how to quickly set up a useful MedSky account! 🦋 Mix of basic & more advanced stuff (eg designing user-curated hashtag feeds) 🦋 Take a look & add any useful tips you have in the comments section blog: emcrit.org/pulmcrit/blu... #MedSky

Holiday gift for ya: the IBCC chatbot app 😁 Free AI chatbot searches IBCC contents Answers seem pretty good & it links to relevent chapters for additional info Works as an Ebook index on steroids Created by emergency med folks at Columbia (credit to Joshua Farber & David Fisher) #EMIMCC

New-Onset DM and risk of Pancreatic Cancer 🤔Large prospective study: 6-fold increased risk (at 3yr) 🤔Median lead time 8 months 🤔Not ready to recommend screening, but perhaps looking into other frisk factors (mostly family, hereditary syndromes etc) higher yield in this group #IMsky #MEDsky

IBD, AIH, EoE, etc... ✔️MMR status 🤔With 🔼Measles, consider MMR status, ideally before starting immunotherapy 👍 Immune if: IgG+, Born before 1957, 2MMR shots, doc history infection 👍Nice review, with good flow sheet 👍They also suggested checking out household members. #IMsky #GISky #Medsky

Risk of Cervical Cancer in IBD... 🤔? risk of CC in IBD actually ⬇️, BUT 🔼 in pts on immunosuppression 🤔Not powered to differentiate among immunosupp meds 👍A reminder to screen for Cerv Ca while pts on immunosuppressives, and to re-consider use of HPV vaccine #GIsky #IMsky #Medsky

Indef dysplasia in Barrett's ?What to do 🤔Treat, recheck. What's next? 🤔223 with f/u EGD in one year, 9.87% with neoplasia of any grade. Of those with just IND, repeat f/u 22% incident neoplasia, Risk🔼 with length and smoking 🤔?F/u as LGD, and consider Endo Rx #GIsky #IMSky #Medsky

G-POEM for Gastroparesis 😟Refractory GP hard to treat, miserable for pts 🤔Meta analysis of 23 studies, 871 pts s/p POEMs Observational study 👍Long term benefit (5 years) in 81%. Predicting success was idiopathic, shorter duration, higher baseline severity #GIsky #IMSky #Medsky Poetry anyone?

CDiff going to or coming from the dogs? (and cats) 🤔73yo recur Cdiff Rx'd with Van, Fidax, FMT, bezlotoxumab 👍Dogs + for Cdiff, dogs placed, no more Cdiff 🤔Studies have shown cats and dogs can harbor CDiff 🤔Consider in tough cases (With apologies to dog/cat owners) #GIsky #IMsky #Medsky

Recompensation after HCV cure 🤔Achieved in 36.6% of patients 👍Lower risk for liver-related mortality and PVT 😐Does not change HCC risk (So keep on screening) Let's hear it for DAA's, even in advanced liver disease #GIsky #IMSky #Medsky

My name is Paul and I am a coffee addict 🤔Review suggesting regular consumption reduces progression of liver disease, slowing progression to cirrhosis and HCC. (also reviews mechanisms) 👍Of benefit in pts with ALD, Viral hep, MASLD, and Cirrhosis 😀Can I have another cup?? #GIsky #IMSky #medsky

Cannabinoid Hyperemesis Syndrome(CHS)...taking off CHS cases in Mass (legal here) increased by 1,350% between 2012 and 2021. Still about 10.6 cases/10,000 ED visits (California is 50!) Miserable for the patients, tough to treat. #IMsky #MEDsky

The saga continues: Resmetirom for MASH 🤔1 yr extension Maestro-NAFLD ( Medscape, presented at ACG scientific meeting) 👍Child A MASH at 1 year res of clinically sig portal hypertension in 20%, year 2 28% 👍50% with 25% ⬇️ liver stiff 👍35% from F4 to F3 Not too shabby #GISky #IMsky #MedSky

ETOH Hepatitis...protocol for Steroids? 🤔Ed referring to article suggesting ⬇️90 day mortality with tapered steroid 🤔One concern, always, infections 👍Useful flow sheet, mostly suggesting tapering prednisolone (If Lille <.45) from 40 mg/day by 10 mg/week for 3 weeks. #IMsky #Medsky #GIsky

You want me to do what with that coffee? 😟Coffee enemas, colon cleanses, irrigation, detox drinks? 🤔Review GI and Hep news... No evid benefit. NIH: can be unsafe and falsely advertised 🤔One detox product has tadalafil Risks: change biome, perf, colitis, interact with meds #imsky #medsky

updated the acute liver failure chapter biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure) now rec'd for clinically overt encephalopathy (Grade 2-4) if admitting to ICU for ALF & encephalopathy, just dialyze emcrit.org/ibcc/alf/ #EMIMCC

The truth and nothing but the truth...PEth 🤔Phosphatidylethanol (PEth) detects ETOH exposure up to 12 days after a binge, up to 4 weeks with heavy use 🤔Reported ETOH consumption may not be accurate 🤔Useful to help sort out MASLD; MetALD, ALD See flow sheets below #IMsky #GIsky #Medsky

Patient with cirrhosis and INR of 3 needs a procedure Please step away from the FFP EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures) Plt & fibrinogen are more controversial Discussion emcrit.org/ibcc/cirrhos... #EMIMCC

GLP-1's...GI safety better than we thought?? 🤔🔼 risk of cholelithiasis by 2cases/1,000 🔼 risk of reflux by 4/1,000 😀No apparent increase in cholecystitis, cholangitis, pancreatitis, obstruction, ileus There ain't no perfect drug, but this one has real benefits #IMsky #Medsky #GIsky

And the winner is ... Carvedilol 🤔Article in DigDisSci shows carvedilol compared with propranolol has lower risk of EVH (more and more accepted) 👍Also reports a lower risk of ascites, SBP, HRS, HCC, mortality So maybe time to really switch over??? #IMsky #Medsky #GIsky

A reminder: Early CCY after ERCP 🤔Although guidelines rec: Early CCY (same admission), only done about half the time 🤔Study: ACG Scientific Meeting 😒Biliary comps in 23% delayed, vs 0.8% early ccy 🔑: Risk NOT mitigated by sphincterotomy or stenting. Carpe Diem: #gisky #medsky #imsky

Steatotic liver disease: worldwide problem 🤔Global incidence 37.5%; Mostly MASLD; MedALD 4%; ALD 2.2% 🤔Highest in Region of the Americas (56%) 🤔While high in T2Dm (70%); T1DM only 29.6% It is out there...we just have to hunt it down. #Imsky; #Medsky

Save the kidneys! Outpt AKI in cirrhosis 🤔Defined AKI with labs up to 1 yr apart 🤔12% developed AKI in 3 year 🤔🔼 with ascites, HCC, ETOH, 👍Need to avoid/modify precpt causes: diuretics, GI losses ie with lactulose, nephrotoxins Review of AKi emcrit.org/ibcc/aki/#top #gisky #medsky #imsky

Hepatic Encephalopathy with healthy liver? 🤔Pt with cognitive impairment, - neuro workup. Discharged with diagnosis of dementia, focal seizures. 👍CT lge intrahepatic portovenous shunt; Ammonia 🔼 😀Improved with PSE Rx, ultimately treated in IR Sort of a congenital TIPS #IMsky #GIsky #Medsky

AUD Rx: Much room for improvement 🤔We Rx AUD in only <5% eligible patients! 👍Study (not ideal) showing meds tolerated in severe ALD (no adverse liver issues) 👍(Naltrexone, acamprosate) were major ones Message: We should all be more aggressive in trying to treat AUD.

Priming the Pump: Colon Prep 🤔Maeda et al AmJGastro: Linaclotide before low vol prep ➡️ better prep in "High-Risk" pts than senna 🤔Ed: suggests better tol than stimulant laxative 👍Personally found works great with large and small vol preps: especially with 🔼risk poor prep #IMsky #GIsky #medsky

Review of MASLD (Adults) in JAMA 👍Re-emphasizing value/use of the FIB-4 and follow up with elastography 👍Useful summary of therapeutic options: diet, exercise, no ETOH, considerations of Bariatric Surgery, semaglutide (GLP-1), and Resmetirom for moderate-advanced fibrosis #IMSky #Medsky #GIsky

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

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