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The 2017 Postgraduate Course started out with four hot topics that dominated the year – opioid dependence, a cure for hepatitis C, and understanding and then manipulating the microbiome. From David Dickerson, MD, we learned that abdominal pain is complex and with an evolving classification scheme. Ignoring the biopsychosocial aspects and origins of pain is a sure way to lead to addiction and “pain behavior.” He reviewed the opioid guidelines that involve a comprehensive approach to therapy – setting functional goals, assessing the risks and benefits, and using the lowest necessary doses of short-acting agents for a defined period of time and then reassessing. In patients with chronic pain and opioid dependence, the gastroenterologist should seek the help of a chronic pain specialist. We should also refer for nonpharmacologic therapy such as cognitive behavioral therapy and biofeedback.
Norah Terrault, MD, MPH, discussed management of chronic hepatitis C (HCV) after the cure, achievable in more than 95% of patients, which has resulted in a sharp decline in listings for liver transplant. A cure is defined as undetectable HCV RNA 12 weeks after completion of therapy. So what happens next? If the patient is at risk for reinfection, they should have HCV RNA testing annually or if their liver enzymes increase. Otherwise, if their pretreatment fibrosis is low stage, no further monitoring is needed and they can follow up with their primary care provider. Intermediate-stage fibrosis should be monitored for progression. Advanced-stage fibrosis needs long-term follow-up for hepatocellular carcinoma and variceal surveillance. Modifiable risk factors, i.e., metabolic fatty liver and alcohol abuse, should be identified with appropriate counseling provided.
We went back to the microbiome for our last talk: Larry Brandt, MD, AGAF, discussed FMT for Clostridium difficile infection (CDI). Patients should be considered for FMT if they have more than 3 recurrences of mild to moderate CDI and failure to respond to standard therapy; more than 2 episodes of CDI resulting in hospitalization and significant morbidity; moderate CDI with no response after 1 week of standard therapy; and severe CDI with no response to standard therapy within 48 hours. Serious adverse events associated with FMT include infections and perhaps new-onset immune-mediated disease such as Sjogren’s, rheumatoid arthritis, and idiopathic thrombocytopenic purpura. It is hoped that the NIH-sponsored AGA national registry for FMT will help better define outcomes and adverse events over the next 10 years.
Dr. Mahadevan is professor of clinical medicine at UCSF Medical Center, San Francisco. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017.
The 2017 Postgraduate Course started out with four hot topics that dominated the year – opioid dependence, a cure for hepatitis C, and understanding and then manipulating the microbiome. From David Dickerson, MD, we learned that abdominal pain is complex and with an evolving classification scheme. Ignoring the biopsychosocial aspects and origins of pain is a sure way to lead to addiction and “pain behavior.” He reviewed the opioid guidelines that involve a comprehensive approach to therapy – setting functional goals, assessing the risks and benefits, and using the lowest necessary doses of short-acting agents for a defined period of time and then reassessing. In patients with chronic pain and opioid dependence, the gastroenterologist should seek the help of a chronic pain specialist. We should also refer for nonpharmacologic therapy such as cognitive behavioral therapy and biofeedback.
Norah Terrault, MD, MPH, discussed management of chronic hepatitis C (HCV) after the cure, achievable in more than 95% of patients, which has resulted in a sharp decline in listings for liver transplant. A cure is defined as undetectable HCV RNA 12 weeks after completion of therapy. So what happens next? If the patient is at risk for reinfection, they should have HCV RNA testing annually or if their liver enzymes increase. Otherwise, if their pretreatment fibrosis is low stage, no further monitoring is needed and they can follow up with their primary care provider. Intermediate-stage fibrosis should be monitored for progression. Advanced-stage fibrosis needs long-term follow-up for hepatocellular carcinoma and variceal surveillance. Modifiable risk factors, i.e., metabolic fatty liver and alcohol abuse, should be identified with appropriate counseling provided.
We went back to the microbiome for our last talk: Larry Brandt, MD, AGAF, discussed FMT for Clostridium difficile infection (CDI). Patients should be considered for FMT if they have more than 3 recurrences of mild to moderate CDI and failure to respond to standard therapy; more than 2 episodes of CDI resulting in hospitalization and significant morbidity; moderate CDI with no response after 1 week of standard therapy; and severe CDI with no response to standard therapy within 48 hours. Serious adverse events associated with FMT include infections and perhaps new-onset immune-mediated disease such as Sjogren’s, rheumatoid arthritis, and idiopathic thrombocytopenic purpura. It is hoped that the NIH-sponsored AGA national registry for FMT will help better define outcomes and adverse events over the next 10 years.
Dr. Mahadevan is professor of clinical medicine at UCSF Medical Center, San Francisco. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017.
The 2017 Postgraduate Course started out with four hot topics that dominated the year – opioid dependence, a cure for hepatitis C, and understanding and then manipulating the microbiome. From David Dickerson, MD, we learned that abdominal pain is complex and with an evolving classification scheme. Ignoring the biopsychosocial aspects and origins of pain is a sure way to lead to addiction and “pain behavior.” He reviewed the opioid guidelines that involve a comprehensive approach to therapy – setting functional goals, assessing the risks and benefits, and using the lowest necessary doses of short-acting agents for a defined period of time and then reassessing. In patients with chronic pain and opioid dependence, the gastroenterologist should seek the help of a chronic pain specialist. We should also refer for nonpharmacologic therapy such as cognitive behavioral therapy and biofeedback.
Norah Terrault, MD, MPH, discussed management of chronic hepatitis C (HCV) after the cure, achievable in more than 95% of patients, which has resulted in a sharp decline in listings for liver transplant. A cure is defined as undetectable HCV RNA 12 weeks after completion of therapy. So what happens next? If the patient is at risk for reinfection, they should have HCV RNA testing annually or if their liver enzymes increase. Otherwise, if their pretreatment fibrosis is low stage, no further monitoring is needed and they can follow up with their primary care provider. Intermediate-stage fibrosis should be monitored for progression. Advanced-stage fibrosis needs long-term follow-up for hepatocellular carcinoma and variceal surveillance. Modifiable risk factors, i.e., metabolic fatty liver and alcohol abuse, should be identified with appropriate counseling provided.
We went back to the microbiome for our last talk: Larry Brandt, MD, AGAF, discussed FMT for Clostridium difficile infection (CDI). Patients should be considered for FMT if they have more than 3 recurrences of mild to moderate CDI and failure to respond to standard therapy; more than 2 episodes of CDI resulting in hospitalization and significant morbidity; moderate CDI with no response after 1 week of standard therapy; and severe CDI with no response to standard therapy within 48 hours. Serious adverse events associated with FMT include infections and perhaps new-onset immune-mediated disease such as Sjogren’s, rheumatoid arthritis, and idiopathic thrombocytopenic purpura. It is hoped that the NIH-sponsored AGA national registry for FMT will help better define outcomes and adverse events over the next 10 years.
Dr. Mahadevan is professor of clinical medicine at UCSF Medical Center, San Francisco. This is a summary provided by the moderator of one of the AGA Postgraduate Courses held at DDW 2017.