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

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

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

Delta is ready when you are 🤔Guidelines exist for testing for D in chronic B hepatitis 🤔Delta associated with worse prognosis In safety-net pop only 6.1% tested, and 15.7% positive A reminder to think of Delta and test for it. #medsky #IMsky #gisky

2nd Victim Syndrome 🤔Distress we experience after being involved in medical error, adverse event or outcome. Can be severe 🤔Can effect all health workers 🤔Well defined stages 🤔We need wider recognition of SVS, and improved support for ourselves and our colleagues #GIsky #IMsky #Medsky

Nice guideline on Gastroporesis 🤔A tough subject, often frustrating for us and pts 👍Role of early small-particle, low-fat, low residue diet 👍Use of erythro with drug holidays 👍Low risk of TD with metaclopramide, but ?drug holidays. 👍Slowly escalating metaclopramide dose #GIsky #Medsky #IMsky

😮You are entering an evidence free zone (sort of) Diet for IBD Good review 🤔Some evidence for enteral feeds in peds CD 🤔Maybe better with combination of Enteral and CDED (CD Exclusion Diet). 🤔Med Diet preferred over CHO Specific Diet. FODMAP may help with symptoms. #Medsky #GISky #IMSky

A gentle reminder: Check patients with Cryptogenic Cirrhosis for Celiac Disease 🤔Up to 1/20 pts with CC had Celiac 👍Liver status improved with Gluten Free Diet Celiac Disease is everywhere. #IMsky #GIsky #medsky

THE DREADED Cannabis Hyperemesis Syndrome 😮CHS: Challenging, frustrating, endless 😟A consult you do not want to get Nice review of CHS Some meds to add to our list... Topical Capsaicin cream Droperidol Olanzapine Follow the yellow brick road: emcrit.org/ibcc/cannabis/ #GIsky #IMsky #Medsky

Dr. House Warned Us 🤔Pts not always honest 🤔Phosphatidylethanol correlate with ETOH past 1-4 weeks 🤔Pts with MASLD, MetALD, ALD 39% pts in ALD groups underestimated consumption 11% in non ALD groups Overall 39% MASLD also met ALD criteria Should we be checking this? #IMSky #Medsky #GIsky

Say it Ain't So...Ocaliva for PBC withdrawn (and another one bites the dust) Just wanted to share this, as one who had placed patients with PBC (Primary Biliary Cholangitis) on Ocaliva (obeticholic acid) Fortunately other options available/in pipeline. #GIsky #Medsky #IMsky

Viral Infections with injection drug use (JAMA brief review) 🔼HIV, Hep B & C 👍Remember Delta and test in B 👍32%of Hep A pts with hx injection drug use Reminders to test, frequently To vaccinate A/B Pre/Post proph for HIV #medsky #IMsky #GIsky

Review of MASLD/MASH from UK 🤔1/4 young adults with fatty liver Most not aware 🤔🔼 rates of advanced liver disease predicted 🤔Rx being developed/approved: GLP 1; Thyroid hormone B receptor agonists 👍Weight loss, no ETOH Message: Look for it, evaluate it, and treat it #Medsky #IMsky #GIsky

988 A great resource (In US) 🤔In GI a substantial number of pts with depression. Increased suicide rate (x11) in pts with chronic abdominal pain But across all fields/specialties. 988 Sort of like 911, but for help with mental health crises Available 24/7 #GIsky #IMsky #Medsky

Percutaneous cholecystostomy drain for acute cholecystitis: The evidence is VERY weak If someone is deteriorating with refractory septic shock, then drain it If the patient is responding to medical tx, then there is no need to place a tube.... 🧵 #1/3 pubmed.ncbi.nlm.nih.gov/40900585/ #EMIMCC

😮HELP: Patient with Cirrhosis needs Surgery 👍Vocal Penn Score Calculator online 🙂ACG guidelines If MELD 6-9 very low risk pro and anti thrombotic paths changed, usual labs not accurate Focus on nutrition, Rx liver, ?Pre op txp eval, viscoelastic test Worth reviewing #medsky #IMsky #gisky

I'm Back... 🤔Pt with fatigue, sore throat, fever, rash and Bili 16, ALT 2850 🫢RPR 1:256 Syphilis Hepatitis Incidence of Syph up 80% from '18-'22; We will be seeing more of this. (Though liver manifestations still rare) To include in differential diagnosis #IMsky #GISky #MedSky

Captain Cook warned us 🤔pt with bruising, severe anemia, pulm hypertension 🤔Ultimately noted to have perifollicular macules, gingival changes 👍Scurvy, restrictive diet quotes 5.9% in US with Vit C deficiency Quick recovery with C Reminds us to ask about pts diets #IMsky #GIsky #medsky

Incretin-based meds. Managing SE's 🤔Increasingly common use: obesity, fatty liver, DM, hyperlipids, CV, CKD, OSA. (Should we just add to the water supply :) ) SE's common. Nausea, diarrhea, constipation, dyspepsia Short review with some common-sense recs. #IMsky #Gisky #medsky #liversky

Hemorrhoids (Gasp) A nice review 👍Great (short) review of a universal topic Useful for review or teaching. They recommend Phlebotonics. Commonly used in Europe/Asia Plant flavinoids or synthetic For 1 and 2nd degree Wondering if folks have had experience using this??? #GIsky #medsky #IMsky

New guidelines on management of IBD in Pregnancy 😱A topic that strikes terror in many 👍Useful guidelines...(some based on conditional evidence) 👍ASA to prevent eclampsia, drugs to avoid or modify, ie No JAK, S1P's. See Below #IMsky #GIsky #medsky

Global warming is increasing the rate of Vibrio vulnificus infections in Louisiana and Florida. Also, the CDC has stopped tracking Vibrio infections. So basically, don't eat any oysters 🤷‍♂️ www.nbcnews.com/news/us-news... #IDsky

Hypercoagulability in UC inpats Persists after hospitalization? 🤔Increased risk of DVT for up to 12 weeks post discharge in patients with acute severe UC Likely will not alter treatment now, but 👍 A reminder to put our IBD patients on DVT prophylaxis on admission #IMsky #gisky #medsky

Recurrent abdominal pain, some edema, SB edema 👍Case: Hereditary angioedema Autosomal dominant, mostly C1-INH deficiency or dysfunction Low C4 levels screening test. C1 inhibitor and function best. Review of other causes of angioedema and Rx emcrit.org/ibcc/angioed... #gisky #Medsky #imsky

Recomb Zoster vaccine in immunocompromised (ic) 🤔Always best to vaccinate before start ic meds Consider in all IBD patients 🤔Often we do not have the opportunity when patients require these meds for acute flares 👍Nice to know that vaccine is successful in many patients #ibdsky #imsky #Medsky

Case : Bentonite Clay. on Amazon. "Revitalize your body, get your glow back" 🤔Patient taking 85gm clay a day (above usual): low phos (Al in clay binds), low K (Silicates) Constipated with hematochezia Geophagia, variant of PICA (Pt also ⬇️ iron) Food for thought???? #gisky #imsky #medsky

7-OH Available at a store near you. 7-OH (Derived initially from Kratom plant) 😆Legal, available, in gummies, candies, drink mixes 😱Opioid-like effects. Addiction, sedation, euphoria Worth reading ... #IMsky #medsky

Diarrhea/colitis of ?etiol Case Report 🤔s/p ccy, with diarrhea and mild colitis. Mult admits 🤔Hx sleeve gast, MS on Teriflunomide +C.diff, but colon/biopsies not consistent with this Teriflunomide likely cause Reminder: check all meds, mostly those not familiar with. #imsky #medsky

We all knew it: progressive incidence of hospitalizations for liver disease 🤔Need to be vigilant screening for CLD, especially fatty liver 🤔Need to be aggressive treating CLD, especially fatty liver 🤔ETOH remains a major problem..hopefully we can improve here as well #imcrit #Medcrit #GIcrit

Wegovy (Semagltide) FDA approved for MASH 🤔Need to be more aggressive in Rx MASH. Preventing cirrhosis/liver decomp/HCC is key 👍Approved for adults with moderate to advanced fibrosis Essence trial: significant improve inflammation and fibrosis. #medsky #imsky www.fda.gov/drugs/news-e...

Blood tests for CRC Screen....You can't always get what you want 🤔Compliance CRC screening not ideal 🤔Stool/blood tests may be more acceptable 😐AGA Update: Sensitivity blood tests lower than stool/colon, especially for advanced precancerous lesions. But Better than nothing.... #IMSky #MedSky

Life is change: ACG Nutrition in CLD 🤔Low fructose diet in CLD 🤔Late evening snacks 🤔MASH consider 800u VitE 🤔Coffee 2 cups/day 🤔NO protein restriction, even PSE 🤔Plant based protein 🤔Did not Push Na restriction 🤔No H2O restriction till Na in mid 120's Nutrition is 🔑 #IMsky #Medsky

Beware the Iceberg of Metabolic assoc Fatty Liver 🤔Up to 38% pop worldwide ⚠️NEJM article with great graphics 👍Need to try to prevent progression Need to think of it, test patients for fibrosis, and have lower threshold for treating medically or surgically #imsky #medsky NEJM 2025;393:683-98

Hepatic Recompensation.....beautiful. We have come a long way 😀Resolution of cirrhosis clinical features: PSE, ascites, without variceal bleed for 12 months 👍Esp with hep C virus eradication, hep B control, persistent ETOH abstinence Numbers low, but encouraging #imsky #gisky #medsky

Myth busting: Antibiotics don't reduce mortality in variceal hemorrhage! I updated the IBCC & explained what happened here emcrit.org/ibcc/gib/#va... We probably don't need antibiotics at all🤦‍♂️ Nice illustration of how meta-analyses can be fragile (even Cochrane) emcrit.org/pulmcrit/meta/ #EMIMCC

How to Rx gastric varices?? Is TIPS TOPS? 🤔Higher mortality than EV's 🤔Study compared standard Rx, continuing with (Glue + NSBB) with pre-emptive TIPS after bleeding controlled 👍⬇️Risk of rebleeding, likely ⬇️mortality, and no 🔼 in PSE See accompanying editorial #gastrosky #imsky #medsky

EUS GJ tube in malignant gastric outlet obstruction 🤔Surgery remains most common treatment 🤔Options have included stents, and now EUS with stent to small bowel Apparently ⬇️ rates of comps, length of stay Associated editorial To consider if expertise available #gisky #IMsky #Medsky

ERCP The good, the bad, the ugly 🤔Review focusing on prevention of comps. Rectal indomethacin, Ringers Lactate, consideration of post op panc stent. Antibiotics when indicated. Of course careful patient selection. Nice that we can better prevent comps, and better manage them.

Is Dr. Google better than Dr. TicTok? 🤔Many patients get their information from social media 😱At times scary Article found, surprise-surprise, many patient driven posts on TT inaccurate/misleading (IBD and IBS) Perhaps we should be paying more attention??? #gisky #IMsky #Medsky

the trial found that early drainage of acute necrotic collections in patients with persistent organ failure didn't affect outcomes reassuring: [1] supports current conservative tx strategy [2] if you DO need to drain (eg to treat bowel obstruction or compartment syndrome) this seems *safe*...

IgG4 GB disease with ?NPL 🤔Interesting case report 👍IgG4-related diseases more and more commonly recognized. Involving most organs Though often initially missed Important to consider this in our differential dx's So maybe next step is routine IgG4 levels/autoimmune w/u on all comers :)?

Dx Celiac in gluten-free (GFD) pts 🤔🔼1.7% in US on GFD TTG-IgA may be false negative on GFD. Article summarizes approach Genetics, if positive gluten challenge. Even if asymptomatic important to dx CD Useful listing of gluten content in foods. (For gluten challenge) #gisky #imsky #medsky

F/u on EUS drainage for acute gb in high-risk pts 🤔One argument is difficulty with surgery after 👍Article (and ed) show feasible, with same conversion to open as in patients s/p per cut drainage Depends on local expertise #Gisky #imsky #medsky www.giejournal.org/article/S001...

Phosphatidylethanol (PEth) improves id of liver fibrosis risk 🤔PEth seems to be the HgbA1c of liver disease 🤔More accurate in identifying ETOH use than pt history 👍Article suggests also helps identify pts higher risk of fibrosis Are we underutilizing this test? #gisky #medsky #imsky

Defining the role of EUS GB drainage 🤔High-risk surgical patient with acute GB What is best approach? Increasing preference for EUS-GBD Fewer adverse events than percut drain Meta-analysis 701 pts 👍Success rates of over 90% 1 yr f/u: Readmission 19%, reintervention 6% #gisky #medsky #IMsky

Controversy continues...GLP-1's and Endoscopy 🤔🔼 risk of retained solid contents in EGD NOT in patients having EGD AND Colon (?benefit of Prep) No increased risk of aspiration 🔼 risk of aborted EGD's The battle continues...?cancel double endos in patients who took their GLP-1 #GIsky #medsky

"Grass" and the liver... 🤔5mg/kg/day CBD ➡️ LFT's 🔼3x ULN in 5.6% Associated with eosinophilia 10% US adults use CBD daily This upper limit of general use No evidence on long term effects. Wonder about additive effects with MASH, CLD? #IMsky #Medsky #GIsky jamanetwork.com/journals/jam...