Paul Farkas

PBC: They took away my Obeticholic acid :(

🤔OCA taken off market

👍Two new meds emerging for PBC: elafibranor and seladelpar

Nice article summarizing dx, meds, etc. (though no mention of fibrates) in JAMA.

#GIsky #IMsky #Medsky

my pressor strategy hepatorenal syndrome in the ICU:

#1) start with NE gtt for immediate BP target acquisition

#2) once pt is improving, use PO midodrine to accelerate weaning off NE

midodrine can be helpful to help liberate patients from ICU

but as initial therapy, midodrine is some weak sauce

Arguments with Neph. Rectal NSAIDS and AKI

🤔Rectal NSAIDS decrease ERCP Pancreatitis

🤔Study with stage 1-3b CKD >7,000 pts each group

👍NO difference in aki and group with NSAIDS less post-ERCP pancreatitis. (Abstract at ACG)

Once got trashed for doing this.😟

#GIsky #IMsky #MEDsky

Fear is the path to the Dark Side.... Embrace the FIB-4

👍We need to be aggressive in r/o advanced fibrosis especially in fatty liver. FIB available from common labs, MD Calc etc to quick calculation.

👍If high risk (see below) or FIB 🔼 elastography.

Crucial with Rx available

#IMsky #MEDsky

"But I want it all"...combining surgery with meds for weight loss

🤔Reviews advantages of pre-op meds, and post-op, as well as long term

👍Something to consider as we increasingly face the issues of 🔼BMI, Metabolic Syndrome, Fatty Liver Disease

#IMSky #GIsky #Medsky

Alpha-Gal Syndrome...nothing to do with Wonder Woman or T Swift😟

🤔Probably missing most of this, often IBS symptoms

🤔Allergy to alpha 1,3 galactose, brought on by lone star tic bite

🤔Symptoms 2-8 hr after ingesting animal products incl milk

🤔No treatment; IgE testing available

#IMsky #Medsky

Ascites...always a controversial issue

🤔AGA Clinical Practice update on Ascites, volume overload and hyponatremia

🤔Not to restrict water till Na <125

😟Still uncertain re-role of Vaptans???

🤔Pts with refractory ascites/hydrothorax consider liver txp referral

#IMsky #medsky #GIsky

The "little blue pill" returns...Exercise induced colon ischemia

🤔Seen in distance runners
🤔Likely due to vasoconstriction
🤔Difficult to prevent at times

👍Novel use of sildenafil and fludrocortisone worked.

Nice review and discussion of workup.

#IMsky #Medsky #GISky

Eosinophilic Esophagitis. Patient handout

🤔Had posted on EoE days ago

👍Perhaps useful with your patients: ACG handout on EoE.

#medsky #IMsky #GIsky

Is Shorter better? Esophageal variceal bleed
due to portal hypertension

🤔Always wondered about value of 5 days of Octreotide after successfully banding varices

😀Study: 1 vs 5 days Rx: No difference in 5 day re-bleeding or 6 week re bleeding and all cause mortality

#GIsky #IMsky #medsky

Gastroporesis thoughts, AmJGastro 10/25 Liu etal

🤔Yearly testing for nut deficiencies: ie D; B12, Folate, Iron
🤔?Daily MVI
🤔Dietary suggestions (below)
🤔Prucalopride ?1mg especially if constipated
🤔They support gastric electrical stimulation
🤔Some differential Dx thoughts

#GIsky #IMSky #MedSky

Food Impaction?? Think EoE.

🤔Nice quick review of Eosinophilic Esophagitis

🤔Many who present acutely have had these symptoms for years

🤔Requires long term management

#Imsky #Gisky #Medsky

Early feeding in post-ERCP pancreatitis

🤔PEP: We all dread it, and treating it makes us nervous.

👍Trial supporting early feeding, within 24 hours. Shorter hospital stays

This already increasingly supported and accepted. ACG and other guidelines.

#GIsky #Medsky #IMsky

Beware of Fake foreign bodies...in the gut

🤔Case of ?FB at EGJ Was Lanthanum Carbonate

Radio-opaque meds: CHIPES (Chloral hydrate, heavy metals, iron, phenothiazides, slow release meds) Another take on CHIPES from Gu et al Korean J Spine 9/15 attached

History is 🔑

#IMsky #GIsky #medsky

Unusual case in Gastro:

16yo: obstipation, 🔼 lfts, ileus, 🔼calcium

Athlete on Ayurvedic supplements (Bhasmas) from incineration of metals and minerals,and Shilajit resin from mountain rocks

All available on Amazon

Lead level 🔼

Resolved with chelation

#IMsky #Medsky #GIsky

Delta Hep: 3 articles/one editorial CinGastro&Hep

🤔Only testing 4.9% meeting AASLD Criteria

🤔HDV associated with markedly 🔼 HCC

🤔Can use PAGE-8 score (or FIB-4) to predict HCC
(On Medscape Reach-B score)

Identifying D important with new meds coming out, and interferon

#IMsky #GISky #Medsky

Acute Variceal Bleeding in cirrhosis...are we there yet?

😀No...not quite, but encouraging that in past two decades recurrent bleeding from 19.4% to 11.8%, Bleeding related mortality 23.6% to 18.3%.

🤔There is always room for improvement

#IMsky #GISKY #Medsky

Scan shows Fatty Pancreas. What is that anyway?

🤔Often considered incedentaloma

🤔Marin-Serrano et al in Pancreas shows associated with cardiometabolic risk factors.

🤔Associated with hepatic steatosis.

Maybe we should consider this an Early Warning Sign, and delve in.

#GIsky #IMSky #Medsky

If all else fails, re-examine the patient

🤔Tet Toe posted a case on Doximity

🤔Have seen it before as well

Pt with severe abdominal pain, negative workup
Re-examined ... Shingles

Can present with abdominal pain before rash.
One pt I saw was on her way to OR

#GIsky #IMsky #medsky

Canadian GI Guidelines re non ulcer UGI Bleed (endorsed by ASGE)

🤔Bleed from NPL Rec Hemostatic spray over conventional endo therapy

🤔Mallory Weiss with non bleeding visible vessels or clots rec no hemostatic Rx

🤔GAVE: Preferred band ligation over APC, prefer APC to RFA.

#GIsky #imsky

Hot Potato...Who treats Obesity?

PCP? GI? Endocrine??

Medscape Commentary: Dr. Muratore Opines that GI should treat
So many GI issues MASLD, MASH, GERD

Training pathways do exist, as well as specific courses

Often this responsibility ignored or passed off

Thoughts?

#GIsky #IMSky #Medsky

Agree. Still a puzzle. Blood tests? Stool tests? Colon??? As someone said perhaps the best test is the one that gets done.

CRC Screening...remains a quandry

🤔Multitarget Stool DNA (Cologuard) at U.Pitt

😟Only 54.7% completed the test

Previous studies 87%-72% of positives undergo Colonoscopy
(Also disappointing)

Best approach to CRC screening remains a puzzle

#IMsky #GIsky #Medsky

Refractory Ascites: The ALFA pump...

👍RA tough to treat. Paracenteses, TIPS, Txp options.

🤔Many not suitable for TIPS, Txp.

ALFA pumps ascites into bladder. Still issues including renal, and its place still uncertain

Recent study encouraging

Anyone with experience?

#Medsky #GIsky #IMSky

I always get antibiotics for my colds

Survey: 54% unaware of C. Diff risk with ABs

Continue efforts to limit AB's.

Need to educate on risk of C. Diff, and warn that if they get diarrhea on antibiotics to let us know

Pt's may not call till critically ill

ICU's busy enough

#IMsky #Medsky

First step would be diuretics/treating as ascites.
If fails can consider periodic pleural taps.
Ultimately (if the patient is a suitable candidate) usually will come down to a TIPS.
Transplant GREAT if pt qualifies and you can get it.

Large R Pleural Effusion

Cirrhosis but no evid of Portal Hypertension
Hx CHF (stable)

Alb gradient 1.6 🔼
+Tc-99m peritoneal cavity scintigraphy

Hepatic Hydrothorax can occur in absence of ascites, but also in absence of other signs of portal hypertension.

Rx challenging

#GIsky #IMsky #Medsky

Celiac: Beware of borderline negative TTG

311 pts with Nml IgA levels
39 borderline negative TTG
Of borderline negative TTG 36% Dx'd with CD (79% in those with borderline neg TTG and +EmA)

Low + and borderline - TTG frequently with dx of CD

Need to follow up on these patients.

#IMsky #Medsky

Ideally primary docs will screen. FIB 4 simple and on med calculators. Most pts probably will not need meds. And primary generally more facile with GLP 1s. As to next level meds will be up to primary. If question of cirrhosis to specialist. Probably all depends on comfort level of primary

Screen high risk pts for MASLD, and TREAT

👍Pts with T2DM, Obesity with 1 met risk factor, abnl LFT's..check FIB4 If abnl elastography

👍If F2-F3 consider treating.

👍All need review diet, exercise, weight loss, ETOH; consider bariatrics.

Reviewed before approval GLP-1

#Medsky #IMsky #GIsky