She tiative allowed participating sites to tis Congress 2020, Session 28.

outpatient opioid use. Among inpatients who Demonstrates more education is needed received only oral or transdermal opioids, a Opioids from page 1 similarly increased likelihood of postdischarge opioid prescription was observed (OR, 4.2), al- Gastroenterology and Hepatology. “Despite these phine. Following discharge, almost half of the pop- though this was a small cohort (n = 67). concerns, opioids are commonly prescribed to ulation (44.7%) was prescribed opioids, and about Compared with other physicians, gastroenterolo- IBD patients in the outpatient setting and to as three out of four patients (77.9%) received an ad- gists were the least likely to prescribe opioids. Con- many as 70% of IBD patients who are hospital- ditional opioid prescription within the same year. sidering that gastroenterologists were also most ized.” After confounders such as IBD severity, pre- likely aware of IBD-related risks of opioid use, the To look for a possible relationship between admission opioid use, pain scores, and psychi- investigators concluded that more interdisciplinary inpatient and outpatient opioid use, the inves- atric conditions were considered, data analysis communication and education are needed. tigators reviewed electronic medical records of showed that inpatients who received intrave- “Alternative analgesics such as acetamino- 862 IBD patients who were treated at three urban nous opioids had a threefold (odds ratio, 3.3) phen, dicyclomine, hyoscyamine, and celecoxib hospitals in the University of Pennsylvania Health increased likelihood of receiving postdischarge could be advised, as many of these therapies System. The primary outcome was opioid pre- opioid prescription, compared with patients have been deemed relatively safe and effective scription within 12 months of discharge, includ- who received no opioids while hospitalized. in this population,” they wrote. ing prescriptions at time of hospital dismissal. This association was stronger among those who The investigators disclosed relationships During hospitalization, about two-thirds (67.6%) - with Abbott, Gilead, Romark, and others. of patients received intravenous opioids. Of the nous dose was positively correlated with post- [email protected] total population, slightly more than half (54.6%) dischargehad IBD flares opioid (OR, prescription. 5.4). Furthermore, intrave received intravenous hydromorphone and about Avoiding intravenous opioids had no impact SOURCE: Dalal RS et al. Clin Gastro Hepatol. 2019 Dec one-quarter (25.9%) received intravenous mor- on the relationship between inpatient and 27. doi: 10.1016/j.cgh.2019.12.024.

MDedge.com/gihepnews / March 2020 13

01_3_4_5_11_12_13_GIHEP20_3.indd 13 2/21/20 3:15 PM †IBD AND AND INTESTINAL DISORDERS IVF, surgery, education have improved IBD fertility

BY RICHARD MARK KIRKNER 8 MDedge News She said gastroenterologists ). “We found that women with- REPORTING FROM CROHN’S & COLITIS CONGRESS should keep in mind that much of - Crohn’s and UC had a decreased the evidence documenting reduced chance of having a clinical preg AUSTIN, TEX. – Patients with in- fertility after ileo-pouch anal anas- nancy, but they had no problem tomosis is dated and focused on carrying the pregnancy to term,” open surgery, which caused pro she said. - flammatory bowel disease (IBD) found scarring of the pelvis and Those findings raised questions who want to have children can fallopian tubes, thus hindering about the etiology of decreased -fer benefit from better education conception. Laparoscopic ileoanal - tility in IBD patients, which could about recent findings that disease J-pouch surgery (IPAA) has yielded include factors such as IVF tech -

control, laparoscopic surgery, and- ews much improved outcomes in wom nique, reproductive hormone and N in vitro fertilization (IVF) have en of child-bearing age, she said, - microbiome changes, or IBD med edge

improved their chances of con D citing a study late last year that ications. “How can we carry that

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published reports presented here i scopic IPAA had a median time to she said. Women with IBD have less K

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at the Crohn’s & Colitis Congress r pregnancy of 3.5 months versus 9 chance of conceiving with each IVF a

a partnership of the Crohn’s & M months for women who had open treatment cycle than do women d Colitis Congress Foundation and r IPAA (Surgery. 2019;166:670-7). without IBD, she said. “The most - icha

the American Gastroenterological R “It’s really important to discuss- interesting thing is that the reduced Association. Dr. Sonia Friedman of Harvard Medical the issues of fertility, especially - chance of live birth after IVF treat “Decreased fertility in IBD is due- School discussed advances in IBD fertility. for patients contemplating sur ment in Crohn’s and UC is related to to voluntary childlessness, which gery,” Dr. Friedman said. “Empha the stages of implantation and not we can change with education; sur- - size that there are good outcomes- to the ability to maintain the fetus- gery for IBD, which we can improve with laparoscopic surgery, and throughout pregnancy,” she said. with laparoscopic surgery; and in Crohn’s surgery had decreased fer they can have assisted reproduc Dr. Friedman has [email protected] financial re creased disease activity, which we tility by 2.54 times greater relative tive technology [ART], or in vitro lationships to disclose. can also make a difference in,” Sonia risk,” she said. fertilization, if needed. Never SOURCE: Friedman S. Crohn’s & Colitis Friedman, MD, of Harvard Medical “Fertility, pregnancy is the most withhold surgery based on fear of Congress, Session Sp86. School, Boston, said in an interview. important thing to patients,” Dr. infertility.” Dr. Friedman and coauthors Friedman said in an interview. Her practice is to refer women last year published an analysis of “That’s what people ask me about with IBD in remission for IVF if AGA Resource the Danish National Birth Cohort,- the most. In the population of IBD they’ve tried to get pregnant every which showed women with IBD had patients, the onset is age 15-35, month for a year or more and to a 28% greater relative risk of tak and these people are in the prime refer women with IBD surgery for The AGA IBD Parenthood ing a year or more to get pregnant of their reproductive years.” Sexual IVF after trying to get pregnant for Project can help guide your than controls without IBD, and that function, known to be decreased in- 6 months. Dr. Friedman coauthored patients with IBD throughout the relative risk was even higher in men and women with IBD, is also two studies of the Danish National- their pregnancy, from trying to- women with Crohn’s disease – 54% an overriding concern in these pa Birth Cohort of ART in women with conceive through postpartum (Clin Gastroenterol Hepatol. 2019. tients, she said. “There needs to be Crohn’s disease and ulcerative coli care. Learn more at IBDParent doi: 10.1016/j.cgh.2019.08.031). a lot more information out there tis (UC) along with controls (Gut. hoodProject.org. “We found that women with about it.” 2016;65:767-76; Gut. 2017;66:556- High stress responsiveness linked to UC flare risk

BY RICHARD MARK KIRKNER MDedge News clustered on two ends of the stress spectrum, with REPORTING FROM CROHN’S & COLITIS CONGRESS high and low stress responsiveness, said Emeran - AUSTIN, TEX. A. Mayer, MD, who is co–principal investigator of the study with Jenny Sauk, MD, both of the Univer – Early results from a cohort - sity of California, Los Angeles. - study that aims to characterize the brain-gut The goal of the longitudinal follow-up study is relationship in ulcerative colitis (UC) have iden to identify brain, gut microbiome, and stress sig tified potential structural and functional brain natures that predict the risk of flares for up to 2 -

changes consistent with the effect chronic bowel years in UC patients in clinical remission, he said.- ews N inflammation has on the brain and found two Patients’ clinical, microbiome, and stress-psycho edge

subgroups of patients that differed in how they logical measures are evaluated quarterly. The in D /M

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® into the role of the brain in symptom flares, the data on 70 patients have been analyzed so far. k r study leader reported at the Crohn’s & Colitis “What we found so far is that, at baseline using - a M d Congress , a partnership of the Crohn’s & Colitis the questionnaire data and clustering analysis, you r icha

Foundation and the American Gastroenterological- can identify two distinct subgroups: one character R Association. - ized by stress hyperresponsiveness and one that - Dr. Emeran A. Mayer, of UCLA, found two subgroups of So far, the study has shown that, based on val does not have that feature,”Continued Dr. Mayer on said following in an page UC patients that differ in how they respond to stress. idated measures of perceived stress or neuroti interview. “Then we found in the stress hyperres 14cism, patients with UC in clinical remission are March 2020 / GI & Hepatology News

14_15_16_17_GIHEP20_3.indd 14 2/21/20 3:16 PM †GI ONCOLOGY Colorectal cancer cases spike after start of routine screening at 50 BY HEIDI SPLETE increased by 46.1% from 49 to 50 years of age, MDedge News and 93% of these cases were invasive. The increase in cancer rates occurred across andThe inability findings to were determine limited the by number several factors,of years ncidence of colorectal cancer (CRC) spiked geographical regions, sex, and race, and likely thatincluding the cancers the lack existed of specific before outcomes diagnosis, data the among adults in the United States between the researchers said. However, the results were ages of 49 and 50 years, the age when many have strengthened by the large study population and I ‘We would expect to see some degree routine screening colonoscopies, based on data detailed yearly assessment. from a cross-sectional study of 165,160 patients. of CRC incidence increase from 49 to “Our analysis of the transition from 49 to 50 “We would expect to see some degree of CRC 50 years of age owing to screening uptake years provides new, registry-based data re- incidence increase from 49 to 50 years of age garding risk among individuals younger than owing to screening uptake and diagnosis of and diagnosis of preexisting CRCs that 50 years, which can add to preexisting mod- preexisting CRCs that may have been clinically may have been clinically undetected.’ eling studies to help inform decision-making undetected,” wrote Wesal H. Abualkhair, MD, of on the age at which to initiate screening,” the Tulane University, New Orleans, and colleagues. researchers said. In a study published in JAMA Network Open, the reflects the impact of screening rather than The study did not receive outside funding. researchers reviewed data from the Surveillance, advancing age, the researchers said. - Epidemiology, and End Results (SEER) registries from 2000 to 2015 on colorectal cancer incidence 5-year relative survival (6.9% absolute in- Lead author Dr. Abualkhair had [email protected] financial con in 1-year intervals for adults aged 30-60 years, fo- crease,They 10%also found relative a significant increase) for increase the transition in flicts to disclose. cusing on the year between ages 49 and 50. between 49 and 50 years of age; no other age SOURCE: Abualkhair WH et al. JAMA Network Open. 2020 Overall, the incidence of colorectal cancer Jan 31. doi: 10.1001/jamanetworkopen.2019.20407.

transitions showed a significant change. Continued from previous page The findings so far have also determined that the differences said, with more data on biological parameters expected next year. reported and documented during a in stress responsiveness and flare frequency don’t seem The study is funded with a meanponsive follow-up group there of 8.1 are months.” more flares to be related to baseline fecal calprotectin levels. Crohn’s & Colitis Foundation grant. - determined that the differences can just answer a short question- lationships with Amare, Axial The findings so far have also disease, the study may ultimately naire,” he said. Another potential Biotherapeutics,Dr. Mayer disclosed Bloom financial Science, re frequency don’t seem to be related simplifytribute to the inflammatory process of identifying bowel Danone, Mahana Therapeutics, toin stressbaseline responsiveness fecal calprotectin and flarelevels, IBD patients in remission who are Pendulum, Ubiome, and Viome. said Dr. Mayer, who is director of microbiomebenefit of the interactions study would associat- be to [email protected] the G. Oppenheimer Center for Neu- said. “Patients won’t need to un- identify changes in the brain–gut robiology of Stress and Resilience dergoat highest brain risk imaging of flares, or assessmentDr. Mayer Full study results would be avail- SOURCE: Mayer EA et al. Crohn’s & Colitis and codirector of the CURE: Diges- of microbiome parameters; they ableed with in about flares, 2 he years, said. Dr. Mayer Congress 2020, Session Sp74. tive Diseases Research Center.

responsivenessEarly findings group show wasthe incidence 27.4% vs.of clinical 9.3% in flares the low-stress in the high group, stress–

was 11.8% vs. 4.6%, respectively. andWith the regardrate of tosymptomatic baseline biolog- flares ical measures, there were no sig- With the right planning and care, women with inflammatory bowel disease (IBD) can have tone or morning salivary cortisol healthy pregnancies and healthy babies. measuresnificant differences between thein cardiovagal two clus- ters, Dr. Mayer noted, although the We help GIs provide care for them. had higher sympathetic tone be- The IBD Parenthood Project has fore,high stress–responsivenessduring, and after a brief cluster psy- chological stress. learning activities and videos He noted that the same clus- designed to support GIs and related tering into low and high stress health care providers with proper different data set of 66 UC subjects planning and care for women with IBD responsivenessand that the two was clusters confirmed showed in a throughout all stages of family planning. - ical connectivity of the default Learn more at modesignificant network differences in the brain, in anatom a set of regions involved in chronic pain ibdparenthoodproject.gastro.org/for-hcps/ and emotion regulation. EDU19-136 By identifying factors that con-

MDedge.com/gihepnews / March 2020 15

14_15_16_17_GIHEP20_3.indd 15 2/21/20 3:16 PM †GI ONCOLOGY Multiomics blood test outperforms others for CRC

BY SUSAN LONDON ing, and entails whole-genome sequencing, was not involved in the study. “The loss of sen- MDedge News sitivity in early tumors has been a limitation of other tests – FOBT [fecal occult blood test], FIT – SAN FRANCISCO – A blood-based test that in- bisulfite sequencing (for assessment of DNA - tegrates data from multiple molecular “omes,” methylation), and protein quantification methods. Although the study was small for a CRC screening such as the genome and proteome, performs At 94% specificity, the test had a 94% sensitivi assessment,so if this is replicable, “the preliminary this is results exciting.” presented in well at spotting early-stage colorectal cancer ty for spotting stage I and II CRC, 91% sensitivity the poster were certainly compelling enough to (CRC), the AI-EMERGE study suggests. for stage III and IV CRC, and 91% sensitivity for support more research,” Dr. Hall said. CRCThe of multiomics any stage. Bytest location, outperformed sensitivity a ctDNA was test, 92% a Dr. Putcha said that the test will be validated for distal tumors and 88% for proximal tumors. in a prospective, multicenter trial of roughly CRC.At aMoreover, specificity the of test94%, netted the multiomics better sensitivity test had tests, the multiomics test yielded a higher sensi- thana sensitivity a fecal immunochemical of 94% for detecting test stage(FIT), I aand circu- II tivityCEA test, than and a commercially a FIT. At a specificity available of FIT 96% stool for test both to open later this year. Further research will lating tumor DNA (ctDNA) test, and a carcinoem- (OC-Auto FIT, Polymedco) for also10,000 help participants assess the attest’s average performance risk, expected among bryonic antigen (CEA) test. Findings were reported in a poster session at - whom false-positive results with some screening the 2020 GI Cancers Symposium, which is co- stage I and II disease (100% testspatients have with been inflammatory problematic. bowel disease, for sponsored by the American Gastroenterological vs. 70%), stage III and IV dis The study was sponsored by Freenome. Dr. Association, American Society of Clinical Oncology, ease (100% vs. 50%), and- any- Putcha is employed by Freenome and has a re- American Society for Radiation Oncology, and Soci- stage disease (100% vs. 67%). lationship with Palmetto GBA. Dr. Hall disclosed ety of Surgical Oncology. outperformedWhen set at 100%a commercially spec relationships with Ambry Genetics, AstraZeneca, “Today, about a third of age-appropriate adults availableificity, the plasma multiomics ctDNA test test Caris Life Sciences, Foundation Medicine, Invitae, are not up to date with [CRC] screening,” lead and Myriad Genetics, and he shares a patent with study investigator Girish Putcha, MD, PhD, chief Dr. Putcha institutional colleagues for a novel method to in- - yielded(Avenio, a Roche) higher setsensitivity at 75% for vestigate hereditary CRC genes. ed at the symposium. “A noninvasive blood-based specificity. The multiomics test [email protected] medical officer of Freenome in San Francisco, not- ity for [CRC] generally, but especially for early- stage I and II disease (94% vs. 38%), stage III and SOURCE: Putcha G et al. 2020 GI Cancers Symposium, screeningstage disease, test couldhaving help high improve sensitivity adherence and specific and IV disease (91% vs. 55%), and any-stage disease - Abstract 66. ultimately reduce mortality.” tiomics(90% vs. test 47%). yielded a higher sensitivity than Dr. Putcha and colleagues evaluated a blood- At a specificity of 94% for both tests, the mul based multiomics test in 32 patients with CRC of AGA Resource - plasma CEA level for stage I and II disease (94% Visit the AGA GI Patient Center for educa- tive control subjects. vs. 18%), stage III and IV disease (91% vs. 45%), tion to share with your patients about cur- allThe stages test and uses 539 a multiomics colonoscopy-confirmed platform to pick nega up toand this any-stage study, the disease test’s (91%ability vs. to 31%). detect cancers both tumor-derived signal and non–tumor-de- without“Although loss there of sensitivity were many for early-stageexciting aspects cancers - rived signal from the body’s immune response was striking to me,” said Michael J. Hall, MD, of rently available CRC screenings at https:// and other sources. The test uses machine learn- www.gastro.org/practice-guidance/gi-pa tient-center/topic/colorectal-cancer-crc. CLINICALFox Chase CHALLENGES Cancer Center in Philadelphia, AND who IMAGES

What is your diagnosis? - - By Diogo Turiani Hourneaux de and the gastrojejunal anastomo- lium,abnormal which color seemed of approximately to be more loss. A 1-year follow-up endoscopy Moura, MD, MSc, PhD, Kelly E. sis (GJA) were characterized by similar25% of totheir the gastric esophageal pouch epitheli- epithe showed a 10-mm GJA, but the gas- Hathorn, MD, and Christopher healthy-appearing mucosa. In all um (Figure C). The GJAs remained normaltric pouch epithelium was now (Figure approximately E). A C. Thompson, MD. Published three cases, the pouch size mea- forceps80%-100% biopsy covered was performed with this ab for previously in Gastroenterology sured between 3 and 5 cm and the mm, and their third APC sessions histologic evaluation (Figure F). (2019;156:2139-41). GJA was dilated, with diameters of weredilated, performed measuring (Figure more D).than The 14 What is the histopathologic di- more than 20 mm (Figure A). Laser patients did well after the pro- We describe three unique pre- resurfacing of the stoma by argon The diagnosis is on page 19. sentations of patients with a agnosis of this finding? min and 70 watts was successfully cedures, with significant weight bypass who were referred for plasma coagulation (APC) at 0.8 L/ endoscopicprior history treatment of Roux-en-Y of weight gastric ring fashion around the gastric regain. All of the patients had sideperformed of the GJAin a (Figure1-cm concentric B). Three failed prior attempts at lifestyle months after the initial APC, the patients returned for reevaluation. weight loss treatment. On physi- The pouch mucosa again seemed modifications and pharmacologic to be normal, but there was per- sistent, albeit improved, dilation of mcal2 examination, their body mass the GJA. Repeat APC sessions were laboratoryindexes ranged evaluation, from 27 including to 30 kg/ performed without any adverse thyroid-stimulating, but examination hormone, and complete were events. tute - i nst

upper gastrointestinal esophago- agogastroduodenoscopies, all I

gastroduodenoscopies,otherwise normal. During the the pouch first patientsOn their were next noted follow-up to have esoph an AGA

16 March 2020 / GI & Hepatology News

14_15_16_17_GIHEP20_3.indd 16 2/21/20 3:16 PM †GI ONCOLOGY Sociodemographic disadvantage confers poorer survival in young adults with CRC

BY SUSAN LONDON rate less than 79%), and those living efforts are needed to increase ac- ogy is unknown, but the microbiome MDedge News in urban or rural areas (versus met- cess and remove barriers to care, has come under scrutiny. ropolitan areas) had 24% and 10% with the hope of eliminating dispar- “So you are a victim of your cir- Young adults higher risks of death, respectively. ities and achieving health equity.” cumstances,” he summarized. “You with colorectal cancer (CRC) who live Patients in the low-income, low-ed- are living in a low-income area, you inSAN neighborhoods FRANCISCO with– greater dis- ucation group were more than six Mitigating disparities advantage differ on health measures, times as likely to be black and to lack Several studies have looked at mit- type foods, you are getting your pol- present with more advanced disease, private health insurance, had greater igating sociodemographic-related ypsare eatingearlier, more and then proinflammatory- you are getting and have poorer survival. These were comorbidity, had larger tumors and disparities in CRC outcomes, ac- your cancers earlier.” cording to session cochair John M. cohort study reported at the 2020 GI Carethers, MD, AGAF, professor and Study details Cancersamong key Symposium. findings of a retrospective chair of the department of internal Rural, urban, or metropolitan status The incidence of CRC has risen medicine at the University of Michi- was ascertained for 25,861 patients sharply – 51% – since 1994 in in- gan, Ann Arbor. in the study, and area income and dividuals aged younger than age A large Delaware initiative tack- education were ascertained for 50 years, with the greatest uptick led the problem via screening (J 7,743 patients, according to data re- seen in those aged 20-29 years (J Clin Oncol. 2013;31:1928-30). ported at the symposium, sponsored Natl Cancer Inst. 2017;109[8]. doi: “Over 50, you can essentially elim- by the American Gastroenterological 10.1093/jnci/djw322). inate this disparity with navigation Association, the American Society of “Sociodemographic dispari- Dr. Matusz-Fisher Dr. Carethers services and screening. How do Clinical Oncology, the American So- ties have been linked to inferior you do that under 50? I’m not quite ciety for Radiation Oncology, and the survival. However, their impact more nodal involvement at diagnosis, sure,” he said in an interview, add- Society of Surgical Oncology. and association with outcome in and were less likely to have surgery. ing that some organizations are rec- Compared with counterparts liv- young adults is not well described,” Several factors may be at play ommending lowering the screening ing in areas with both high annual said lead investigator Ashley Ma- for the low-income, low-education age to 45 or even 40 in light of ris- income (greater than $68,000) and tusz-Fisher, MD, of the Levine Can- group, Dr. Matusz-Fisher speculated: ing incidence in young adults. education (greater than 93% high cer Institute in Charlotte, N.C. limited access to care, lack of aware- However, accumulating evidence school graduation rate), patients The investigators analyzed data ness of important symptoms, and suggests that there may be inherent living in areas with both low annual from the National Cancer Database inability to afford treatment when it biological differences that are harder - for the years 2004-2016, identifying is needed. to overcome. cantly more likely to be black (odds 26,768 patients who received a CRC “To try to eliminate these dispar- “There are a lot of data … showing ratio,income 6.4), and not education have private were insurance signifi diagnosis when aged 18-40 years. that polyps happen earlier and they (OR, 6.3), have pathologic T3/T4 Results showed that those living which is what we are doing – rec- are bigger in certain racial groups, stage (OR, 1.4), have positive nodes in areas with low income (less than ognizingities, the firstthere step are isdisparities recognition, – and particularly African Americans and (OR, 1.2), and have a Charlson-Deyo $38,000 annually) and low education- then making people aware of these American Indians,” Dr. Carethers comorbidity score of 1 or greater al attainment (high school graduation disparities,” she commented. “More elaborated. What is driving the biol- (OR, 1.6). They also were less likely to undergo surgery (OR, 0.63) and more likely to be rehospitalized within 30 days (OR, 1.3). AGA gratefully acknowledges the members of the After adjustment for race, insur- ance status, T/N stage, and comor- 2019-2020 AGA bidity score, relative to counterparts Corporate Roundtable in the high-income, high-education group, patients in the low-income, Gold supporters as of Jan. 2, 2020. low-education group had an in- creased risk of death (hazard ratio, 1.24; P = .004). And relative to coun- terparts living in metropolitan areas, patients living in urban or rural areas had an increased risk of death (HR, 1.10; P = .02). In patients with stage IV disease, median overall survival was 26.1 months for those with high income, The roundtable engages corporate partners and AGA high education, but 20.7 months for leadership in dialogue regarding innovations in practice, clinical those with low income, low educa- and research advances, public policy, and other issues that tion (P less than .001). impact the future of gastroenterology and hepatology care. Dr. Matusz-Fisher reported no con-

receive any funding. flicts of interest. The [email protected] did not

FND19-40 SOURCE: Matusz-Fisher A et al. 2020 GI Cancers Symposium, Abstract 13.

MDedge.com/gihepnews / March 2020 17

14_15_16_17_GIHEP20_3.indd 17 2/25/20 10:58 AM †LIVER DISEASE Serum keratin 18 promising as AAH biomarker

BY M. ALEXANDER OTTO Standard biomarker scores – Model forms of liver injury” and guiding agents such as steroids or [inter- MDedge News for End-stage Liver Disease (MELD), therapy, explained investigators led leukin]-1 receptor antagonists, but age, serum bilirubin, International by Vatsalya Vatsalya, MD, of the divi- would incur their side effects.” For erum keratin 18, an epithelial Normalized Ratio, and serum creati- sion of gastroenterology, hepatology, - protein released from dying nine (ABIC) – predict prognosis and and nutrition at the University of Lou- markers are needed for diagnosing S severity of alcoholic liver disease, but isville (Ky.). AAH,those assessingand other the reasons, degree “new of hepato- bio with severe acute alcoholic hepa- It’s important to identify people cyte death, and predicting mortality,” titis (AAH)hepatocytes, at high risk identifies for death, patients cell death nor the form of cell death with alcoholic cirrhosis but not ac- they said. according to an investigation of 173 (apoptosis/necrosis),they don’t reflect “the whichmagnitude may beof Keratin 18 – both the cleaved form subjects. important in distinguishing various (K18M30) and the uncleaved protein tive hepatitis, as they “would likely (K18M65) – have been suggested not benefit from anti-inflammatory before as a marker for AAH, so the investigators took a closer look. They analyzed serum from 57 peo- ple with severe AAH (MELD score above 20), 27 people with moderate AAH (MELD score 12-19), 34 with nonalcoholic steatohepatitis, 17 healthy controls, and 38 people with

2020 AGA Serum levels of K18 also identified patients who died Tech Summit within 90 days with greater Coming together to move accuracy than did MELD, ABIC, and other scores. forward in GI innovation

June 3-6, 2020 / San Francisco, CA alcohol use disorder and either mild or no liver injury. Patients were in their mid 40s, on average; there were Learn more at more men than women. techsummit.gastro.org Overall, 51.9% of moderate AAH cases and 38.9% of severe cases had RSH19-20 K18M65 levels between 641 and 2,000 IU/L; 25.9% of moderate and 61.1% of severe cases had K18M65 levels greater than 2,000 IU/L. All se- vere cases had levels above 641 IU/L.

patients who died within 90 days withSerum greater levels accuracyof K18 also than identified did MELD, ABIC, and other scores. The K18M65:ALT ratio distin- guished AAH from nonalcoholic steatohepatitis with a sensitivity AGA Honors Findings were similar for the K18M30:ALTof 0.971 and specificity ratio. of 0.829. Celebrating Difference Makers in Our Field Levels of K18M65 and K18M30 - Donate to put a spotlight on today’s luminaries ease worsened, as did the degree ofincreased necrosis significantly as indicated as by liver the dis AGA Honors: Celebrating Difference Make a donation to help AGA celebrate K18M65:K18M30 ratio. Meanwhile, although k18 levels correlated with Makers in Our Field recognizes these distinguished leaders, mentors MELD scores, levels of ALT, AST, and individuals who have played a and visionaries. All contributions will go the ratio of AST:ALT did not. pivotal role in shaping the field of towards funding talented researchers The National Institutes of Health gastroenterology and hepatology. working to improve digestive disease care. supported the work; the investigators had no disclosures. [email protected] Donations are tax-deductible and support the Learn more at gastro.org/honors. AGA Research Foundation endowment fund. SOURCE: Vatsalya V et al. Clin Gastroen- FND19-38 terol Hepatol. 2019 Dec 4. doi: 10.1016/j. cgh.2019.11.050).

18 March 2020 / GI & Hepatology News

18_19_21_22_23_GIHEP20_3.indd 18 2/21/20 3:17 PM †LIVER DISEASE Telehealth helps speed front end of liver transplant

BY GREGORY TWACHTMAN P less than P health offers to improve overall ac- MDedge News added. wrote,group (22adding vs. 54 that, days, after conduct- (325 vs. 409 days; = .08),” they- adding that more studies are need- he incorporation of telehealth .001),” Dr. John and colleagues cess to transplantation,” they stated,- in the liver transplantation “telehealth was associated with an Additionally, “there was no dif - Tprocess is demonstrating the ing a propensity-matched analysis, ference in pretransplant mortality ed, both in and out of the VA sys potential to expedite the evaluation to evaluation.” between [those] evaluated by tele of patients and get them added on 85% reduction in time from referral health or usual care in unadjusted the transplant wait list. analysis,” Dr. John and colleagues New research shows “a trans- Patients ‘who underwent the observed, noting that 169 of 465 plant hepatologist evaluation using initial evaluation by telehealth notpatients listed) (51 who on werethe waiting referred list died for telehealth was associated with were listed significantly earlier awithout transplant receiving and 118 a liver who transplant. were - Researchers suggested that, than the usual care group,’ significantly reduced time to evalu the authors stated, adding that been shorter with the use of comparedation and listing to the withoutcurrent standardadversely while evaluation times may have ofaffecting care of pretransplant in-person evaluation mortality at ‘telehealth was associated with a to shorter transplantation times thinkstock a transplant center,” Binu V. John, 74% reduction in time to listing.’ telehealth, they did not translate - / MD, of McGuire VA Medical Center, plex metric that is driven primari- raxion

Richmond (Va.), and colleagues “likely because the latter is a com E wrote in a report published in Clin- - Dr. John and colleagues cau- - tionedly by organ that theavailability.” centralized nature Additionally, patients “who un ical Gastroenterology and Hepatol earlierderwent than the theinitial usual evaluation care group by accesstem, “to for confirm patients that undergoing telehealth eval- is ogy (2019 Dec 27. doi: 10.1016/j.- telehealth were listedP significantly generalizableof the VA medical across system private could care uationa safe and for livereffective transplantation.” way to expand tientscgh.2019.12.021). who had evaluations for liver the authors stated, adding that make the results of this study not Lead author Dr. John serves on transplantsResearchers at thelooked Richmond at 465 Vet-pa “telehealth(95 vs. 149 wasdays; associated less than with .001),” a needs to cross state lines, which erans Affairs Medical Center from doessettings, not particularlypresent an issue when within care and Eisai and received research fundingmedical fromadvisory a number boards of for pharma- Gilead 74% reduction in time to listing” 2005 through 2017. Nearly half after conducting a propensity- the VA medical system. - evaluated(232 patients) with weretraditional evaluated in-per- via tomatched referral analysis. and listing, “the median tientsThat via being telehealth said, the and “ability obtain to the otherceutical authors. manufacturers. No conflicts sontelehealth, evaluations. with the remaining 233 However, while speeding up time- samesuccessfully outcomes evaluate in terms and of list time pa of interest [email protected] reported by the “Patients in the telehealth group to transplant and pretransplant - time to transplant was not signifi SOURCE: John BV et al. Clin Gastroenterol er than patients in the usual care cantlyP different between the two the numerous advantages that tele- Hepatol. doi: 10.1016/j.cgh.2019.12.021. were evaluated significantly fast groups on unadjusted (218 vs. 244 mortality is significant because of days; = .084) or adjusted analysis CLINICAL CHALLENGES AND IMAGES ferential) containing specialized intestinal after the procedure, in combination with a The diagnosis metaplasia on histopathologic examination. It postoperative decrease in acid production, is well documented that treatment of BE with allows for a shift in the cell proliferation and Answer to “What is your diagnosis?” on page 16: Squamous metaplasia results in re-epithelialization of the esophagus - withthermal neosquamous ablation and mucosa. acid-suppression In contrast therapy with lancedifferentiation of BE, owing in the to pouch.the risk Notably, of progression although this, in our patients, after we2 burned the gas- tothere esophageal are well-defined adenocarcinoma, guidelines it for is surveilunclear Weight regain can accompany re-emergence tric columnar mucosa with APC to treat their 2 of obesity-related comorbidities and, thus, - dilated GJA, the gastric pouch mucosa has been have in the future. It is important to continue early intervention is important. Although diet, replaced with squamous epithelium, which we what clinical significance this reverse BE may- endoscopicexercise, and management behavior modifications is important, are with fun have termed “reverse BE.” To our knowledge, damental, they can have limited efficacy. Thus, there are no reports of this condition in the lit- to monitor these patients and clarify the natu pouch dilation, and GJA dilation, all of which erature, nor do we know the precise cause. Referencesral history of this finding. specific evaluation for gastrogastric fistulae, - 1. Brunaldi VO, Jirapinyo P, de Moura DTH et al. Endoscopic treat- ment of weight regain following Roux-en-Y gastric bypass: a system- atic review and meta-analysis. Obes Surg. 2018;28:266-76. beencan be used successfully with promising intervened results. upon endoscop metaplasiaThere is a in series the proximal of patients gastric without cardia. a historyThe 2. Weusten B, Bisschops R, Coron E et al. Endoscopic management of ically.In the For normal GJA dilation GI tract, in theparticular, esophagus1 APC is has lined of bariatric surgery who developed squamous3 Barrett’s esophagus: European Society of Gastrointestinal Endoscopy with squamous epithelium, and the stomach - (ESGE) Position Statement. Endoscopy. 2017;49:191-8. is lined with columnar epithelium. One of authors hypothesized that this condition may 3. Fass R, Sampliner RE. Extension of squamous epithelium into the proximal stomach: a newly recognized mucosal abnormality. Endos- the most well-known and well-documented be due to chronic mucosal injury owing to hi copy. 2000;32:27-32. potentialatal hernia, mechanisms reflux, caustic for thisingestion, condition chronic in our gastritis, or pyloric stenosis. We suggest two Christopher C. Thompson is a consultant for scenarios in which the typical mucosal lining- Boston Scientific and Medtronic, a consultant mentis replaced of the by normal abnormal distal mucosa squamous is Barrett’s epithe- forpatients: the distal 1) extending extension the of squamousablation to mucosa the Z-line for and has institutional grants from USGI Medi- lialesophagus lining with (BE). columnar BE is defined epithelium by the with replace a on the medial aspect of the pouch may allow- cal, Olympus, and Apollo Endosurgery. - [email protected] during the healing process; and 2) acid-sup minimum length of 1 cm (tongues or circum pression therapy with proton pump inhibitors MDedge.com/gihepnews / March 2020 19

18_19_21_22_23_GIHEP20_3.indd 19 2/21/20 3:17 PM CLASSIFIEDS Also available at MedJobNetwork.com

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20 March 2020 / GI & Hepatology News †PRACTICE MANAGEMENT TOOLBOX Prepare for major changes to E/M coding starting in 2021

BY BRADEN KUO, MD, JOSEPH LOSURDO, MD, - SHIVAN J. MEHTA, MD, MBA, AND PATRICIA care & Medicaid Services (CMS) in reducing GARCIA, MD response to interest from the Centers for Medi most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients valuation and Management (E/M) coding physician burden, simplifying documentation withIn sum, complex what conditions. are the 2021 E/M changes and guidelines are about to undergo the requirements, and making changes to payments - E - for the E/M codes. CMS’s initial proposal was - mentation in the 1990s. For now, the changes are to collapse office visit E/M levels 2-5 to a single While there will be many changes to office/outpa most significant changes since their imple payment. While the new rates would have pro tient E/M visits, the most significant are deletion (CPT codes 99202-99205, 99211-99215) and will vided a modest increase for level 2 and 3 E/M of code 99201 (Level 1 new patient visit), addition limited to new and established outpatient visits codes, they would have cut reimbursement for of a 15-minute prolonged services code that can be the top-level codes by more than 50%. There reported with 99205 and 99215, and the following take place as of Jan. 1, 2021. Changes to all E/M- was concern that these changes would adversely 1.restructuring Elimination ofof officehistory visit and code physical selection: as elements codes are anticipated in the coming years. affect physicians caring for complex patients for code selection: healthThe changescare who to assigns the new codes, and established manages health of across medical specialties. There was an outcry- fice/outpatient codes will impact everyone in from the physician community opposing CMS’s While obtaining a pertinent proposal, and the agency agreed to get more in bothhistory time and and performing medical decision a relevant making, physical these information, or pays claims including physicians put from the public before moving forward. exam are clinically necessary and contribute to- and qualified health professionals, coders, health E/MThe guidelines AMA worked that withdecrease stakeholders, documentation including information managers, payers, health systems, the AGA and our sister GI societies, to create - medicalelements decision will not making factor in or to time. code selection. In and hospitals. The American Medical Association stead, the code level will be determined solely by (AMA) has already released a preview of the - requirements while also continuing to differen 2. Choice of using medical decision making (MDM) or CPT 2021 changes as well as free E/M education tiate payment based on complexity of care. CMS total time as the basis of E/M level documentation: modules. They are planning to release more edu announced in the 2020 Medicare Physician Fee - • MDM. - cationalWhy were resources changes in the needed? near future. Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommend While there will stillContinued be three on following MDM sub page ed relative values for 2021 CPT E/M codes. Of components (number/complexity of problems, The AMA developed the 2021 E/M changes in note, there will be modest payment increases for CLASSIFIEDS Also available at MedJobNetwork.com Also available at MedJobNetwork.com

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MDedge.com/gihepnews / March 2020 21

MDedge.com/gihepnews / March 2020 21

18_19_21_22_23_GIHEP20_3.indd 21 2/21/20 3:17 PM †PRACTICE MANAGEMENT CMS’s new rule for antibiotic stewardship: H. pylori

BY DAVID Y. GRAHAM, MD, AND - H. pylori have - HASHEM B. EL-SERAG, MD, MPH, AGAF antibiotic-use/healthcare/pdfs/hos ship. Therapies for count. Finally, some of the most high- he Centers for Medicare & pital-core-elements-H.pdf). Antibiotic- largely been developed using trial ly recommended effective regimens - stewardship includes optimization of and error, antimicrobial susceptibility inevitably contain at least one anti T - several aspects of antimicrobial ther testing is rarely available, and local biotic unnecessary for the outcome, Medicaid Services (CMS) final apy including the drugs, formulations, and regional susceptibility are not and inadvertently serve to increase ized a new regulation requir doses, and dosing intervals. It also readilyTherapies available for H. or pylori updated. have Current population antibiotic exposure. ing all hospitals participating in its includes obtaining and updating local, largely been developed using Clarithromycin-amoxicillin-PPI programs to establish antimicrobial guidanceregional, andregarding national diagnosis susceptibility and triple is still the most often used stewardship programs by March data to provide regularly updated trial and error, antimicrobial legacy therapy in the United States 30, 2020 (https://federalregister. susceptibility testing is rarely with an average cure rate of 70%. gov/d/2019-20736). This welcome therapy. Recent guidelines have suggested - available, and local and regional action was prompted by the rise in - How does this new CMS rule affect adding a fourth drug, metronidazole, antimicrobial resistance; recent Cen gastroenterologists and what role, - susceptibility are not updated. to produce a quadruple therapy ters for Disease Control and Preven if any, do we play in the epidemic of (concomitant therapy); the premise tion estimates more than 2.8 million antibiotic resistance?Helicobacter The one infec py- is that, although both clarithromycin - antibiotic-resistant infections with loritious disease that gastroenterology - and metronidazole resistance are more than 35,000 deaths occur in the effectively owns is national treatment recommendations common, dual resistance is not. How United States each year (www.cdc. - . Treatment of this infection has containingare most often different based drugs, on compar doses, and ever, this benefit comes at the price gov/drugresistance/biggest-threats. - Currentthe potential H. pylori to be involved in the isons of regimens grouping trials of every patient receiving at least one html). CMS recommended that hospi epidemic of antimicrobial resistance. unnecessary antibiotic, and patients tals follow stewardship guidelines es therapies were - neitherdurations assessed of therapy nor performedtaken into ac-in with treatmentContinued failures on receiving following page tablished by CDC, and other nationally largely devised without considering populations in whom resistance was three unnecessary antibiotics. The recognized sources (www.cdc.gov/ the principles of antibiotic steward Continued from previous page care related to a patient’s single, serious, or com- plex chronic condition. (Add-on code, list sepa- rately in addition to office/outpatient evaluation Contact your Electronic Health Records (EHR) data, and risk), extensive edits were made to and management visit, new or established.). vendor to confirm the system your practice uses • theTime. ways in which these elements are defined will be ready to implement the new E/M coding- and tallied. - and guidelines changes on Jan. 1, 2021. The definition of time is now minimum GPC1X can be reported with all levels of E/M - Run an analysis using the new E/M office/out time, not typical time or “face-to-face” time. office/outpatient codes in which care of a pa patient payment rates recommended by the AMA- Minimum time represents total physician/ tient’s single, serious, or complex chronic condi for 2021 (https://www.ama-assn.org/about/ qualified health care professional time on tion is the focus. CMS plans to reimburse GPC1X rvs-update-committee-ruc/ruc-recommenda the date of service. This redefinition of time atWho 0.33 do RVUs these (about changes $12). apply to? tions-minutes-voting) for each of your practice’s allows Medicare to better recognize the work contracted payers to determine if your practice involved in non–face-to-face services like care will benefit from the new rates. While CMS has coordination and record review. Of note, these The changes to the E/M office/outpatient CPT proposed to accept the AMA recommended rates, definitions only apply when code selection is codes and guidelines for new and established this will not be finalized until CMS publishes the 3.basedModification on time of andthe criterianot MDM. for MDM: patients apply to all traditional Medicare and 2021 proposed rule in early July 2020. Medicare Advantage plans, Medicaid, and all - Once CMS confirms its decision, reach out to The current commercial payers. E/M HCPCS codes apply to your payers to negotiate implementing the new •CMSTerms. Table of Risk was used as a foundation for Medicare, Medicare Advantage plans, and Medic E/M rates starting in 2021. designing the revised required elements for MDM. aid only; commercial payers are not required to With changes this big, we encourage you to Removed ambiguous terms (e.g., “mild”) Whataccept shouldHCPCS codes. you do? prepare early. Watch for more information on and defined previously ambiguous concepts the 2021 E/M changes in Washington Insider • Definitions.(e.g., “acute or chronic illness with systemic Dr.and Kuo AGA is eDigest. the AGA’s Advisor to the AMA CPT Ed- symptoms”). Visit the AMA E/M Microsite; there you will find itorial Panel and a member of the AGA Practice • Data elements.Defined important terms, such as the AMA’s early release of the 2021 E/M coding Management and Economics Committee’s (PMEC) “independent historian.” and guideline changes, the AMA E/M learning Coverage and Reimbursement Subcommittee Re-defined the data elements - module and future resources on the use of time (CRS) and assistant professor of medicine and to move away from simply adding up tasks to - AMAand MDM E/M Microsite:that are expected to be released in gastroenterology, Harvard Medical School and focusing on how those tasks affect the manage March. - Massachusetts General Hospital, Boston; Dr. Lo- ment of the patient (e.g., independent interpre https://www.ama-assn. surdo is the AGA’s Alternate Advisor to the AMA tation of a test performed by another provider 2021org/practice-management/cpt/cpt-evalua E/M changes CPT Editorial Panel, a member of the AGA PMEC’s and/or discussion of test interpretation with tion-and-management CRS, and Managing Partner and medical director another physician). - : https://www.ama-assn.org/ of Illinois Gastroenterology Group, Elgin, Ill.; Dr. AMAsystem/files/2019-06/cpt-office-prolonged-svs- E/M learning module Mehta is the AGA’s advisor to the AMA RVS Update CMS also plans to add a new Healthcare Com- code-changes.pdf Committee (RUC), a member of the AGA PMEC’s mon Procedure Coding System (HCPCS) add-on- AMA MDM table : https://edhub. CRS, and assistant professor of medicine at the code as of Jan. 1, 2021, that can be used to rec ama-assn.org/interactive/18057429 University of Pennsylvania, Philadelphia; and Dr. ognize• additionalVisit complexity resource inherent costs that to evaluationare inher : https://www.ama-assn.org/ Garcia is the AGA’s Alternate Advisor to the AMA entand in managementtreating complex associated patients. with medical care system/files/2019-06/cpt-revised-mdm-grid.pdf- RUC, a member of the AGA PMEC’s CRS, and assis- serGPCX1vices - that serve as the continuing focal point - tant professor of medicine and gastroenterology for all needed health care services and/or with Connect with your coders and/or medical bill at Stanford (Calif.) University. There were no con- medical care services that are part of ongoing ing company to create a plan for training physi flicts of interest. cians and staff to ensure a smooth transition on 22 Jan. 1, 2021. March 2020 / GI & Hepatology News

18_19_21_22_23_GIHEP20_3.indd 22 2/25/20 11:04 AM Continued from previous page of local susceptibility and resistance infection as well as posttreatment forward and deal with H. pylori like cumulative effect given the approxi- patterns. Therapies that reliably evaluations. We must add our voice other infectious diseases. mately 2 million treatments annually cure H. pylori without unnecessary to advocate for hospitals and central is tens of thousands of kilograms of antibiotics need to be used whereas laboratories to offer susceptibility Dr. Graham is a professor of medicine, inappropriate antibiotic use annually regimens that fail to reliably achieve testing locally or as a send out for Baylor College of Medicine, Houston; with the likely consequence of in- high cure rates should be abandoned. clinicians to provide locally relevant Dr. El-Serag is chair of the department creasing resistance. We should consider establishing antimicrobial therapy for H. pylori in- of medicine, Baylor College of Medi- How to move forward? The CDC quality metrics related to appropriate fections. The CMS rule provides both cine. Neither had conflicts of interest documents regarding antimicrobial diagnostic testing for both the initial the impetus and the methods to move related to this comment. stewardship in hospitals with limited resources (www.cdc.gov/antibiot- ic-use/core-elements/resource-lim- ited.html) suggest creation and promotion of evidence-based treat- ment guidelines for common clinical syndromes, tracking of antibiotic dis- pensing using available data, setting of national targets for improvement, and description of resistance patterns to improve treatment guidelines and identify priority pathogens. The CDC documents require creating and promoting of evidence-and suscep- tibility-based treatment guidelines, tracking antibiotic dispensing, and setting targets for improvement (i.e., monitoring and reporting). It is important to note that the CMS rule focused on hospitals as they have tra- ditionally been the sites where local susceptibility data are obtained and gathered to provide the regional data and updated treatment guidelines used to treat most infectious diseases. The Houston Consensus Confer- ence on Testing for Helicobacter pylori Infection in the United States in 2017 had several recommenda- tions that would effectively address the CMS rule and CDC recommen- dations. For example, statement 15: that empiric eradication therapy for H. pylori be based on region or - ceptibility data (Grade 1B); state- mentpopulation-specific 17: that validated antibiotic diagnostic sus testing of stool or gastric mucosal biopsy by culture and susceptibility, or molecular analysis be universally available (Grade 1); statement 18: that antibiotics that may be rou- tinely evaluated for susceptibility include amoxicillin, clarithromycin,

tetracycline (Grade 2C); and state- mentlevofloxacin, 19: that metronidazole, professional societies and provide the research needed to sup- port evidence-based reimbursement decisions for antibiotic susceptibility testing for H. pylori (Grade 1).

to join with the infectious disease communityOrganized to gastroenterology make H. pylori an needs infection of joint interest. Mass erad- ication of H. pylori worldwide offers the promise of elimination of gastric cancer. The CMS rule should result in

to treating H. pylori infections that in- cludessignificant improved changes testing in the and approach availabil- ity and implementation of knowledge

MDedge.com/gihepnews / March 2020 23

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