Gastroenterology by Recog- Nopathy and Vascular Architecture Is Maintained

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September 2019 Volume 13 / Number 9 Test could inform INSIDE FROM THE AGA JOURNALS care of patients with Inflammation in NAFLD pancreatic cysts It reduces quality of life, not fibrosis. • 12 BY JENNIFER SMITH those who need no addi- MDedge News tional care. AGA PRESIDENTIAL Simeon Springer, PhD, PLENARY

eiring . newly developed of Ring Therapeutics in test could help Cambridge, Mass., and GI’s stars present clinicians more colleagues described the essential information uzanne M

s A

. Get the details. • 22

r accurately identify which development and testing patients with pancreatic of CompCyst in Science cysts require surgery, ac- Translational Medicine. AGA POSTGRADUATE D ourtesy

C cording to researchers. The researchers collect- Dr. Annieke C.G. van Baar found that endoscopic duodenal mucosal The test, CompCyst, ed data from 875 patients COURSE SUMMARIES resection improved glycemia in patients with type 2 diabetes. incorporates clinical and who had undergone Moderators imaging data as well surgical resection of pan- summarize DDW® as data on genetic and creatic cysts. The team sessions Endoscopic duodenal biochemical markers as- used clinical, imaging, Read news from GI’s sociated with pancreatic and molecular data from subspecialties. • 27 cancer. 436 of those patients to mucosal resection CompCyst proved more train CompCyst to clas- effective than standard sify patients into three AGA GUIDELINE practice in estimating categories. Diagnosis of watery found effective in T2D the risk of cancer so as • Patients with benign, diarrhea to differentiate patients nonmucin-producing It’s important to rule out BY DOUG BRUNK crease in liver transaminase who should undergo sur- cysts who do not require things first. • 28 MDedge News levels at 24 weeks, which gery from patients who surgery or monitoring was sustained at 12 months require monitoring and See Cysts · page 31 mong patients with post procedure,” researchers suboptimally con- led by Annieke C.G. van Baar, Atrolled type 2 diabetes MD, wrote in a study pub- Vitamin D supplementation may who use oral glucose-lower- lished online in Gut. ing medication, endoscopic For the study, Dr. van Baar, improve ulcerative colitis duodenal mucosal resection of the department of gastro- (DMR) can be implemented enterology and hepatology at BY WILL PASS bo-controlled trial involv- MD, of the Postgraduate In- safely and effectively, results Amsterdam University Med- MDedge News ing 60 patients with active stitute of Medical Education from a multicenter, interna- ical Center, and colleagues at disease. and Research in Chandi- tional, phase 2 study demon- seven clinical sites enrolled itamin D supplemen- Those who achieved vi- garh, India, and colleagues. strated. 46 patients with type 2 di- tation may lead to tamin D levels greater than They noted that the find- “DMR elicited a substantial abetes who were on stable Vsignificant improve- 40 ng/mL were most likely ings contribute much-need- improvement in parameters glucose-lowering medication ments in ulcerative colitis to benefit, reported lead ed clinical data to a largely of glycemia as well as a de- See Resection · page 20 (UC), based on a place- author Rizwan Ahamed Z, See Vitamin D · page 32

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Presorted Standard Presorted CHANGE SERVICE REQUESTED SERVICE CHANGE GI & Hepatology News Hepatology & GI This advertisement is not available for the digital edition. NEWS LETTER FROM THE EDITOR: The month of new beginnings is here

This month’s Letter from the Editor is guest Our September issue also emphasizes authored by Dr. Megan A. Adams the importance of professional advocacy by Quick quiz chronicling the participation of four AGA lead- eptember is a month of new beginnings, ers (Dr. Carr, Dr. Kaufman, Dr. Ketwaroo, and Q1. A 43-year-old woman presents to the office as summer transitions to fall, kids go Dr. Mathews) in the 2019 Alliance of Specialty after Roux-en-Y surgery for weight loss. She has a Sback to school, and we return to more Medicine Fly In, a multisociety effort to lobby strong family history of gallstones, and asks about consistent work routines, refreshed and re- legislators on key issues such as reducing measures to prevent gallstone formation after her invigorated after some well-deserved surgery. time off with family and friends. A large study by Dr. Paul Among our cover stories this month is Moayyedi and colleagues Which of the following agents has potential efficacy a study showing a novel application of to reduce gallstone formation for this patient? deep learning to inform clinical care of demonstrates that PPI therapy A. Conjugated estrogens patients with pancreatic cysts. We also may be unnecessary in the B. Ursodeoxycholic acid feature several high-impact studies C. Fenofibrate from AGA’s journals, including a large majority of patients on oral D. Simvastatin randomized controlled trial by Dr. Paul anticoagulants, despite current E. Cholestyramine Moayyedi and colleagues, demonstrating that PPI therapy may be unneces- Dr. Adams guideline recommendations. Q2. A 56-year-old male with known chronic pan- sary in the majority of patients on oral creatitis presents with progressive abdominal pain, anticoagulants, despite current guideline rec- prior authorization burdens and minimizing weight loss, and obstructive jaundice and a bilirubin ommendations. This study has the potential to the strict constraints of step-therapy proto- of 8 mg/dL. A CT scan with contrast reveals a 4-cm substantially change clinical practice, partic- cols. We also are pleased to acknowledge the mass in the pancreas head. There is no lymphade- ularly in the context of the current discussion future leaders of gastroenterology by recog- nopathy and vascular architecture is maintained. regarding PPI benefits and harms, and our nizing the 17 exceptional fellows who demon- transition to value-based care. We also high- strated their passion for advancing GI clinical What is the next best step in management? light a proof-of-concept study demonstrating care by presenting their institutional quality A. Pancreaticoduodenectomy (Whipple procedure) a potential role for probiotics (specifically Bi- improvement projects at a special session at B. Lateral pancreaticojejunostomy procedure (Peus- fidobacteria) in reducing the risk of NSAID-re- DDW® 2019. We hope you find these stories tow) procedure lated gastrointestinal bleeding, and another to be thought provoking, inspiring, and direct- C. EUS +/- FNA study showing a possible role for clopidogrel ly relevant to your clinical practice – thank D. MRI/MRCP in chemoprevention of colorectal cancer. Both you for reading! E. ERCP with bile duct brushing and stent articles are accompanied by expert commen- taries highlighting their potential effect on Megan A. Adams, MD, JD, MSc The answers are on page 20. clinical practice. Associate Editor

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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 gastroenterologist VP/Group Publisher; Director, FMC Society Partners Mark Branca Editor in ChiEf, The New GasTroeNTeroloGisT with timely and relevant news and commentary about clinical developments Editor in Chief Mary Jo M. Dales Bryson Katona, MD, PhD and about the impact of health care policy. Content for Gi & hEpatoloGy nEws is developed through a partnership of the newspaper’s medical board of editors Executive Editors Denise Fulton, Kathy Scarbeck assoCiatE Editors Megan A. Adams, MD, JD, MSc (Editor in Chief and Associate Editors), Frontline Medical Communications Inc. Editor Lora T. McGlade Ziad Gellad, MD, MPH, AGAF and the AGA Institute Staff. “News from the AGA” is provided exclusively by the Creative Director Louise A. Koenig AGA, AGA Institute, and AGA Research Foundation. All content is reviewed by the Kim L. Isaacs, MD, PhD, AGAF Director, Production/Manufacturing Rebecca Slebodnik Gyanprakash A. Ketwaroo, MD, MSc medical board of editors for accuracy, timeliness, and pertinence. To add clarity and context to important developments in the field, select content is reviewed by and National Account Manager Artie Krivopal, 973-290-8218, Larry R. Kosinski, MD, MBA, AGAF cell 973-202-5402, [email protected] Sonia S. Kupfer, MD commented on by external experts selected by the board of editors. Digital Account Manager Rey Valdivia, 973-206-8094, [email protected] Wajahat Mehal, MD, PhD The ideas and opinions expressed in Gi & hEpatoloGy nEws do not necessarily Senior Director of Classified Sales Tim LaPella, 484-921-5001, reflect those of the AGA Institute or the Publisher. The AGA Institute and Frontline Editors EmEritus [email protected] Colin W. Howden, MD, AGAF Medical Communications Inc. will not assume responsibility for damages, loss, Advertising Offices 7 Century Drive, Suite 302, Parsippany, Charles J. Lightdale, MD, AGAF or claims of any kind arising from or related to the information contained in NJ 07054-4609 973-206-3434, fax 973-206-9378 this publication, including any claims related to the products, drugs, or services aGa institutE staff mentioned herein. Advertisements do not constitute endorsement of products on Managing Editor, Gi & hepaToloGy News, Brook A. Simpson the part of the AGA Institute or Frontline Medical Communications Inc. Managing Editor, The New GasTroeNTeroloGisT, Ryan A. Farrell FRONTLINE MEDICAL COMMUNICATIONS Senior Publications Coordinator Jillian L. Schweitzer POSTMASTER Send changes of address (with old mailing label) to GI & Corporate VP, Human Resources & Facility Operations Director of Publications Lindsey M. Brounstein Hepatology News, Subscription Service, 10255 W Higgins Road, Suite 280, SVP, Finance Steven J. Resnick Carolyn Caccavelli Vice President of Publications Erin C. Landis Rosemont, IL 60018-9914. VP, Operations Jim Chicca Data Management Director Mike Fritz offiCErs of thE aGa institutE RECIPIENT To change your address, contact Subscription Services at 1-800-430- VP, Sales Mike Guire Circulation Director Jared Sonners President Hashem B. El-Serag, MD, MPH, AGAF 5450. For paid subscriptions, single issue purchases, and missing issue claims, VP, Society Partners Mark Branca Corporate Director, Research & Comms. President-Elect M. Bishr Omary, MD, PhD, AGAF call Customer Service at 1-833-836-2705 or e-mail [email protected] VP, Editor in Chief Mary Jo M. Dales Lori Raskin Vice President John M. Inadomi, MD, AGAF The AGA Institute headquarters is located at 4930 Del Ray Avenue, VP, Editorial Director, Clinical Content Director, Custom Programs Patrick Finnegan Secretary/Treasurer Lawrence S. Kim, MD, AGAF Bethesda, MD 20814, [email protected]. Karen Clemments Editorial Offices 2275 Research Blvd, Suite 400, Rockville, MD VP, Digital Content & Strategy Amy Pfeiffer ©2019 by the AGA Institute. All rights reserved. No part of this publication 20850, 240-221-2400, fax 240-221-2548 President, Custom Solutions JoAnn Wahl may be reproduced or transmitted in any form or by any means, electronic or Gi & hEpatoloGy nEws (ISSN 1934-3450) is published monthly for VP, Custom Solutions Wendy Raupers mechanical, including photocopy, recording, or any information storage and In affiliation with Global Academy for Scan this QR VP, Marketing & Customer Advocacy retrieval system, without permission in writing from the publisher. $230.00 per year by Frontline Medical Communications Inc., Code to visit Medical Education, LLC 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609. mdedge.com/ Jim McDonough President David J. Small, MBA Phone 973-206-3434, fax 973-206-9378 gihepnews

MDedge.com/gihepnews / September 2019 5 FROM THE AGA JOURNALS Pantoprazole not needed for most patients on anticoagulant/antiplatelet therapies

BY WILL PASS aspirin alone, and related findings ulcer disease (2.6%). The median coronary artery disease or symp- MDedge News were reported previously. follow-up was 3.01 years, ranging tomatic peripheral artery disease, While combination therapy did from 2.49 to 3.59 years. Perma- as there was no overall impact on or most patients taking anti- reduce cardiovascular risks, it had nent discontinuations occurred at clinical upper-GI events or upper-GI platelet and/or anticoagulant less favorable effects on gut health, approximately equal rates in the bleeding,” the investigators wrote. Ftherapies, the proton pump highlighted by an associated in- pantoprazole (21%) and placebo “This is in contrast to previous inhibitor (PPI) pantoprazole is un- crease in major GI bleeding events. (22%) group, after a median of 11 systematic reviews of randomized necessary, based on findings from Despite early cessation of the car- months (338 days). In both groups, trials reporting that PPIs were as- the prospective COMPASS trial, diovascular portion of the trial, the more than 96% of participants who sociated with a 50%-70% reduction which involved more than 17,000 pantoprazole regimen was contin- continued treatment took their in bleeding and symptomatic peptic participants. ued, offering a look at the effect of medications as prescribed at least ulcers related to nonsteroidal an- Pantoprazole may reduce the risk long-term PPI use on gut health. 80% of the time. ti-inﬂammatory drugs, including in of bleeding from gastroduodenal At baseline, about two-thirds of the critical care setting.” lesions, but it is unlikely to prevent participants (64%) were not taking Post-hoc analysis, which allowed upper-gastrointestinal events, re- a PPI, requiring randomization to Pantoprazole may reduce for a broader definition of upper-GI ported lead author Paul Moayyedi, either 40-mg pantoprazole once the risk of bleeding from events related to gastroduodenal MB ChB, PhD, AGAF, of McMaster daily or matching placebo. The pri- ulcers, revealed a slightly greater University in Hamilton, Canada, and mary efficacy outcome was time to gastroduodenal lesions, but it reduction in risk of bleeding lesions colleagues. first upper-GI clinical event, defined is unlikely to prevent upper- in patients taking pantoprazole, The investigators wrote in Gas- as a composite of the following: compared with placebo (hazard troenterology, “Guidelines suggest upper-GI obstruction, perfora- gastrointestinal events. ratio, 0.45), and additional risk that patients receiving the com- tion, at least five gastroduodenal reductions for peptic ulcers (HR, bination of antiplatelet and anti- erosions with at least 3 days of GI 0.46) and erosions (HR, 0.33). Ul- coagulant therapy should receive pain, symptomatic gastroduodenal Analysis showed that upper-GI timately, pantoprazole reduced the PPIs to reduce the risk of upper-GI ulcer involving at least 3 days of GI events occurred marginally less of- combined rate of post-hoc events bleeding. However … there are no pain, overt upper-GI bleeding of un- ten in the pantoprazole group than by 56%. randomized data to support the known origin, occult bleeding (drop the placebo group, but without sta- The investigators noted that these use of PPI therapy in patients tak- in hemoglobin of at least 2 g/dL), tistical significance (1.2% vs. 1.3%; ulcer- and erosion-reducing effects ing oral anticoagulants, and a pau- overt bleeding with a gastroduode- P = .35). Of the outcomes measured, of pantoprazole align with previous city of data relating to aspirin.” nal lesion (active bleeding during only overt bleeding of gastroduode- reports. “It is therefore possible To fill this knowledge gap, the endoscopy), or a symptomatic nal origin detected by radiography that PPIs might be beneficial for investigators recruited 17,598 gastroduodenal ulcer involving at or endoscopy was statistically less patients at particularly high risk for participants from 33 countries least 3 days of GI pain. In addition common in the pantoprazole group peptic ulcer disease who are also who had stable peripheral artery to this measure, the investigators than the placebo group, with a taking aspirin and/or anticoagu- disease and cardiovascular disease. evaluated a post-hoc endpoint with 48% reduced rate (0.2% vs. 0.4%; lants,” the investigators concluded. Participants were randomized to a looser definition of peptic ulcer P = .03). No statistical efficacy dif- The COMPASS trial was funded one of three groups: 100-mg aspi- events, most notably eliminating ferences or statistical interactions by Bayer AG. The investigators rin once daily, 5-mg rivaroxaban the requirement that a lesion be ac- were detected between population disclosed additional relationships twice daily, or a combination of tively bleeding during endoscopy. subgroups. with Allergan, Takeda, Janssen, and 2.5-mg rivaroxaban twice daily with Most patients in the trial (78%) “The data suggest that routine others. 100-mg aspirin once daily. This were male, and 23% were current use of PPI therapy is not warranted [email protected] part of the trial was discontinued smokers. Smaller proportions of for patients receiving low-dose ri- before completion because of early the population were taking a non- varoxaban with or without aspirin SOURCE: Moayyedi P et al. Gastro. cardiovascular advantages associat- steroidal anti-inflammatory drug for the prevention of atherothrom- 2019 May 2. doi: 10.1053/j.gas- ed with combination therapy over (5%) and/or had a history of peptic botic events in patients with stable tro.2019.05.056. Clopidogrel matches aspirin for reducing risk of colorectal cancer

BY WILL PASS antiplatelet properties, they noted. the potential role of locally activated platelets in MDedge News “The mechanism of action of low-dose aspirin upregulating COX-2 expression in adjacent nucle- to explain its protective effect is subject to debate,” ated cells of the intestinal mucosa, have led [to] the lopidogrel appears to reduce the risk of col- the investigators wrote in Clinical Gastroenterol- postulation that low-dose aspirin could exert its Corectal cancer (CRC) as much as low-dose ogy and Hepatology. “Although aspirin is a non- chemoprotective effect via its antiplatelet action.” aspirin, based on a case-control study involving steroidal anti-inﬂammatory drug (NSAID) and Although previous studies have explored the more than 15,000 cases. these drugs are known to prevent CRC through the chemoprotective potential of other antiplatelet Risk of CRC was reduced by 20%-30% when inhibition of cyclooxygenase (COX)-2 in epithelial agents, such as clopidogrel, the resultant body clopidogrel was given alone or in combination and stromal cells in the large bowel, at low doses of evidence remains small. In 2017, for example, with aspirin, reported lead author Antonio Ro- (75-300 mg/d) aspirin has only transient effects Avi Leader, MD, and colleagues reported that dríguez-Miguel of Príncipe de Asturias University on this isozyme, while permanently inactivating the chemoprotective effect of dual-antiplatelet

Hospital in Madrid and colleagues. This finding platelet COX-1 and suppressing thromboxane A2 therapy (DAPT) with clopidogrel and aspirin was adds support to the hypothesis that low-dose as- production. The apparent lack of dose-dependence superior to aspirin monotherapy, based on an pirin is chemoprotective primarily because of its of the chemoprotective effect of aspirin, as well as Continued on page 8

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GIHEP_7.indd 1 8/22/2019 9:07:16 AM FROM THE AGA JOURNALS Probiotic protects against aspirin-related intestinal damage

BY WILL PASS troenterology. These findings may be en issues in the small intestine via MDedge News relevant for millions of people, the disruption of microbiota. investigators noted, because 30% of “Whereas acid and pepsin are he probiotic Bifidobacterium Americans older than 40 take low- the principal luminal aggressors in breve Bif195 could protect pa- dose acetylsalicylic acid (ASA/aspi- NSAID-gastropathy, bile and indeed Ttients from aspirin-related gut rin) for cardiovascular disease (CVD). bacteria are the luminal factors in tions may offer an attractive, pre- damage, according to investigators. NSAID-associated gastrointesti- NSAID-enteropathy,” the investigators ventative strategy,” they wrote. The Healthy volunteers given aspirin nal issues are a long-standing and wrote. investigators noted that previous and Bif195 had significantly less well-known problem, but the patho- “Given that deleterious composi- human trials using probiotics for damage and fewer ulcers in their genesis of this process in the small tional changes to the microbiota, in NSAID-enteropathy have been in- small intestines than did control intestine appears more complex than addition to direct effects on mucus consistent; however, they suggested participants who received aspirin in the stomach. The investigators and epithelial tissue, may increase that Bifidobacteria remain worthy alone, reported lead author Brynjulf pointed out that proton pump in- the risk of NSAID-enteropathy, we candidates because of their reported Mortensen, PhD, an employee of Chr. hibitors, which limit gastropathy by hypothesized that an intervention abilities to outcompete pathogenic Hansen A/S, and colleagues in Gas- suppressing acid, may actually wors- targeting microbiome-host interac- Continued on following page

Continued from page 6 additional 8% risk reduction. The present study he role of aspirin in reducing the risk of col- patient age or sex. The caveat is that history of aimed to build on such findings with evaluation of Torectal cancer is well established, although CRC screening or colonoscopy was not known a Mediterranean cohort, which could reduce con- the mechanisms of actions are not entirely clear. for cases or controls, and many other confound- founding lifestyle factors, owing to a lower rate of One possible mechanism is through inhibition of ers, such as diet, exercise, and other lifestyle and cardiovascular morbidity than other populations. the cyclooxygenase-1 (COX-1) pathway. medication history that may account The nested, case-control study involved 15,491 The authors investigated the role of for the differences could not be easily cases of CRC and 60,000 controls who were ran- aspirin but also clopidogrel, another teased apart. If confirmed by others, domly selected and frequency matched by sex, antiplatelet drug that works through these data suggest an additional bene- age, and year of indexing. Data were drawn from inhibition of the COX-1 pathway in ficial effect of antiplatelet agent clopi- Base de datos para la Investigación Farmacoep- reducing the risk of CRC in a case-con- dogrel in reducing risk of CRC, if taken idemiológica en Atención Primaria (BIFAP), a trol study from Spain. CRC cases were for more than 1 year. The study opens Spanish medical record database with more than randomly matched with cancer-free the door to exploring mechanisms by 7 million patients. Records of patients involved in controls, and the use of aspirin and which antiplatelet agents may reduce the present study were screened for prescription clopidogrel as a risk factor for CRC was risk of CRC, and the potential role of of three antiplatelet agents: low-dose aspirin, studied. Not surprisingly, aspirin use Dr. Shaukat other antiplatelet agents in reducing clopidogrel, and triflusal. Additional categoriza- was associated with reduced risk of risk of CRC. tion identified current users, recent users, past CRC by 17%, However, what’s new is users, and nonusers. The effects of clopidogrel that the use of clopidogrel was associated with Aasma Shaukat, MD, MPH, AGAF, GI section chief and aspirin were evaluated separately, as mono- reduced risk of CRC by 20% also but use of dual Minneapolis VAMC and professor of medicine, therapies, and together, as DAPT. therapy (aspirin plus clopidogrel) did not confer University of Minnesota, Minneapolis. She has Demographically, the mean age of the entire additional benefit. The results did not differ by no conflicts of interest. study population was 68.6 years, with a slight male predominance (59%). Median follow-up was similar between cases and controls, at approximately tigators found similar rates of chemoprotection. to appear early in treatment, independently 3 years, ranging from about 1.5 to 6 years. Cases Current aspirin usage of any duration offered an from lifestyle factors, but risk reduction depends showed higher rates of gout, alcohol abuse, acute adjusted risk reduction of 17%, compared with on current usage. Although short-term usage digestive diseases, and peripheral artery disease, 25% for clopidogrel, and 29% for DAPT. Beyond of either aspirin or clopidogrel was associated whereas controls were more likely to have histo- 1 year of continuous and current usage, the su- with an increased risk of CRC, the investigators ries involving stroke, acute myocardial infarction, periority of DAPT was called suggested that this was more chronic digestive diseases, and constipation. into question, as clopidogrel likely a perceived risk rather Controls were more likely to be current aspirin monotherapy offered the than an actual one. “In our users than patients diagnosed with CRC (12.8% vs. greatest risk reduction, at view, this observation could 12.2%), giving an associated adjusted odds ratio 37%, compared with 22% for be explained in part by a (AOR) of 0.83. Risk reduction became statistically aspirin, and 22% for DAPT. detection bias, owing to an apparent after 180 days of aspirin usage, with Risk analyses involving triflusal lacked statistical increased risk of GI bleeding induced by anti- an AOR of 0.79, and more prominent in the 1- to significance. platelet agents that could lead to a greater num- 3-year range, with an AOR of 0.73. This chemopro- “The results of the present study are compati- ber of colonoscopies, and, as a result, an early tective effect faded rapidly with discontinuation. ble with a chemoprotective effect of clopidogrel cancer diagnosis,” they wrote. Current clopidogrel usage led to a compara- against CRC, equivalent in magnitude to the one The study was funded by the Fundación In- ble level of risk reduction, with an AOR of 0.80. observed for low-dose aspirin,” the investiga- stituto Teóﬁlo Hernando. Dr. García-Rodríguez It wasn’t until a year of continuous clopidogrel tors wrote. “This finding indirectly supports the disclosed a relationship with CEIFE, which has monotherapy that risk reduction became sta- hypothesis that the chemoprotective effect of received funding from Bayer and AstraZeneca. tistically significant, with an AOR of 0.65, which low-dose aspirin is mediated mostly through the [email protected] dropped to 0.57 between years 1 and 3. permanent inactivation of platelet COX-1.” Turning to a matched comparison of aspirin or The investigators pointed out that the chemo- SOURCE: Rodríguez-Miguel et al. Clin Gastroenterol Hepa- clopidogrel monotherapy versus DAPT, the inves- protective effects of antiplatelet therapy begin tol. 2018 Dec 20. doi: 10.1016/j.cgh.2018.12.012.

8 September 2019 / GI & Hepatology News Continued from previous page astrointestinal bleeding related group. This is a proof of concept with 4,351 plus or minus 3,195 au bacteria, strengthen the intestinal Gto NSAID use is a significant study, and the clinical implications in the placebo group (P = .0376). epithelial layer, and modulate in- cause of morbidity and mortality of these findings are unclear. This For ulcers alone, the Bif195 co- flammation. “Our strain selection in patients taking these drugs. The study evaluated healthy volunteers hort had an AUC ulcer number of was based on the anti-inflammatory risk of NSAID-related peptic ulcer taking a higher dose of aspirin than 50.4 plus or minus 53.1 au, versus properties of certain Bifidobacteria can be reduced by PPI therapy, but usually used for cardioprotection 75.2 plus or minus 85.3 au for the and experimental preclinical evi- no intervention has been proven over a relatively short time period. placebo arm (P = .0258). Fecal dence for a role of Bifidobacteria in to reduce ulceration Bif195 should be evalu- calprotectin was also significantly NSAID-associated ulceration.” beyond the duodenum ated in a phase 3 clinical lower in the Bif195 group than in The double-blind, placebo-con- in NSAID users. Animal trial involving patients the placebo group, whereas the trolled trial involved 75 healthy models suggest the gut requiring NSAIDs over a remaining five secondary end- volunteers aged 18-40 years microbiota may be im- longer time frame, with points did not achieve statistical who lived a sedentary lifestyle; portant in the develop- small-bowel bleeding significance. during the study, they refrained ment of NSAID-related being the main clin- Fecal microbiome analysis re- from medications and bacterial small-bowel intestinal ical endpoint. These vealed changes were limited to a products that might alter gastro- injury, but how this are fascinating results marked increase in the total B. breve intestinal function. Participants translates to patients is and suggest protection population in the Bif195 arm, the were randomized in a 1:1 ratio to unclear. Dr. Moayyedi from NSAID-related investigators wrote. These data pro- received Bif195 or placebo for 8 Mortensen et al. con- small-bowel injury may vide further evidence that microbial weeks. Aspirin 300 mg was given ducted the first randomized trial of be added to the growing list of intervention strategies can be clin- daily to all participants for the Bifidobacterium breve (Bif195) to conditions that manipulating gut ically efficacious without inducing first 6 weeks. At six time points, prevent aspirin-induced small-bow- microbiota may treat major alterations in the overall mi- video capsule endoscopy was per- el injury as determined by video crobial population structure. formed to determine the effect of capsule endoscopy in healthy Paul Moayyedi, MB ChB, MPH, “The trial results indicate that Bi- treatment. The primary endpoint volunteers taking 300-mg aspirin PhD, AGAF, is the Audrey Campbell fidobacterium breve Bif195 confers was intestinal damage, reported for 6 weeks. They reported a sig- Ulcerative Colitis Research Chair significant and objectively verifi- as area under the curve (AUC) nificant reduction in small-bow- and assistant dean of research at able protection against small-intes- for Lewis score, which incorpo- el ulceration, as well as overall McMaster University. He is also tinal damage caused by a 6-week rates stenosis, villous edema, small-bowel injury score in the the principal investigator of the ASA challenge in healthy volun- and ulcers. The main secondary group randomized to Bif195, com- Inflammation, Microbiome, and Al- teers,” the investigators wrote. endpoint focused on ulcers, quan- pared with placebo. There was also imentation: Gastro-Intestinal and The study was funded by Chr. tified by a separate AUC. Six other a statistically significant reduction Neuropsychiatric Effects network. Hansen A/S. One author reported secondary endpoints evaluated in fecal calprotectin in the probiotic He has no conflicts of interest. additional support from the Science symptoms, blood intestinal fatty Foundation Ireland. acid binding protein (I-FABP), red [email protected] spots visualized on video capsule trial. Significantly less intesti- did not. Specifically, for Lewis endoscopy, and calprotectin. nal pathology was encountered score, AUC in the Bif195 group SOURCE: Mortensen B et al. Gastroenter- After the 8-week period, 66 of among patients who received was 3,040 plus or minus 1,340 ology. 2019 May 13. doi: 10.1053/j.gas- 75 participants remained in the Bif195 than among those who arbitrary units (au), compared tro.2019.05.008.

CLINICAL CHALLENGES AND IMAGES spiratory rate of 18 breaths per minute, and a pelvis showed marked circumferential wall What’s your blood pressure of 114/71 mm Hg. The physical thickening with mural enhancement of multiple examination was notable for a well-nourished loops of jejunum (Figure A). Small-bowel en- diagnosis? appearance, diffuse abdominal tenderness to teroscopy showed diffuse erosions in the entire palpation without distension, organomegaly, duodenum and many oozing superficial ulcers By Obaidullah Aseem, MD, Daniel S. Childs, MD, or rigidity, and pitting lower extremity edema. with edematous and erythematous mucosa in and Conor G. Loftus, MD. Published previously Laboratory evaluation showed hemoglobin 10.3 the proximal jejunum (Figures B, C). CT scan of in Gastroenterology (2018;154[5]:1241-3. g/dL (normal, 13.5–17.5 g/dL), leukocytes 10 the chest showed right lower lobe consolidation × 109/L (normal, 3.5–10.5 × 109/L), platelets associated with a large right pleural effusion, 34-year-old man with a medical history of 212 × 109/L (normal, 150–450 × 109/L), sodi- and mediastinal, bilateral, hilar and abdominal A psoriasis, on adalimumab, presented with um 131 mmol/L (normal, 135–145 mmol/L), lymphadenopathy (Figure D). Endobronchial a 2-week history of progressively worsening creatinine 1 mg/dL (normal, 0.8–1.3 mg/dL), ultrasound-guided transbronchial biopsy of abdominal pain, nausea, vomiting, melenic albumin 1.8 g/dL (normal, 3.5–5.0 g/dL), and lymph nodes was positive for oval-shaped or- diarrhea, subjective fevers, and generalized C-reactive protein 53 mg/L (normal, less than ganisms exhibiting narrow-based budding on weakness. One week into the illness, he devel- 8 mg/L). Liver chemistries were all normal. GMS stain (Figure E). oped progressive bilateral extremity and scro- Urinalysis was unremarkable with normal urine Based on the clinical scenario and images, tal swelling. protein levels. The enteric pathogen panel by what is the most likely diagnosis? His vital signs included a temperature of polymerase chain reaction was negative. Com- 36.8°C, heart rate of 104 beats per minute, re- puted tomography (CT) of the abdomen and The diagnosis is on page 15.

MDedge.com/gihepnews / September 2019 9 FROM THE AGA JOURNALS Inflammation reduces QoL in NAFLD, not fibrosis

BY WILL PASS registry via centers in Germany (n = 133), the aspartate transaminase (AST) and HbA1c, where- MDedge News United Kingdom (n = 154), and Spain (n = 17). as ferritin was positively correlated. Patient data included demographic factors, lab- Generally, patients with NASH reported variety of demographic and disease-re- oratory findings, and histologic features. Within worse quality of life than that of those with lated factors contribute to poorer quality 6 months of liver biopsy, patients completed the just NAFLD (4.85 vs. 5.31). Factors contrib- Aof life in patients with nonalcoholic fatty CLDQ. uting most to this disparity were fatigue, liver disease (NAFLD), based on questionnaires The mean patient age was 52.3 years, with systemic symptoms, activity, and worry. On a involving 304 European patients. slightly more men than women (53.3% vs. histologic level, hepatic steatosis, ballooning, In contrast with previous research, lobular 46.7%). Most patients (75%) were obese, lead- and lobular inflammation predicted poorer inflammation, but not hepatic fibrosis, was ing to a median body mass index of 33.3 kg/ quality of life; although advanced fibrosis and associated with worse quality of life, reported m2. More than two-thirds of patients (69.1%) compensated cirrhosis were associated with lead author Yvonne Huber, MD, of Johannes had NASH, while approximately half of the a trend toward reduced quality of life, this Gutenberg University in Mainz, Germany, and pattern lacked statistical significance. Multi- colleagues. Women and those with advanced variate analysis, which accounted for age, sex, disease or comorbidities had the lowest body mass index, country, and type 2 diabetes, health-related quality of life (HRQL) scores. The Generally, patients with NASH reported revealed independent associations between investigators suggested that these findings could worse quality of life than that of those reduced quality of life and type 2 diabetes, sex, be used for treatment planning at a population age, body mass index, and hepatic inflamma- and patient level. with just NAFLD. On a histologic level, tion, but not fibrosis. “With the emergence of medical therapy for hepatic steatosis, ballooning, and lobular “The striking finding of the current analysis [nonalcoholic steatohepatitis (NASH)], it will be in this well-characterized European cohort was of importance to identify patients with the high- inflammation predicted poorer quality of life. that, in contrast to the published data on pre- est unmet need for treatment,” the investigators dictors of overall and liver-specific mortality, wrote in Clinical Gastroenterology and Hepatolo- lobular inflammation correlated independently gy, emphasizing that therapies targeting inflam- with HRQL,” the investigators wrote. “These mation could provide the greatest relief. population (51.4%) had moderate steatosis, results differ from the NASH [Clinical Research To determine which patients with NAFLD were no or low-grade fibrosis (F0-2, 58.2%), and no Network] cohort, which found lower HRQL using most affected by their condition, the investiga- or low-grade lobular inflammation (grade 0 or the generic [SF-36 Health Survey Questionnaire] tors used the Chronic Liver Disease Question- 1, 54.7%). The three countries had significant- in NASH compared with a healthy U.S. popula- naire (CLDQ), which assesses physical, mental, ly different population profiles; for example, tion and a significant effect in cirrhosis only.” social, and emotional function, with lower scores the United Kingdom had an approximately The investigators suggested that mechanistic indicating poorer health-related quality of life. 10% higher prevalence of type 2 diabetes and differences in disease progression could explain “[The CLDQ] more specifically addresses symp- obesity compared with the entire cohort, but a this discordance. toms of patients with chronic liver disease, in- decreased arterial hypertension rate of a sim- Although hepatic fibrosis has been tied with cluding extrahepatic manifestations, compared ilar magnitude. The United Kingdom also had quality of life by some studies, the investigators with traditional HRQL measures such as the a significantly lower mean CLDQ score than pointed out that patients with chronic hepatitis [Short Form–36 (SF-36)] Health Survey Ques- that of the study population as a whole (4.73 B or C have reported improved quality of life tionnaire,” the investigators explained. Recent vs. 4.99). after viral elimination or suppression, which research has used the CLDQ to reveal a variety of Analysis of the entire cohort revealed that a reduce inflammation, but not fibrosis. “On the findings, the investigators noted, such as a 2016 variety of demographic and disease-related fac- basis of the current analysis, it can be expect- study by Alt and colleagues outlining the most tors negatively impacted health-related quality ed that improvement of steatohepatitis, and in common symptoms in noninfectious chronic of life. Women had a significantly lower mean particular lobular inflammation, will have mea- liver disease (abdominal discomfort, fatigue, and CLDQ score than that of men (5.31 vs. 4.62; P surable influence on HRQL even independently anxiety), and two studies by Younossi and col- less than .001), more often reporting abdominal of fibrosis improvement,” the investigators con- leagues describing quality of life improvements symptoms, fatigue, systemic symptoms, reduced cluded. after curing hepatitis C virus, and negative im- activity, diminished emotional functioning, and The study was funded by H2020. The investi- pacts of viremia and hepatic inflammation in worry. CLDQ overall score was negatively influ- gators reported no conflicts of interest. patients with hepatitis B. enced by obesity (4.83 vs. 5.46), type 2 diabetes [email protected] The current study involved 304 patients with (4.74 vs. 5.25), and hyperlipidemia (4.84 vs. histologically confirmed NAFLD who were pro- 5.24), but not hypertension. Laboratory findings SOURCE: Huber Y et al. CGH. 2018 Dec 20. doi: spectively entered into the European NAFLD that negatively correlated with CLDQ included 10.1016/j.cgh.2018.12.016. Top AGA Community patient cases

hysicians with difficult patient 1. Combination therapy with Entyvio nosed with multiple small bowel Pscenarios regularly bring their (http://ow.ly/jS7C30phgMe) – The GI ulcers. questions to the AGA Community community shared their experiences (https://community.gastro.org) to with combination therapy of Entyvio 3. When losing weight is too difficult seek advice from colleagues about and immunomodulators in patients (http://ow.ly/4Has30phgSi) – How do therapy and disease management with ulcerative colitis who have you approach NAFLD patients who options, best practices, and di- developed antibodies to anti-TNF (http://ow.ly/mDjc30phgKX) – Read an have a difficult time committing to a agnoses. In case you missed it, therapy. update on this patient with rheuma- weight-loss treatment plan? here are the most popular clinical toid arthritis who was experiencing Access these clinical cases and discussions shared in the forum 2. Small bowel ulcerations in anemic recurrent abdominal pain associated more discussions at https:// recently: patient with rheumatoid arthritis with iron-deficiency anemia diag- community.gastro.org/discussions.

12 September 2019 / GI & Hepatology News NEWS FROM THE AGA Prior authorization and step therapy: My visit to Capitol Hill

BY AVINASH G. KETWAROO, MD, BAYLOR COLLEGE ernment affairs, we visited the offices of our How to get involved in advocacy OF MEDICINE, HOUSTON congressional representatives and senators Interested in advocacy but not sure how to or throughout the afternoon. During our meet- whether you have time in your busy schedule? s an early-career gastroenterologist, I ings with congressional staff, we stressed the AGA has an array of options for how you can be ac- have become increasingly aware of the importance of making changes to current prior tive in advocacy. Some take as little as 5 minutes. Aimpact of advocacy in championing legis- authorization and step-therapy approaches to Letter writing. AGA uses GovPredict, an online lation important to our patients. Initially naive make it easier for our patients to access the advocacy platform that allows members to con- about health care advocacy, I owe much to AGA right treatments as soon as possible. We also tact their member of Congress with just a few in preparing and arranging for opportunities discussed the importance of supporting grad- to speak with elected officials and their staff on uate medical education to ensure we have a During our meetings with congressional GI-related priorities and bills. As a member of future cohort of gastroenterologists and other the AGA Congressional Advocates Program, I specialists to meet the rising demands of our staff, we stressed the importance of making received training and support in visiting Capitol population. We were well received, and the changes to current prior authorization Hill, discussing specific legislation and upcoming briefs prepared by the alliance and AGA, as bills, writing op-eds, and hosting site visits. well as tips on effectively communicating our and step-therapy approaches to make Most recently, AGA sponsored my attendance at positions, made the whole process seamless. it easier for our patients to access the the Alliance of Specialty Medicine Annual Advoca- Discussing our own personal experiences and right treatments as soon as possible. cy Fly In. With colleagues from around the country sharing patient stories, we found our meetings – in specialties ranging from ophthalmology to to be productive and insightful. dermatology – we listened to invited congressional Now, I hope to host my congresswoman, Rep. clicks. AGA develops messages on significant representatives and senators on important bills Lizzie Fletcher, D-Tex., for a site visit locally at pieces of legislation, key efforts in Congress or that can directly affect the care we provide to our Baylor, after a successful meeting with her aide on issues being advanced by federal agencies patients. We had the opportunity to ask questions on Capitol Hill. that have a great effect on gastroenterology. of these legislators, many of whom were fellow None of this would have been possible without AGA’s ongoing letter writing campaigns can al- physicians, and gain advice on effective advocacy, AGA’s support in arranging these presentations, ways be found on gastro.org, but be sure to keep as well as build camaraderie with our colleagues in meetings, and physically supporting us through- an eye out for advocacy emails, AGA eDigest, and other specialties who face similar issues. out the process. I encourage all of you to utilize social media, so you do not miss your opportu- With colleagues from Texas, and assisted by AGA in advocating for our patients. It is fun, high nity to take action on timely issues. AGA encour- Kathleen Teixeira, AGA vice president, gov- impact, and incredibly insightful! Continued on page 19

CLINICAL CHALLEGES AND IMAGES ology, but commonly The diagnosis includes generalized edema owing to hy- Answer to: “What is your diagnosis? poproteinemia and on page 9: Erosive protein- resulting reduced losing enteropathy secondary to oncotic pressure. GI disseminated histoplasmosis symptoms are not fre- quently observed. The This patient was treated with amphotericin initial step in evaluating a patient with symp- treatment resulted in healing of intestinal B and transitioned to oral itraconazole with toms concerning for PLE is to rule out more ulcers and correction of hypoalbuminemia, frequent blood level monitoring to ensure common causes of hypoproteinemia, such as thereby confirming the diagnosis of PLE and absorption. His symptoms improved gradu- renal or hepatic disease, and malnutrition. To obviating the need for a confirmatory alpha ally. Small-bowel enteroscopy 3 weeks after confirm enteric protein loss, alpha 1-antitryp- 1-antitrypsin clearance study. presentation showed a normal duodenum and sin clearance with a 24-hour stool collection is healing, superficial ulcers in the proximal jeju- commonly and reliably used. Treatment of PLE References num (Figure E, F, G). Blood albumin levels had is centered on treating the underlying cause 1. Umar SB, DiBaise JK. Protein-losing enterop- recovered to 3.1 g/dL (normal, 3.5–5.0 g/dL). while monitoring and treating malnutrition, athy: case illustrations and clinical review. Am Protein-losing enteropathy (PLE) is a rare including micronutrient deficiencies. J Gastroenterol. 2010;105:43-9. syndrome characterized by loss of serum pro- Fungal infections are a rare cause of PLE, but 2. Tsiodras S, Samonis G, Boumpas DT. et al. teins in the gastrointestinal (GI) tract, resulting important to recognize as a potential complica- Fungal infections complicating tumor necrosis in significant hypoproteinemia and consequent tion of tumor necrosis factor–therapy, because factor alpha blockade therapy. Mayo Clin Proc. edema.1 PLE can also result in ascites, pleural these medications are commonly used for a 2008;83:181-94. and pericardial effusions, and, in prolonged variety of autoimmune diseases.2 Although 3. Kok J, Chen SC, Anderson L, et al. Pro- cases, malnutrition. There are a variety of histoplasmosis is an uncommon cause of GI tein-losing enteropathy and hypogamma- causes of PLE that can be broadly grouped into inflammation, disseminated histoplasmosis globulinaemia as first manifestations of erosive GI disorders, disorders of increased causing PLE has been previously reported.3 In disseminated histoplasmosis coincident GI mucosal permeability, and disorders of our patient, Histoplasma capsulatum infection with Nocardia infection. J Med Microbiol. increased interstitial pressure. The clinical caused diffuse GI ulcers, which allowed protein 2010;59:610-3. presentation depends on the underlying eti- loss in the GI tract (erosive PLE). Antifungal [email protected]

MDedge.com/gihepnews / September 2019 15 This advertisement is not available for the digital edition. NEWS FROM THE AGA AGA participates in 2019 Alliance of Specialty Medicine Fly In

hank you to the following members who Patients experience significant barriers to #steptherapy with the bipartisan Safe Step joined us to advocate for some of the most medically necessary care because of prior au- Act (H.R. 2279). #Patients should be given a Tpressing issues facing gastroenterologists thorization requirements for services that are clear, equitable & transparent appeals process and our patients at the 2019 Alliance of Specialty eventually routinely approved. H.R. 3107, the concerning step therapy. Urge your member of Medicine Fly In. Our advocates met with House Improving Seniors’ Timely Access to Care Act, Congress to take action: https://t.co/q4ljhu- and Senate offices to push for reducing prior would increase transparency and accountability MO9X#specialtydocs pic.twitter.com/B2zvRT- authorization burdens and minimizing the strict and reduce the burdens of prior authorization. 6mG5 constraints of step-therapy protocols. • Rotonya M. Carr, MD, University of Pennsyl- Step therapy — AGA (@AmerGastroAssn) July 16, 2019 vania Health System Step-therapy treatment, or “fail first,” requires “Thank you, GI docs. I had colon cancer and a • Peter Kaufman, MD, AGAF, Capital Digestive patients to try and fail medications before insur- GI surgeon saved my life.” Thank you, @RepMark- Care, Bethesda, Md. ers agree to cover the initial therapy prescribed Green, for supporting reducing prior authoriza- • Avinash G. Ketwaroo, MD, Baylor College of by their health care provider. While this protocol tion. https://t.co/kc9fWnA8XB #specialtydocs Medicine, Houston may initially act as a cost-containment mecha- • Simon C. Mathews, MD, Johns Hopkins Medi- nism, it can ultimately lead to more expensive — AGA (@AmerGastroAssn) July 17, 2019 cine, Baltimore health care costs because of devastating patient The Alliance of Specialty Medicine is a coalition complications. H.R. 2279, the Safe Step Act, would of national medical societies representing special- Prior authorization provide a clear and timely appeals process when ty physicians in the United States. Prior authorization is a tedious process and a patient has been subjected to step therapy. This conference took place July 15-17, 2019, at management tool that requires physicians to the Liaison Washington Capitol Hill in Washing- obtain preapproval for medical treatments or Twitter highlights ton, DC. tests before rendering care to their patients. @CongressmanRuiz from Cali combats [email protected]

Continued from page 15 tive voice in policy discussions. ages its members to share letter AGA PAC supports candidates 17 fellows advancing GI and writing campaigns with their col- who support our policy priorities, leagues, as well as posting them such as fair reimbursement, cut- on social media. ting regulatory red tape, support- patient care Meetings with your member of ing patient protections and access Congress. In-person meetings to specialty care, and sustained hese fellows showcased their com- University of California, Los Angeles are an excellent opportunity federal funding of digestive dis- Tmitment to advancing our field @AniKardashianMD to share with your member of ease research. If you are interest- through their quality improvement Sonali Palchaudhuri, MD Congress, or their staff, how the ed in learning more, contact AGA projects presented at DDW® 2019. University of Pennsylvania, Philadelphia issues that affect gastroenter- Government and Political Affairs Each year during Digestive Disease @sopalchaudhuri ology affect you, your patients, Manager, Navneet Buttar, at nbut- Week®, AGA hosts a session titled “Ad- Nasim Parsa, MD and your practice. AGA has a [email protected] or 240-482-3221. vancing Clinical Practice: GI Fellow-Di- University of Missouri Health System, plethora of resources to help Congressional Advocates Pro- rected Quality-Improvement Projects.” Columbia you set up a meeting with your gram. This grassroots program is During the 2019 session, 17 quality Sahil Patel, MD member of Congress, including aimed at establishing a stronger improvement initiatives were present- Drexel University, Philadelphia up-to-date issue briefs, tips and foundation for our current and ed – you can review these abstracts in @sahilr tricks for productive meetings, future advocacy initiatives by the July issue of Gastroenterology in the Vikram Raghu, MD and webinars on how to host creating state teams to work on “AGA Section,” www.gastrojournal.org/ Children’s Hospital of Pittsburgh an on-site visit. AGA staff is al- advocacy on the local, state, and issue/S0016-5085(19)X0009-8. Kudos Amit Shah, MD ways more than happy to help national levels. Participation to the promising fellows featured be- Children’s Hospital of Philadelphia you arrange a meeting either in can include a wide variety of low, who all served as lead authors for Lin Shen, MD Washington, DC, or your home activities, ranging from creating their QI projects. Brigham and Women’s Hospital, Boston state. If you are interested in educational posts on social me- @LinShenMD arranging a meeting with your dia to meeting with members of Manasi Agrawal, MD Charles Snyder, MD member of Congress, please Congress. Members of the Con- Lenox Hill Hospital, New York City Icahn School of Medicine at Mount contact AGA Public Policy Co- gressional Advocates Program @ManasiAgrawalMD Sinai, New York City ordinator, Jonathan Sollish, at are mentored and receive advo- Jessica Breton, MD Brian Sullivan, MD [email protected] or 240- cacy training by AGA leadership Children’s Hospital of Philadelphia Duke University, Durham, N.C. 482-3228. and staff. Participating members Adam Faye, MD Ashley Vachon, MD AGA PAC. AGA PAC is a vol- receive an AGA Congressional Columbia University Medical Center, University of Colorado Anschutz untary, nonpartisan political Advocate Program Certificate, a New York City Medical Campus, Aurora organization affiliated with and Digestive Disease Week® (DDW) @AdamFaye4 Ted Walker, MD supported by AGA. The only polit- badge ribbon, policy badge on Shelly Gurwara, MD Washington University/Barnes Jewish ical action committee supported the AGA Community, and recog- Wake Forest Baptist Health Medical Hospital, St. Louis, Mo. by a national gastroenterology so- nition on AGA’s website. Appli- Center, Winston-Salem, N.C. Xiao Jing Wang, MD ciety, its mission is to give gastro- cations for the next cycle will be Afrin Kamal, MD Mayo Clinic, Rochester, Minn. enterologists a greater presence released in 2019. Stanford University, Calif. @IrisWangMD on Capitol Hill and a more effec- [email protected] Ani Kardashian, MD [email protected]

MDedge.com/gihepnews / September 2019 19 NEWS FROM THE AGA Dr. Juanita Merchant: A researcher to be reckoned with uanita Merchant, MD, PhD, is a renowned University of Arizona department of medicine gastroenterologist whose contributions and chief of the division of gastroenterology Help AGA build a community of investigators Jto the understanding of chronic inflam- and hepatology, used the AGA grant to focus through the AGA Research Foundation. mation and its association with gastric cancer on an important signaling Your donation to the AGA Research Founda- have been called game-changing. She has built pathway that regulates tion can fund future success stories by keep- a remarkable career that spans more than gastric acid levels in the ing young scientists working to advance our 2 decades. Early on, she received the 1998 stomach. The Merchant lab understanding of digestive diseases. Donate AGA-R. Robert & Sally D. Funderburg Research AGA-funded project specif- today at www.gastro.org/donateonline. Award in Gastric Cancer from the AGA Re- ically focused on exploring search Foundation. That funding was key to how Hedgehog signaling her career. Dr. Merchant was able to intensify regulates gastric homeo- tect the disease at an early stage. her investigation into how chronic inflamma- stasis and when dysregu- Gastric cancer is the fourth most common mation can drive cancer cell growth in the upper lated contributes to gastric lignant disease and the second leading cause of gastrointestinal tract, possibly changing physi- cancer. Building on this Dr. Merchant cancer-related death worldwide. In the United cians’ approach to diagnosis and treatment. As research over the years, Dr. States, more than 26,000 people were diagnosed we reflect on her trailblazing research, which Merchant has identified potential biomarkers with the disease in 2018, according to the Na- originated at the University of Michigan, Ann for gastric cancer in chronic Helicobacter-in- tional Cancer Institute. Arbor, and now continues at the University of fected patients’ blood. If physicians are aware Read more and get to know Juanita Merchant, Arizona in Tucson, we celebrate Dr. Merchant that a patient’s Hedgehog-regulated immune MD, PhD by visiting: https://www.gastro.org/ as our AGA Research Foundation researcher of cells in the stomach are supporting the devel- news/dr-juanita-merchant-a-researcher-to-be- the month. opment of gastric cancer, then they can begin reckoned-with-1 Dr. Merchant, a professor of medicine in the to monitor the individual more closely to de- [email protected] Durable glycemic response Resection from page 1

to undergo DMR. The procedure “in- static Model Assessment of Insulin volves circumferential hydrothermal Resistance improved significantly Quick quiz answers ablation of the duodenal mucosa (P less than .001). In addition, the resulting in subsequent regeneration procedure resulted in a moderate Q1. Correct Answer: B 2014. Clin Gastroenterol Hepatol. of the mucosa,” they wrote. “Before reduction in weight (a mean loss of 2014;12:1090-1100. ablation, the mucosa is lifted with 2.5 kg) and a decrease in hepatic Rationale saline to protect the outer layers of transaminase levels. The effects Risk factors for gallstone forma- Q2. Correct Answer: A the duodenum.” DMR was performed were sustained at 12 months. tion include increased age, female under either general anesthesia or While the majority of patients gender, pregnancy, dyslipidemia, Rationale deep sedation by a single endoscopist showed a durable glycemic response diabetes, obesity and rapid In a patient with chronic pan- at each site with extensive experience over 12 months, a minority exhibited weight loss – especially after gas- creatitis and a pancreatic mass, in therapeutic upper GI endoscopy. less benefit from DMR and required tric bypass surgery. Medications the most likely etiology is ad- The mean age of the study par- additional glucose-lowering medi- such as hormone replacement enocarcinoma. This patient ticipants was 55 years; 63% were cation at 24 weeks. “Approximately therapies/ oral contraceptive has radiologically resectable male. Of the 46 patients, 37 (80%) two-thirds of the patients who re- agents, fibrates, somatostatin pancreas cancer. There is no ev- underwent complete DMR and required addition of antidiabetic medi- analogues also increase gallstone idence of lymphadenopathy or sults were reported for 36 of them. cation in the latter phase of study had risk. Currently, there is evidence vascular invasion. Performing A total of 24 patients had at least undergone insulin secretagogue med- suggesting potential benefit of an ERCP with stent placement to one adverse event related to DMR ication withdrawal at screening. For prophylactic cholecystectomy relieve biliary obstruction has (52%), mostly GI symptoms such as future study, it may not be necessary during Roux-en-Y gastric by- not been shown to be of bene- diarrhea, abdominal pain, nausea, to discontinue these medications.” pass, given the potential risk of fit in patients with a resectable and oropharyngeal pain. Of these, Dr. van Baar and colleagues ac- gallstone formation with rapid pancreatic mass. In fact, surgical 81% were mild. One serious adverse knowledged limitations of the study, weight loss following surgery. outcomes are worse if a stent is event was considered to be related including its open-label, uncontrolled However, there is also data from placed in the bile duct. Surgical to the procedure, which “concerned design. “Nevertheless, this study randomized controlled trials that consultation should be obtained a patient with general malaise, mild forms the requisite solid foundation the use of ursodeoxycholic acid and the patient should undergo fever, and increased C-reactive pro- for further research, and controlled following surgery may help re- pancreaticoduodenectomy. EUS tein level on the first day after DMR,” studies are currently underway.” duce risk of gallstone formation is sometimes done, but most cas- the researchers wrote. “The mild The study was funded by Fractyl for this group of patients. es of resectable disease should fever resolved within 24 hours and Laboratories. Dr. van Baar reported go straight to surgery. [C-reactive protein] level normalized having no financial conflicts. Four Reference within 3 days.” study authors reported financial re- Stokes et al. Ursodeoxycholic Reference During follow-up measures tak- lationships with numerous pharma- acid and diets higher in fat pre- Ghaneh P, et al. Biology and man- en 24 weeks after their DMR, he- ceutical and device companies. vent gallbladder stones during agement of pancreatic cancer. Gut moglobin A1c fell by a mean of 10 [email protected] weight loss: A meta-analysis of 2007;56(8)1134-52. mmol/mol (P less than .001), fasting randomized controlled trials. [email protected] plasma glucose by 1.7 mmol/L (P SOURCE: van Baar ACG et al. Gut. 2019 Jul less than .001), and the Homeo- 22. doi: 10.1136/gutjnl-2019-318349.

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* Use as directed. Take 1 pill in the morning for 14 days. May take ‡Complete resolution of heartburn was defi ned as 7 consecutive 1 to 4 days for full e† ect. days without heartburn. † Based on a post hoc analysis of 2-week data from 2 previously § First resolution defi ned as a study day when patients recorded published identical phase IV, multicenter, randomized, double- “NO” sleep disturbances due to frequent heartburn on daily blind, placebo-controlled trials that demonstrated effi cacy diary card. and safety of esomeprazole 20 mg once daily in the morning in subjects with sleep disturbances due to refl ux and frequent nighttime heartburn.

References: 1. National Sleep Foundation. Ease heartburn at bedtime. https://sleep.org/articles/ease-heartburn-bedtime/. Accessed August 6, 2018. 2. Johnson DA, Le Moigne A, Hugo V, Nagy P. Rapid resolution of sleep disturbances related to frequent reﬂ ux: e† ect of esomeprazole 20 mg in two randomized, double-blind, controlled trials. Curr Med Res Opin. 2015;31(2):243-250.

GIHEP_21.indd 1 5/21/2019 9:34:53 AM AGA PRESIDENTIAL PLENARY Developments in gastric cancer

BY PRATEEK SHARMA, MD relative with gastric cancer. Histologically, GIM is with clear photographic documentation of gastric characterized as either complete – defined as the regions and pathology. astric cancer is the fifth most common presence of small intestinal-type mucosa with ma- On standard white-light endoscopy, GIM ap- malignancy worldwide with high mortality ture absorptive cells, goblet cells, and a brush bor- pears as small gray-white, slightly elevated Gand morbidity. der – or incomplete – with columnar “intermediate” plaques surrounded by mixed patchy pink and In the United States, gastric cancer accounts for cells in various stages of differentiation, irregular pale areas of mucosa causing an irregular uneven 1.6% of all cancers with an estimated 27,510 cases mucin droplets, without a brush border. Extensive surface. Sometimes GIM can present as patchy erin 2019 per the SEER database. Although the inci- and incomplete type of GIM is ythema with mottling. dence of gastric cancer has been decreasing in the associated with a higher risk On the other hand, presence of features such as United States, there have been trends suggesting of gastric cancer (Endoscopy. differences in color, loss of vascularity, elevation an increased rate in select populations, especially 2019;51[4]:365-88). or depression, nodularity or thickening, and ab- in the young Hispanic population aged 20-49 years Gastric cancer screening normal convergence or flattening of folds should (SEER Cancer Statistics Review [CSR] 1975-2015). has been shown to be effec- raise suspicion for gastric dysplasia or early gastric Risk factors for gastric cancer include increasing tive in countries with a high cancer. Presence of GIM on endoscopy should be age, male sex, presence of intestinal metaplasia, incidence of gastric cancer. documented in detail with photographic evidence and varying degrees of dysplasia (Endoscopy. However, in low-incidence including the location and extent of GIM, and ob- 2019;51[4]:365-88). Gastric cancer is primarily countries, at-risk patients can taining mapping biopsies that include at least two characterized into two subtypes: intestinal type, be identified based on epide- Dr. Sharma biopsies from the antrum (from lesser and great- which is the more common type associated with miology, genetics, and environ- er curve) and from the body (lesser and greater gastric intestinal metaplasia (GIM), and the diffuse mental risk factors as well as incidence of H. pylori, curve). Endoscopic surveillance is recommended type, which is genetically determined. and serologic markers of chronic inflammation every 3 years in patients with extensive GIM affect- GIM, a precancerous lesion, is defined as the such as pepsinogen, and gastrin (Am J Gastroenter- ing the antrum and body, incomplete GIM, and a replacement of the normal gastric mucosa by in- ol. 2017;112[5]:704-15). H. pylori eradication has family history of gastric cancer. testinal epithelium and can be limited (confined to been shown to reduce the risk of developing gas- one region of the stomach) or extensive (involving tric adenocarcinoma in patients with H. pylori-as- Dr. Sharma is professor of medicine and director of more than two regions of the stomach). Risk fac- sociated GIM. For detection of dysplasia and early fellowship training, division of gastroenterology and tors for GIM include Helicobacter pylori infection, gastric cancer, patients with GIM should undergo a hepatology, University of Kansas, Kansas City. He has age, smoking status, and presence of a first-degree full systematic endoscopy protocol of the stomach no conflicts of interest. Colonoscopy: Can we get better?

BY DOUGLAS K. REX, MD, AGAF ments, with recent comparative brighter illumination modes have remarkably high ADRs when applied studies consistently demonstrating brought electronic chromoendoscopy by a trained endoscopist who un- n a study presented at the AGA that colonoscopy has superior sensi- back. A recent meta-analysis found derstands the full spectrum of endo- Presidential Plenary session at tivity, especially for flat and serrated that the brighter illumination with scopic appearances of precancerous IDigestive Disease Week (DDW)® lesions. Similarly, capsule colonos- narrow-band imaging in the most colorectal lesions and applies meticu- 2019, Pilonis et al. from Poland re- copy does not match the sensitivity recent version of Olympus colonos- lous inspection technique. ported that a negative high-quality of colonoscopy, requires extensive copes, when combined with excellent There is still great room for im- screening colonoscopy (to the cecum preparation, and is diagnostic only. preparation, produces substantial provement, including the tolerability and performed by a doctor with an These factors gains in detection compared with of bowel preparation and the safety adenoma detection rate [ADR] over limit even the fu- white-light examination. of colonoscope insertion and resec- 20%) is associated with a substantial ture role of cap- Similarly, the new series of Fu- tion methods. Screening colonoscopy reduction in colorectal cancer risk sule colonoscopy jinon colonoscopes contains two at intervals of 15 years or longer is and death. The benefit persisted for to a small group alternative imaging platforms called likely to enter guidelines. Despite at least 16 years after the colonos- of patients who “blue-light imaging” and “linked-color its inherently invasive character, the copy. A study by Brenner et al. in fear the invasive imaging”, both of which are associat- progressive improvements in colo- Germany found that protection lasted aspect of colo- ed with detection gains in multiple noscopy quality and technology have more than 20 years after a negative noscopy. randomized trials. Chromoendoscopy thus far prevented the disruption of colonoscopy. In the past with methylene blue MMX, delivered screening colonoscopy. Colonoscopy We are now at the 50-year anniver- decade, Endocuff Dr. Rex orally in pills given with the bowel will continue to be a viable screening saries of colonoscopy and polypec- has emerged as preparation, recently has been shown option until a truly convenient, non- tomy. The drivers for the remarkable a dominant mucosal exposure de- to increase detection in a single invasive, affordable test that provides growth of colonoscopy, including as vice, resulting in gains in ADR of 7% large, randomized, controlled trial. long-lasting protection is developed. a screening test in some countries, in meta-analyses. Recent evidence Although not FDA approved, pending have been unparalleled sensitivity shows that Endocuff is the first de- the results of a second study current- Dr. Rex is professor of medicine and and the capacity for single-session vice to allow both faster withdrawal ly being organized, these results sug- director of endoscopy in the division diagnosis and treatment. CT colonog- and improved detection. gest yet another avenue for improved of gastroenterology and hepatology raphy has not achieved widespread Tools for highlighting precancerous detection. at Indiana University Medical Center use for a variety of reasons, but an lesions are making real progress. The first two randomized trials of in Indianapolis. He has been a consul- important issue has been the steady High-definition optics is included in artificial intelligence programs that tant for Olympus, Boston Scientific, improvement in colonoscopy result- the list of technologies that improve highlight polyps have been report- Medtronic, Aries, and Braintree Lab- ing from development and expansion detection, and only high-definition ed, and both produced substantial oratories; he has received research of quality initiatives and technical instruments should be purchased in gains in ADR. Despite these technical support from EndoAid, Olympus, and advances in imaging. CT colonogra- 2019 and beyond. Although recently developments, high-definition white Medivators. He maintains ownership phy has not matched these improve- considered ineffective for detection, light colonoscopy alone can provide in Satisfai Health.

22 September 2019 / GI & Hepatology News AGA POSTGRADUATE COURSE Upper and lower gastroenterology – the state of the art

BY DAVID A. KATZKA, MD der and discussed the emerging ment of inflammatory bowel disease timely talk by Xavier Llor, MD, PhD, role of endoscopic pyloromyoto- (IBD). David Rubin, MD, AGAF, shared on when to suspect and how to test n the upper GI section of the Post- my. Michael Camilleri, MD, AGAF, his expertise and vast experience for the expanding definition of Lynch graduate course program, Ikuo delivered a thorough analysis on for best management of ulcerative syndrome. Lin Chang, MD, AGAF, IHirano, MD, AGAF, educated us the concept of colitis while Edward Loftus Jr., MD, delivered the penultimate clinical on the refractory patient with eo- leaky gut with AGAF, discussed the fact and fiction of lecture on management of irritable sinophilic esophagitis, reinforcing data-driven rec- diet-based therapy in IBD. This was bowel syndrome based on her many the need for chronic maintenance ommendations followed by a timely lecture by Chris- years of clinical expertise in this treatment and the complementary on testing and tina Ha, MD, AGAF, on the need to area. Finally, Gail Hecht, MD, AGAF, a role of dilation. Gregory Ginsberg, the lack of ade- think well outside the GI tract in IBD, former AGA president, summarized MD, AGAF, elucidated the specific quate treatment. discussing infections, cancers, and the exciting world of microbiome strategies needed for gastric polyps Finally, William vaccinations in patients with IBD. The research from the recent annual Gut with advice on which to leave and Chey, MD, AGAF, IBD section finished with an erudite Microbiota for Health World Summit. which to resect. Sachin Wani, MD, gave perspective and timely lecture by Marla Dubin- All in all it was considered one of the AGAF, carefully outlined the chang- to diagnosis and Dr. Katzka sky, MD, evaluating the controversy best AGA Postgraduate courses by ing landscape of Barrett’s esophagus treatment of over use of biosimilars in our clinical many and we look forward to even with emphasis on our move to ab- small-bowel bacterial overgrowth, practice. The remainder of the lower greater improvements for 2020. late rather than observe low-grade particularly with its role in irritable GI section started with AGA Presi- dysplasia. bowel syndrome. dent David Lieberman, MD, AGAF, Dr. Katzka is professor of medicine In the difficult area of treating In the lower GI section of the analyzing recent data on the need to and head of the Esophageal Interest gastroparesis, Linda Nguyen, MD, course, Sunanda Kane, MD, AGAF, move the colonic cancer screening Group at the Mayo Clinic in Rochester, acquainted us with some of the gave a wonderful overview the pres- age to 45 years, particularly in Afri- Minn. He is on the advisory boards for newer medications for this disor- ent and emerging biologics for treat- can Americans. Following this was a Shire and Celgene. The postgraduate course on liver, pancreas, and biliary tract

BY JOSEPH AHN, MD, MS, MBA, AGAF MD, MPH, AGAF, delivered a tract, was headed by Timothy Gardner, MD, who state-of-the-art presentation shared the pearls of the management of pancreati- he course was framed with the theme, “The on the burgeoning burden of tis. Michelle Kim, MD, AGAF, provided fresh and up- TPractice of Gastroenterology: The Literature hepatocellular carcinoma and to-date insights on the management of pancreatic and the Art,” with each speaker highlighting not cutting-edge multidisciplinary and biliary cancer, including updated technological only the relevant updates in the literature, but management. Vijay Shah, MD, options. Finally, Marcia Canto, MD, discussed the also sharing the insights into the art of medical AGAF, then reminded us of the hot topic of pancreatic cancer and whether screen- practice. The course incorporated an audience persistent presence of alcohol- ing should be instituted. Both of these sessions had response system to fully utilize the available ed- ic liver disease in the United designated time set aside for panel discussions ucational technology and increase participant States and the controversies Dr. Ahn with questions from the audience. engagement. surrounding liver transplan- Manal Abdelmalek, MD, provided an update on tation in this setting. Steven Flamm, MD, AGAF, Dr. Ahn is professor of medicine and director of the hot topic of nonalcoholic fatty liver disease, completed the liver session by sharing the secrets clinical hepatology at Oregon Health & Science including new developments in pharmacother- of managing the complications of cirrhosis. University, Portland. He has no relevant conflicts apy. The AGA President-elect, Hashem El-Serag, The second session, on the pancreas and biliary of interest.

UPPER GI TRACT Large prospective trial offers reassurance for long-term PPI use

BY WILL PASS lead author Paul Moayyedi, MB ChB, The present, prospective trial, aspirin, which, in combination, were MDedge News PhD, AGAF, of McMaster University in COMPASS, involved 17,598 par- recently shown to reduce cardiovas- Hamilton, Ont., and colleagues. ticipants from 33 countries with cular outcomes among patients with side from a possible increased “To our knowledge, this is the stable peripheral artery disease and stable cardiovascular conditions. As Arisk of enteric infections, long- largest PPI trial for any indication cardiovascular disease. “We use the such, participants in the trial were term use of the proton pump inhibi- and the first prospective random- term participants, rather than pa- randomized to one of three groups: tor (PPI) pantoprazole appears safe ized trial to evaluate the many long- tients, as not all of those taking part 100-mg aspirin once daily, 5-mg in patients with stable atheroscle- term safety concerns related to PPI in this research would have been rivaroxaban twice daily, or 2.5-mg rotic vascular disease, according to therapy,” the investigators wrote in patients throughout the trial but all rivaroxaban twice daily combined a prospective trial involving more Gastroenterology. They noted that participated in the randomized con- with 100-mg aspirin once daily. The than 17,000 participants. patients are often alarmed by “sen- trolled trial,” the investigators wrote. primary efficacy outcomes for these In contrast with published observa- sational headlines” about PPI safety. In addition to evaluating the safety three groups were stroke, myocardial tional studies, the present trial found “There are balancing articles that of pantoprazole, the study was initial- infarction, and cardiovascular death. no associations between long-term more carefully discuss the risks and ly designed to measure the efficacy This portion of the trial was discon- PPI use and previously reported benefits of taking PPI therapy but of pantoprazole for preventing upper tinued early because of evidence that risks such as pneumonia, fracture, or these receive less media attention,” gastrointestinal events in partici- showed the superiority of combina- cerebrovascular events, according to the investigators added. pants taking rivaroxaban and/or Continued on following page

MDedge.com/gihepnews / September 2019 27 AGA GUIDELINE AGA issues guideline for watery diarrhea

BY JIM KLING low pooled sensitivity and specificity. CRP levels is available, IgG tTG or IgG DGP can be com- MDedge News might be useful in settings in which fecal lacto- bined with IgA tTG. Positive celiac disease tests ferrin or calprotectin tests are not available or should be confirmed by duodenal biopsy. new guideline from the American Gastroen- covered by insurance. Bile acid diarrhea should be tested for in the terological Association (AGA) aims to help Patients should be tested for giardia infec- United States by measuring total bile acids in a Aphysicians diagnose the cause of chronic tion, using the antigen test or PCR, because this 48-hour stool collection to document increased watery diarrhea, particularly to exclude diagnoses pathogen is common in the United States and fecal bile acids, or serum fibroblast growth fac- other than functional diarrhea or diarrhea-pre- easily treated. tor 19, to identify defective feedback of bile acid dominant irritable bowel syndrome (IBS). The Patients who have not recently traveled to or synthesis. The Selenium HomotauroCholic Acid guideline, published in Gastroenterology, does not from high-risk areas should not be tested for ova Test (SeHCAT) has moderate diagnostic efficien- apply to patients with concerning presentations and parasites because this is unlikely to identify a cy, but it is not available in North America. A like weight loss/anemia, diarrhea with signs of fat culprit. There are other guidelines for treating pa- measurement of serum levels of 7alpha-hydroxy- malabsorption, bloody diarrhea, cases with a fam- tients who have traveled to high-risk countries. 4-cholesten-3-one (C4), which measures bile ily history of inflammatory bowel disease (IBD), Celiac disease should be tested for using im- acid synthesis, is not yet available. colon cancer, or celiac disease or to those who have munoglobulin-A tissue transglutaminase (IgA No recommendation was made for using traveled to diarrheal disease–related regions. tTG) and a second test (IgG tTG and IgG or IgA de- available serologic tests for the diagnosis of IBS To rule out IBD, physicians can use either amidated gliadin peptide, or DGP) in case the pa- because existing evidence suggests they lack the fecal calprotectin (threshold value of 50 mi- tient has IgA deficiency that could lead to a false diagnostic accuracy needed for routine use. crog/g, sensitivity, 0.81; specificity, 0.87) or negative on the primary test. Thresholds of 7-15 The guideline development was funded by fecal lactoferrin (threshold, 4.0-7.25 mcg/g; AU/mL in IgA tTG typically provide sensitivity AGA and had no outside funding. pooled sensitivity for IBD, 0.79; specificity, and specificity greater than 90%. A quantitative [email protected] 0.93). Neither erythrocyte sedimentation rate IgA level found to be normal confirms the IgA tTG (ESR) nor C-reactive protein (CRP) should be test. In abnormal findings, either IgG tTG or a test SOURCE: Smalley W et al. Gastroenterology. 2019 Jul 11. doi: used to diagnose IBD because tests have shown for IgG DGP can be used. If no information on IgA 10.1053/j.gastro.2019.07.004.

Continued from previous page At baseline, about two-thirds of safety outcomes centered on those events occurred, precluding statisti- tion therapy over aspirin alone; how- participants (64%) were not taking previously reported by observational cal analysis. ever, the pantoprazole component of a PPI, requiring randomization to studies, including dementia, chronic The investigastors noted that the the trial continued, as planned, for 3 either 40-mg pantoprazole once daily kidney disease, gastric atrophy, frac- increased rate of enteric infection years. or matching placebo. Pantoprazole ture, cancer, pneumonia, diabetes among PPI users was still lower mellitus, chronic obstructive lung dis- than rates reported by systematic ease, Clostrididoides difficile infection, reviews. “The data in the current and other enteric infections. Hospi- randomized trial were not ad- talization rates for noncardiovascular justed for multiple testing so this academy of educators and cardiovascular events were also result should be interpreted with reported. Data were gathered via caution,” they wrote. Although questionnaires, which were conduct- acid suppression may allow for ed every 6 months. increased ingestion of pathogenic Most patients in the trial (78%) organisms, which could theoret- Grant awards were male, and 23% were current ically increase the risk of enteric smokers. Smaller proportions of the infection, the investigators stated Watch your career takeoff population were taking an NSAID that the benefits of PPIs likely out- (5%) or had a history of peptic ulcer weigh their risks. Now accepting applications. disease (2.6%). The median fol- The COMPASS trial was funded by low-up was 3.01 years. Permanent Bayer AG. The investigators disclosed Awardees receive $1,000 to fund an discontinuations occurred at approx- additional relationships with Bayer, imately equal rates in the pantopra- Allergan, Takeda, Janssen, and others. educational project. Deadline is Aug. 31 zole (21%) and placebo (22%) group [email protected] after a median of 11 months (338 Learn more at gastro.org/academygrants. days). In both groups, more than SOURCE: Moayyedi P et al. Gastro. 96% of participants who continued 2019 May 29. doi: 10.1053/j.gas- Enhance your skills to teach greatness treatment took their medications as tro.2019.05.056. to the next generation. prescribed at least 80% of the time. Analysis of cardiovascular outcomes revealed no significant AGA Resource differences between placebo and AGA patient education on GERD pantoprazole groups. Of all the eval- can help your patients better uated safety measures, only enteric understand and manage the infections differed significantly be- disorder. Post this education on tween groups, occurring at a higher your practice website or share rate in the pantoprazole group than with your patients at https:// in the placebo group (1.4% vs. 1.0%; www.gastro.org/practice-guid- odds ratio, 1.33; 95% confidence in- ance/gi-patient-center/topic/ terval, 1.01-1.75). Although C. difficile gastroesophageal-reflux-dis- EDU19-98 infection was more common among ease-gerd. pantoprazole users, only 13 such

28 September 2019 / GI & Hepatology News For 1st-line constipation relief

The gentle power of MiraLAX® (PEG 3350) is prized by both doctors and patients.1-3

AGA recommends #1 GI-recommended 96% patient PEG laxatives as a laxative satisfaction rate3 fi rst-line treatment4

AGA=American Gastroenterological Association. References: 1. Schiller LR, Emmett M, Santa Ana CA, Fordtran JS. Osmotic effects of polyethylene glycol. Gastroenterology. 1988;94(4):933-941. 2. Hammer HF, Santa Ana CA, Schiller LR, Fordtran JS. Studies of osmotic diarrhea induced in normal subjects by ingestion of polyethylene glycol and lactulose. J Clin Invest. 1989;84(4):1056-1062. 3. Survey of 672 consumers, August 2017, Bayer Consumer Health. 4. Bharucha AE, Dorn SD, Lembo A, Pressman A; American Gastroenterological Association. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144(1):211-217. Doctor recommended, patient approved

GIHEP_29.indd 1 5/22/2019 9:46:30 AM GI ONCOLOGY USPSTF recommends against pancreatic cancer screen

BY LUCAS FRANKI affirming its 2004 guideline, which erans Affairs Palo Alto (Calif.) Health person-years; however, pancreatic MDedge News recommended against screening for Care System and associates. cancer is the third most common pancreatic cancer in asymptomatic Pancreatic cancer is uncommon, cause of cancer death because mor- he U.S. Preventive Services Task adults, according to task force mem- with an age-adjusted annual inci- tality is high. The mortality rate TForce has issued a statement re- ber Douglas K. Owens, MD, of the Vet- dence of 12.9 cases per 100,000 is 11.0 deaths per 100,000 person-years, and an estimated 45,750 people will die from the disease in 2019.

The studies included in the review found no evidence that screening for pancreatic ® cancer or treatment of screen- CROHN’S & COLITIS CONGRESS detected pancreatic cancer improves morbidity or mortality. JANUARY 23–25, 2020 | Austin, TX

In 2004, the USPSTF issued a D recommendation for pancreatic cancer screening in asymptomatic adults TRANSFORMING IBD CARE without a family history of pancreatic cancer or a genetic disorder that increases the risk of cancer. For the 2019 update, the task force conduct- ed a systematic review of 13 studies that assessed the benefits and harms of screening for pancreatic cancer, the diagnostic accuracy of screening tests for pancreatic cancer, and the benefits and harms of treating screen-detected or asymptomatic pancreatic cancer. According to the USPSTF, the studies included in the review found no evidence that screening for pancreatic cancer or treatment of screen-detected pancreatic cancer improves morbidity or mortality, found adequate evidence that the magnitude of GET INSPIRED TO TRANSFORM IBD CARE the benefits of screening for pancre- The premier conference for inﬂammatory bowel disease atic cancer in asymptomatic adults can be bounded as no greater than (IBD) professionals is headed to Austin, Texas. small, and found adequate evidence Connect with fellow IBD leaders, learn more about that the magnitude of the harms of the latest research, and hear what’s on the horizon screening for pancreatic cancer and in potential treatments. Leave with practical treatment of screen-detected pancre- information you can immediately implement. atic cancer can be bounded as at least moderate. Register by September 18 Because no new evidence was found supporting pancreatic cancer and save up to $200. screening in asymptomatic adults, “the USPSTF reaffirms its previous Abstract submissions open late August. conclusion that the potential benefits Exhibit Hall: January 24 & 25, 2020 of screening for pancreatic cancer in asymptomatic adults do not out- weigh the potential harms,” the task To learn more and register, visit force members noted. The task force authors reported no www.crohnscolitiscongress.org disclosures related to the recommendation statement. [email protected]

SOURCE: Owens DK et al. JAMA. 2019 Aug 6. doi: 10.1001/jama.2019.10232.

30 September 2019 / GI & Hepatology News GI ONCOLOGY Monitor for surgery

Cysts from page 1

• Patients who require monitoring Surgery was needed in 152 pa- while CompCyst correctly identified surgery, the researchers noted. because they have mucin-produc- tients in the validation cohort. Stan- 91% (n = 138). Neither method Based on these results, the re- ing cysts with low- or intermedi- dard practice correctly identified would have recommended discharge searchers are hoping to make ate-grade dysplasia 89% (n = 135) of these patients, for any patient who actually required Continued on following page • Patients who have invasive cancer or high-grade dysplasia and require surgery The researchers then tested CompCyst in the remaining 426 patients (validation cohort), comparing CompCyst with standard ® ‘An important aspect of this Make ACTIVIA paper is the comparison between the performance of our test and current clinical your probiotic choice. practice. Because the histopathology of all cysts was known from surgical specimens, we could determine, in retrospect, what the optimal treatment should have been.’ practice, which involves use of clinical and imaging criteria only. “Our aim [in developing CompCyst] was not to replace current knowledge derived from clinical data and imaging characteristics with molecular testing but, rather, to integrate all these aspects together,” study author Marco Dal Molin, MD, of Johns Consume twice a day. Hopkins University, Baltimore, said in a press conference. “An important aspect of this paper is the compar- There are several reasons why your patients should get probiotics from food: ison between the performance of • Probiotic foods can buffer stomach acids and increase the chance that the probiotics survive and make it to the intestine. our test and current clinical prac- • Probiotic supplements in the form of pills don’t usually provide nutrients that some cultures produce during fermentation. tice. Because the histopathology of • Fermented dairy products, like yogurt, are a source of nutrients such as calcium, protein, and potassium. all cysts was known from surgical • Some individuals have trouble swallowing, or just don’t like pills; but yogurt is easy and enjoyable to consume. specimens, we could determine, in Forest plot of composite score of the frequency of minor digestive issues. retrospect, what the optimal treat- LSmeans = least squares means; CI = confidence interval; N = number of subjects that ACTIVIA may help reduce the frequency of minor ment should have been.” completed the study; test for heterogeneity P > 0.10; test for overall effect P = 0.003. digestive discomfort.* Histopathology showed that 53 LSmeans and 95% CI LSmeans 95% CI N Study 1 Two double-blind, randomized, placebo-controlled studies, and a pooled analysis of 2 Weeks – 0.64 [–1.23; –0.05] patients in the validation cohort had 199 these studies, show that ACTIVIA may help reduce the frequency of minor digestive 4 Weeks – 0.64 [–1.19; –0.08] discomfort like bloating, gas, abdominal discomfort, and rumbling.1,2* a benign, nonmucin-producing cyst Study 2 2 Weeks – 0.43 [–0.82; –0.05] 336 Both studies were designed to investigate the effect of ACTIVIA on different gastrointestinal and did not require any addition- 4 Weeks – 0.41 [–0.79; –0.02] (GI) outcomes, including GI well-being and frequency of minor digestive discomfort, al intervention. Standard practice Pooled analysis 2 Weeks – 0.50 [–0.82; –0.17] in healthy women. correctly identified 19% (n =10) of 535 4 Weeks – 0.48 [–0.80; –0.16] In both studies, and in the pooled analysis, the composite score of the frequency of minor these patients, while CompCyst cor- 3 1,2 –1.50 –1.25 -1.00 –0.75 -0.50 -0.25 0.00 0.25 0.50 digestive issues over the two- and four-week test periods in the ACTIVIA group was rectly identified 60% (n = 32). Favors ACTIVIA® Favors control product 2 Weeks 4 Weeks signiﬁcantly lower (P<0.05) than that in the control group. There were 140 patients who had mucin-producing cysts with *Consume twice a day for two weeks as part of a balanced diet and healthy lifestyle. Minor digestive discomfort includes bloating, gas, abdominal discomfort, and rumbling. low- or intermediate-grade dys- 1. Guyonnet et al. Br J Nutr. 2009;102(11):1654-62. 2. Marteau et al. Neurogastroenterol Motil. 2013;25(4):331-e252. 3. Marteau et al. Nutrients. 2019;11(1):92. plasia. Standard practice correctly ©2019 Danone US, LLC. identified 34% (n = 48) of these patients, while CompCyst correctly identified 49% (n = 68). Recommend ACTIVIA. Visit www.activiareferralpad.com “Overall, the use of CompCyst to order your referral pad today. Offer available to healthcare professionals only. would have avoided unnecessary surgery in 60% of the patients in this study,” Dr. Dal Molin said.

MDedge.com/gihepnews / September 2019 31 GI ONCOLOGY

Continued from previous page and D.K. Ludwig Fund for Cancer Re- CompCyst available to patients at search, the Sol Goldman Pancreatic Johns Hopkins within the next 6-12 Cancer Research Center, the Michael months. Rolfe Pancreatic Cancer Foundation, “In the long term, we hope that a the Benjamin Baker Scholarship, new, prospective study will be car- and the National Institutes of Health. ried out, which will gain approval The researchers reported relation- of this test by the FDA [Food and ships with Thrive Earlier Detection, Drug Administration],” said study Personal Genome Diagnostics, author Bert Vogelstein, MD, of Eisai-Morphotek, Sysmex Inostics, Johns Hopkins, at the press confer- Nexus Strategy (Camden Partners), ence. “Then, at that point, we hope NeoPhore, and CAGE. the technology can be commercial- [email protected] ized and offered to the public.”

This research was supported by SOURCE: Springer S et al. Sci Transl Med. opkins the Lustgarten Foundation for Pan- 2019 Jul 17. doi: 10.1126/scitranslmed. ns H H o

creatic Cancer Research, the Virginia aav477. J Gut mucosal immunity Vitamin D from page 1 theoretical subject area. included stool frequency, stool consistency, dictors of response included baseline histologic “[T]he discovery of vitamin D receptors on and remission (UCDAI less than 3); in addi- activity (odds ratio, 1.92), and to a greater extent, lymphocytes, monocytes, and dendritic cells tion, the investigators evaluated histologic, vitamin D supplementation (OR, 9.17). No pa- initiated various studies which have high- endoscopic, fecal, and serum inflammatory tients achieved remission, which the investigators lighted the role of vitamin D in regulating gut markers. attributed to the relatively short study duration. mucosal immunity and gut barrier,” the inves- The majority of patients in the study were men Minor, self-limiting side effects occurred in tigators wrote in Journal of Clinical Gastroen- (60%), with a mean age of 36 years. Most pa- 13.3% and 10% of patients given the vitamin D terology. “In experimental interleukin (IL)-10 tients had moderate UC (73.3%), while smaller supplement and placebo, respectively. knockout mice models, vitamin D deficiency proportions had severe (18%) or mild (8%) dis- “[T]he present study showed significant im- was found to result in severe colitis, progres- ease. All patients were taking a 5-aminosalicylic provement in all inflammatory parameters of sive wasting, and high mortality. However, acid oral compound and some (16.6%) were also the disease including clinical, endoscopic, his- vitamin D supplementation not only prevented taking azathioprine. At baseline, the mean vita- topathologic, and serum and fecal markers of but also ameliorated symptoms of colitis in min D level was 14 ng/mL. Most patients (70%) inflammation, all of which paralleled each other the mice model.” were diagnosed with vitamin D deficiency, based in showing [the benefit of] oral nano vitamin D Human studies have revealed similar asso- on measurements below 20 ng/mL. The remain- supplementation,” the investigators concluded. ciations between vitamin D supplementation ing patients were diagnosed with insufficiency They advised that larger, longer-term studies are and inflammatory bowel disease, such as a (13%; 20-30 ng/mL) or suboptimal levels (17%; needed before the findings can be generalized to study by Jørgensen and colleagues that found 30-40 ng/mL). all patients with active UC. a lower risk of relapse in Crohn’s disease, and From baseline to 4-week follow-up, median The investigators disclosed no external fund- another by Sharifi and colleagues that showed vitamin D level in the supplement group in- ing or conflicts of interest. injectable vitamin D could reduce erythro- creased from 15.4 to 40.83 ng/mL, compared [email protected] cyte sedimentation rate (ESR) and C-reactive with a much smaller increase in the placebo protein (CRP) in patients with UC. Still, the group, from 13.45 to 18.85 ng/mL. Compared SOURCE: Ahamed R et al. J Clin Gastroenterol. 2019 Jul investigators suggested that more clinical data with the placebo group, significantly more 24. doi: 10.1097/MCG.0000000000001233. are needed, particularly for outcomes after vi- patients given nano vitamin tamin D therapy. In addition to providing such D3 achieved a UCDAI 3-point data, the present trial was also the first of its reduction (53% vs 13%; kind to test oral nano vitamin D3, which may P = .001); this translated to have better bioavailability than conventional a Pearson correlation coeffi- supplements. cient (rho) of –0.713, between The investigators initially recruited 110 vitamin D level and UCDAI. patients with active UC who had an ulcer- Similar, albeit less strong, ative colitis disease activity index (UCDAI) of inverse relationships were de- at least 3. After screening, 50 patients were tected between vitamin D lev- excluded because they had vitamin D levels el and CRP (rho = −0.603) and greater than 40 ng/mL, were already taking calprotectin (rho = −0.368). a vitamin D supplement, had severe UC re- Benefits observed in the sup- quiring hospitalization, or exhibited severe plement group also extended systemic illness. The remaining 60 patients to stool frequency, stool consis- were randomized in a 1:1 ratio to receive ei- tency, and histologic measures.

ther 60,000 IU nano vitamin D3 once daily for Those who achieved a vitamin

8 days, or placebo. Disease parameters, which D level greater than 40 ng/mL k were measured at baseline and then again were 4 times more likely to have C inksto at 4 weeks, included UCDAI, ESR, CRP, and a UCDAI 3-point reduction than H fecal calprotectin. The primary outcome was those who did not meet the response, defined as a UCDAI reduction of at same criteria (80% vs 20%; unterann / t least 3 points. Secondary outcome measures P = .038). Independent pre- H

32 September 2019 / GI & Hepatology News IBD AND INTESTINAL DISORDERS FDA finds increased blood clot, death risk associated with Xeljanz

BY LUCAS FRANKI itors. There were also 45 cases of thrombosis also receiving tofaci- TNF inhibitors; ulcerative colitis MDedge News death from all causes during fol- tinib should immediately discon- patients should receive the lowest low-up for tofacitinib 10 mg twice tinue the medication. Tofacitinib effective dosage, and if the higher he Food and Drug Adminis- daily, compared with 25 cases in should not be given to patients dosage is necessary, it should be tration has issued a safety patients who received TNF inhib- with ulcerative colitis unless they limited to the shortest amount of Talert approving new boxed itors. are not treated effectively with a time possible, the FDA noted. warnings about increased blood Patients with symptoms of TNF inhibitor or do not tolerate [email protected] clot and mortality risk associated with the 10-mg, twice-daily dose of tofacitinib (Xeljanz), as well as a new limitation for patients with ulcerative colitis receiving the medication. Join GI trailblazers and Tofacitinib, a Janus kinase in- leaders from AGA and DHPA hibitor, was first approved by the FDA in 2012 for the treatment of AGA Partners to network and discuss rheumatoid arthritis (RA). An in- advanced strategies that dication for psoriatic arthritis was will help you succeed in the added in 2017, and one for ulcer-

2019 changing business of health ative colitis was added in 2018. in Value care. Leave equipped to OCT. 4, 2019 make better decisions for Patients with symptoms of CHICAGO, ILLINOIS the future of your practice. thrombosis also receiving tofacitinib should immediately discontinue the medication. Building strategies for Sponsored by Tofacitinib should not be given success in value-based care. to patients with ulcerative colitis Save $200 if you register by Aug. 6. unless they are not treated effectively with a TNF inhibitor. Visit piv.gastro.org.

PNQ19-9 After the 2012 approval, the FDA commissioned a postmarket- ing trial in patients with RA on background methotrexate to evaluate safety and the risk of cancer, heart-related events, and infection. The 5- and 10- mg tofacitinib twice daily doses are being analyzed in an Finding the right ongoing study in comparison with Job Alerts a tumor necrosis factor (TNF) in- Gastroenterology Physician San Francisco, California hibitor. Full Time job or candidate is An interim analysis of the trial’s data, as of January 2019, found an Nurse Practitioner Washington, D.C. increased risk of blood clots and Part Time at your ﬁngertips death in patients receiving 10-mg Pediatric Gastroenterologist tofacitinib twice daily, compared Billings, Montana Full Time New Grad with the TNF inhibitor and the Your career hub across all twice-daily, 5-mg dose. Overall, there were 19 cases of blood disciplines and specialties in GI. clots in the lung out of 3,884 patient-years of follow-up in pa- Start your search today at tients who received tofacitinib 10 mg twice daily, compared with 3 GICareerSearch.com. cases out of 3,982 patient-years in COM19-024 patients who received TNF inhib-

MDedge.com/gihepnews / September 2019 33 CLASSIFIEDS Also available at MedJobNetwork.com

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You can look forward to: • Compensation potential of $800,000 • Joint venture opportunity San Juan Regional Medical Center is a non-profit and community governed facility. Farmington offers a temperate four-season climate • Productivity bonus incentive with no cap near the Rocky Mountains with world-class snow skiing, fly fishing, • Bread and Butter GI with ERCP skills golf, hiking and water sports. Easy access to world renowned • 1:3 call Santa Fe Opera, cultural sites, National Parks and monuments. • Lucrative benefit package, including retirement Farmington’s strong sense of community and vibrant Southwest • Sign on and relocation culture make it a great place to pursue a work-life balance. • Student loan repayment • Quality work/life balance

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Physician-Led Medicine in Montana Gastroenterology We are seeking a BE/BC Gastroenterologist to join our busy, collegial group. Provide a full spectrum of gastroenterology care to patients both in the hospital and through outpatient procedures. Billings Clinic is nationally recognized for Generous loan repayment clinical excellence. Billings, Montana, • Call 1:6 • Region’s tertiary referral center is a friendly college community located near the magnificent Rocky • State-of-the-art cancer center • Research opportunities Mountains with great schools, safe nationally recognized for • “Top 5 Happiest States” neighborhoods and abundant family clinical excellence – Gallup, 2018 activities. Exciting outdoor recreation is just minutes from home. 300 days Contact: Rochelle Woods • 1-888-554-5922 of sunshine every year! #1 in Montana [email protected] • billingsclinic.com

34 September 2019 / GI & Hepatology News CLASSIFIEDS Also available at MedJobNetwork.com

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MDedge.com/gihepnews / September 2019 35 PRACTICE MANAGEMENT TOOLBOX: Customer service in the medical practice – Are you losing additional revenue opportunities?

BY JIM TURNER, MBA, MHA to that problem is their concern happening in the first place. Mistake #2 - Patients about the financial impact of their Listed below are the five addi- are customers, and f you work in health care or man- visit on the family’s budget. The tional patient experience mistakes just like customers, age a medical practice, you are medical group’s unwillingness to that can cost your group, if they patients have options. Iaware of all the radical changes in rethink how it greets patients as are not recognized as being prior- It should be recognized that patients technology, medicine, social values, they approach the receptionist sets ities for both your staff and your are customers who are concerned and interpersonal relations over the stage for the patient to feel patients. about their future and do not want the past few years and you proba- mishandled or underappreciated. to be in a medical practice request- bly do not expect the next several This initial patient interaction Mistake #1 - Educated ing help. They feel vulnerable and years to be less stressful and less stage must be evaluated and rec- patients are taking control out of their routine comfort zone. uncertain. To ensure your practice ognized as an area of improve- of their health care. Reminding your staff that a patient is and your provider’s success, you ment. If not handled properly, When health care is treated like a customer who has multiple health may need to adjust how your team it will significantly affect how a any other paid service, an unhappy care choices, but chose to come to interacts with patients – starting medical practice or provider is patient will move along to a new your practice, will help your staff un- with the first area of patient inter- graded as a group in the field of facility or doctor if they have a bad derstand the value of providing your action. patient experience and managing interaction – whether it is with the patient with a positive experience. Patients who seek care for their patient expectations. Every med- doctor or the support staff. Educat- health problems are looking for ical office needs to recognize that ing, training, or adjusting staff to Mistake #3 - Dr. Google some measure of kindness when people hold on to negative experi- make changes needed is required is becoming the they approach the window of ences and are not likely to change to ensure that your staff under- patient’s best friend. your office’s receptionist. Many their mind after that negative stands the value of patient appre- Research indicates that many pa- are already apprehensive about experience. The best way to avoid ciation and providing the patient tients arrive at the doctor’s office their clinical condition and adding negative bias is to prevent it from with a positive experience. with some information already on CLASSIFIEDS Also available at MedJobNetwork.com

PROFESSIONAL OPPORTUNITIES

WHERE A LANDSCAPE OF OPPORTUNITIES AWAITS A SOUTHERN OREGON

GASTROENTEROLOGIST Gastroenterology Consultants, PC of Medford, Oregon is seeking another BE/BC Gastroenterologist to join our practice. Gundersen Health System in La Crosse, Wisconsin is seeking a BC/BE Gastroenterologist to join its We are a single specialty group of 8 physicians and 5 mid-level established medical team. practitioners located in beautiful Southern Oregon. Practice in our state-of-the-art Endoscopy Center • Call 1:8 and modern outpatient clinic. Outreach services are • Ownership opportunity in adjacent endoscopic center provided at our satellite clinics located within an • 12 month to full partnership easy drive from La Crosse. In addition, you will have • 5-10 minute commute to work opportunities for clinical research and will be actively involved in teaching our Surgical, • Award winning prep school, local university Transitional, and Internal Medicine residents. • Award winning theatre You’ll join a physician-led, not-for-profit health • Excellent restaurants system with a top-ranked teaching hospital and • World-class outdoor activities one of the largest multi-specialty group practices • Clean air, clean water with about 700 physicians and associate medical staff. Visit gundersenhealth.org/MedCareers • Short trip to Portland, Oregon Coast and San Francisco • Job Type: Full-time Send CV to Kalah Haug Medical Staff Recruitment For more information, contact Gundersen Health System [email protected] Debbie Nielson at 541-773-5031 or call (608)775-1005. You may send your CV to [email protected] Please check our website at

EEO/AA/Veterans/Disabilities www.gcpcmedford.com

36 September 2019 / GI & Hepatology News their condition. Various websites routinely provide high-end services already have provided the patient to their clients. Whether groups like with free access to learn about their it or not, their front-line personnel health condition. Popular medical are compared to five-star hotel recep- sites such as WebMD.com give the tionists, who are expected to greet patient the preliminary education their customers both pleasantly and they are looking for, so they are al- professionally after a long day of ready armed with medical informa- traveling and required business function even before they see the doctor tions. Every medical group must un- or their support staff. derstand that patients have options when they select a medical practice Mistake #4 - Surveys are and they expect to be treated with Research Funding carrying more weight. respect and transparency, and not as Outside surveys are becoming even just another person to be cared for at more popular and are carrying the end of a long day. The same level Opportunities additional weight when combined of service needs to be delivered in the with various social media outlets. doctor’s office no matter what time All types of surveys and reviews are of day because for that patient, the being used to measure not only the personal problems and subsequent The AGA Research Foundation is excited to care the patient received, but also the disposition of the medical staff is announce the start of its 2020 research awards interpersonal relationship between not their problem. All they want is the patient and the doctor, and the cycle. This year the foundation will award over $2 Whether groups like it or not, patient’s experience with the medical million in research funding to support researchers practice’s support staff. Some surveys their front-line personnel are cover all levels in the practice area, in gastroenterology and hepatology. The first two down to the cleanliness of the recep- compared to five-star hotel tion area or the patient’s treatment receptionists, who are expected grants open for applications focus on digestive area, and even the adequacy of the cancers and are due on Aug. 7, 2019. parking lot. These surveys are condi- to greet their customers both tioning patients to recall their entire pleasantly and professionally experience. With a patient experi- after a long day of traveling and ence plan in place, excellent service AGA-R. Robert & Sally Funderburg Research becomes second nature and will be required business functions. Award in Gastric Cancer recognized by those surveyed. someone to listen and help them take Designed for established investigators, this award Mistake #5 - Patient-centered care of their medical problem. Their care is customer service too. long-term loyalty to the group will be provides $50,000 per year for two years (totaling It’s not just about the obvious. Ex- solely dependent on how well each cellent patient (customer) service personal interaction is handled. Re- $100,000) to work on novel approaches in gastric extends beyond a pleasant demean- member that the patient is a person cancer research. or. The patient experience does not first and not just a customer. We must start or end at the doctor’s office. approach each patient with humanity AGA-Caroline Craig Augustyn & Damian Perception is built by gathering in- first, and then customer service. formation from multiple channels, Augustyn Award in Digestive Cancer whether it is through review sites, 2) Be courteous office visits, or surveys. It is nec- and respectful. This grant awards $40,000 for one year to an early essary to consider the importance Remind your staff to be courte- career investigator who currently holds a federal or of those channels when looking to ous, always polite, and to use good build patient loyalty. manners. By treating a patient how non-federal career development award devoted to To avoid the mistakes listed above, they expect to be treated, you are conducting research related to digestive cancer. the more progressive medical prac- showing the patient that you respect tices are training their staff to an- them and care for not only their Other grants in the 2019-2020 season include: ticipate the customer service needs health but also their feelings. The of their patients, much like other health care worker must understand • AGA Research Scholar Awards major service industries. By rolling that the patient is viewing their out a patient/customer experience interactions with staff and provid- • AGA-Takeda Pharmaceuticals Research Scholar training program, they can prevent ers as being symbolic of the overall these mistakes from ever happening group’s brand identity. The group’s Award in IBD and affecting their potential revenue. leadership needs to select and train This training should focus on inte- their workforce to recognize their • AGA-Gastric Cancer Foundation Ben Feinstein grating the following strategies into importance in how patients view Memorial Research Scholar Award in Gastric Cancer their daily work habits to provide their clinical offerings and their in- their patients with exceptional cus- teractions with the patient. tomer service while they are guests in their practice. 3) Never show indifference Learn more at gastro.org/research-funding. to patients. 1) Patients are the lifeline Losing patients before they complete to building the future their treatment regimen is a signif- of their practice. icant liability issue for any medical RSH19-16 Patients are comparing their health practice. In an article written by care services to other companies that Continued on following page

MDedge.com/gihepnews / September 2019 37 Continued from previous page agreement. This situation can be 6) Use plain terms and 9) Stay in touch with patients. Strive Labs CEO and cofounder, Scott dispersed by training your staff to simple explanations. The group needs to find ways to Hebert, DPT, wrote: “Patient churn is consider the source of the conflict, We all want to appear to be super keep in contact with their patients, too big of a problem to ignore, and it respect the patient’s perception, intelligent by trying to use complex whether it is by giving them tips on can have a profound impact on your and then teach the staff member terms to describe a situation because how to remain healthy or the need clinic’s bottom line.” In addition to to tell the patient that they never it creates leverage with the other for proactive and preventive med- the rather obvious missed revenue thought of it that way and ease parties engaged in the conversation. icine. The use of technology and opportunity, a churning patient rep- away from the discussion. Their ab- While some of this may be necessary social media, as well as handing resents a practice liability, because sence will help diffuse the situation. when educating patients on their out freebies at health fairs, giving an unsatisfied patient is significantly condition, any additional complex patients informational brochures more likely to leave you a negative re- 5) Tell patients you terms can easily annoy or even con- upon discharge, or even cards tell- view online — or turn the experience appreciate their business. fuse the patient who is only there ing them how to contact the prac- with your practice into a cautionary How you relate to a patient will seeking help. Health care workers tice in case of emergencies, is quite tale for friends and family members. speak volumes to them about how need to talk in a manner that keeps helpful. Calling your patients is a Either way, it’s bad for business — much you appreciate their loyalty, the patients engaged and helps significant signal that your group and your reputation. all because they chose your practice them understand the topic at hand. values the health and welfare of for their health care. All patient and The worker needs to use everyday your patients. A phone call from 4) Don’t contradict, customer training programs should vernacular examples, so the patient either the doctor or their assistant argue, or match wits. include discussions on making eye quickly understands the reason that goes further than any advertise- It’s tough for a health care worker contact, shaking with a firm grasp, brought them to the clinic and what ment when building brand and doc- who is continually being bombard- and always closing a personal en- they need to do to get some relief tor loyalty. ed in a high-pressure environment counter on a sincere and positive from what ails them. Using this meth- to agree to disagree. When a person note. Health care workers need to od when discussing a patient’s condi- 10) Keep your promises. feels they are right or that their understand that they are in the ser- tion isn’t just for the patient’s benefit Do what you say you are going to do, perception is the only logical one, vice business and that the patients because many confused patients should be a commonly shared man- they can be very stubborn in their they care for have options and they ultimately call the office later in the tra for the medical practice. While understanding, and they will dig in can easily walk out of the medical day only to ask additional questions, changing your mind from time to their heels. It takes a strong person practice and share any negative ex- which uses your staff’s time. time when circumstances prevent to allow others to have their opin- perience on social media. Educating you from keeping a promise, is just ion and not be judgmental about it. and reminding your staff on how 7) Good manners will part of being flexible in life, regularly Any customer or patient relations easily a patient can leave your prac- get you everywhere. breaking promises to other people training program to be deployed in tice or share their experience with Emily Post wrote, “Manners are a isn’t healthy. Here’s how to keep a medical office must include skill others needs to be recognized and sensitive awareness of the feelings of your promises: Pay close attention training to teach the staff member discussed at all the group’s town others. If you have that awareness, to your words – every word you how to diffuse an argument or dis- hall meetings. you have good manners, no matter communicate (through speaking what fork you use.” Proper manners or writing), as a patient may take are behaving in a way that is both your words as a promise. Study your aware of and considerate of the peo- patterns of making promises. Figure ple around us. A person with good out when you tend to make careless manners treats everyone with kind- promises and study the situations ness and respect. It is knowing how in which you do, so you can under- to get along without causing offense stand why you’re promising what IBD or harm, no matter how much the you don’t intend to do. Take time current interaction is going south – and careful consideration before pancreatic disease especially when you are engaged in a making a promise to someone. Don’t Learn what you want tough conversation. rush yourself into a promise that you won’t be able to keep. Stop your- nutrition 8) Keep seeing health self before you make a vow, delaying esophageal disorders care as a calling. your decision long enough to think it t health care workers need to know through carefully. The more careful small bowel disease that their vocation of caring for sick you become about making promises, and injured patients is a calling and the easier it will be to keep them. not just a job and all training pro- The last step of deploying a pa- grams designed to teach customer tient/customer service program is service need to stress this point. handling the change in management DDSEP Practicing your vocation means that that is required to train the staff. Ac- Digestive Diseases Self-Education Program you will work hard to eliminate all cepting “No, we are not changing any barriers that exist between the pa- part of the group to meet the needs Customized by you tient and the health care worker. Too of our patients better” is unaccept- often we underestimate the power able. Usually, you will be introducing Whether preparing for a GI board exam or keeping of a simple touch, a smile, a kind this program to employees that have current on advances in the field, DDSEP 9 allows you word, a listening ear, an honest com- been in a group for a while and so to pliment, or the smallest act of caring get them to buy into the new ideas to customize learning where you want, what you want – all of which have the potential to will require constant reinforcement. turn a life or a bad interaction into a It may take some time to align the and how you want. magical moment for both the patient focus of the group from the neutral All at your fingertips. Also available on AGA University and the health care worker. One that zone to the notion that there are has meaning and a bit of affirmation new deliverables that would better and ddsep.gastro.org of the dignity of both individuals serve your patients. The following EDU19-45 interacting to find some common rules will be helpful when begin- ground. ning your training program:

38 September 2019 / GI & Hepatology News Rule #1 – Be consistent. Every poli- customers prefer human customer tomer-service-matters-in-healthcare/ – 5 Leadership Principles for Creating cy, procedure, and list of priorities service. Harvard Business Review Feb. 25, 2014 6. Senge P, Kleiner the Legendary Customer Experience sends a message – make sure it’s 2019 April 15. A, Roberts C, et al. “The Dance of Courtesy of the Ritz-Carlton Hotel the right message. 4. Matt Brannon. 13 Ways to improve Change: A fifth discipline resource.” Company.” (New York, McGraw-Hill, customer services at your medical (New York, Doubleday, 1999). 2008). Rule #2 – Ensure quick successes. practice. Blog post Sept 7, 2018. 7. Bridges W. “Managing Transitions: Look for ways to get the group’s 5. 5 Reasons Why Customer Service Making the Most of Change.” (Boston, Mr. Turner is chief executive officer employees to buy into the program Matters in Healthcare. https://www. Da Capo Books, 2017). of Indianapolis Gastroenterology – early on after its deployment. pointsgroup.com/5-reasons-why-cus- 8. Michelli J. “The New Gold Standard and Hepatology.

Rule #3 – Symbolize the new identity. Make sure the group’s logos and branding support the new identity of the group and the culture change.

Rule #4 – Celebrate all the group’s successes. Make sure the group’s employees recognize the work efforts involved as well as the success the group will enjoy. Stress the fact that the work completed will significantly enhance the care and service levels to the patients, which should feed the ego of the group to do more and more in the future. And lastly, do not forget how vital the buy-in is of the clinicians of the group. They must be introduced early to the new patient/customer service program and embrace it so that their employees will recognize that these efforts are focused on providing a high quality of care throughout the enterprise. As the French philosopher Albert Schweitzer once stated, “Ex- ample is not the main thing in influ- encing others, it’s the only thing.”

References 1. Peters, T. “The Excellence Dividend: Meeting the Tech Tide with Work that Wows and Jobs that Last.” (New York, Vintage Books, 2018). 2. 10 Strategies to Provide Patients with Superior Customer Service. Beck- er’s Hospital Review 2010 Dec 20. 3. Shell MA, Buell RW. Why anxious

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MDedge.com/gihepnews / September 2019 39 This advertisement is not available for the digital edition.