Liver and functional GI issues

Dr. Lin Chang at the University of California, Los Angeles, discussed how to work-up and manage functional abdominal pain. She reviewed a diagnostic algorithm that is evidence based and uses characteristics of the abdominal pain, coexisting warning signs, and a diagnostic work-up. A patient must be diagnosed with functional abdominal pain only after careful medical history, physical examination, and adequate consideration of competing etiologies.

Physical examination can be helpful in differentiating abdominal wall pain from that of visceral pain (Carnett’s sign) although some patients with functional abdominal pain may exhibit positive Carnett’s sign. Managing a patient with suspected functional abdominal pain includes careful attention to warning signs for organic disease (for example, unintended weight loss, hematochezia, abnormal labs, fever, or family history of serious GI disorders), avoiding unnecessary diagnostic testing, consideration of mental health consultation and pharmacotherapy as appropriate.

Dr. Chang reviewed the role of various pharmacologic agents for irritable bowel syndrome (IBS) with diarrhea (alosetron, rifaximin, and loperamide), IBS with constipation (linaclotide, lubiprostone, and polyethylene glycol) and agents such antispasmodics, tricyclic antidepressants, and SSRIs (reviewed extensively in the AGA Technical Review and Guidelines for Pharmacotherapy for IBS published in Gastroenterology. 2014 Nov;147[5]:1149-72.e2). It is important to establish a strong patient-provider relationship and to incorporate behavioral therapies into management of patients with recurrent or chronic functional abdominal pain.

Dr. Peter Gibson at Monash University in Melbourne discussed non–celiac gluten sensitivity and low-FODMAP diet in managing food sensitivity and functional bowel disorders. He pointed out that recent dietary strategies have changed from patient-initiated, whole-food strategies to avoiding specific dietary components such as FODMAPs and gluten and wheat products. FODMAPS (fermentable oligo-, di-, and monosaccharides and polyols) are foods that are generally high in fructose, lactose, oligosaccharides (e.g., beans, onions, garlic, complex carbohydrates) and polyols (e.g., mushrooms). FODMAPs are generally osmotic and lead to fermentation and diarrhea, bloating, and flatulence. General principles in offering a low-FODMAP diet are the selection of appropriate patients; correct education about FODMAP diets, preferably by a trained dietitian; and a step-down approach in which a strict diet is slowly liberalized. Dr. Gibson pointed out that there are a subset of IBS patients who are gluten sensitive but recent data suggest that wheat protein sensitivity may not be as common as it has been suggested and, in fact, FODMAPs may indeed be the major inducers of symptoms in individuals with supposed wheat intolerance. The potential risks of dietary manipulation such as creation of a dietary cripple or induction of an eating disorder should be kept in mind.

Dr. Anna Mae Diehl at Duke University Medical Center in Durham, N.C., spoke about the diagnosis, role of the microbiome, and the treatment of nonalcoholic fatty liver disease (NAFLD). It was pointed out that most patients with NAFLD have benign progression although individuals with nonalcoholic steatohepatitis (NASH), especially those with significant fibrosis, are at risk for developing cirrhosis, liver failure, and liver cancer. Therapeutic investigations undertaken to date have not sufficiently focused on improving fibrosis although several ongoing clinical trials are directed at this goal. Gut microbiome might be a new NAFLD diagnostic/therapeutic target because several recent animal studies have shown that gut microbiome may play a role in conferring susceptibility to liver injury, fibrosis, and cancer.

Dr. Lawrence J. Brandt at Albert Einstein College of Medicine, New York, gave an update on fecal microbiota therapy (FMT). He highlighted that FMT has historic roots going back to the 4^th century when Ge Hong described use of human fecal suspension to treat food poisoning or severe diarrhea. He made it clear that FMT should be offered only to those with recurrent Clostridium difficile infections (CDI), meeting selected criteria such as severe illness and prior treatment failures. The protocol for FMT in recurrent CDI includes careful selection of donor (may range from any healthy person, universal donor, or stool-bank product) and testing stool and blood of potential donors for any transmittable agents. A recent systematic review showed that the success rate for FMT in individuals with CDI is generally quite high (greater than 80%) but it may depend on the site of FMT – for example, if FMT is administered to duodenum/jejunum, the success rate is 86%, whereas if it is delivered to right colon/cecum, then the success rate can be as high as 93%. He highlighted the efficacy of FMT in severe, complicated CDI, which generally carries high morbidity and mortality. Practitioners offering FMT should carefully review the FDA guidance that was issued in March 2014. He noted that long-term consequences of FMT are not well understood and thus, risks versus benefits of FMT on a patient-by-patient basis must be carefully weighed.

Dr. Naga P. Chalasani is the David W. Crabb Professor and director of the division of gastroenterology and hepatology, Indiana University, Indianapolis. He has consulting agreements and receives research support from several pharmaceutical companies but none represent a conflict of interest for this activity.

This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2015.

Dr. Lin Chang at the University of California, Los Angeles, discussed how to work-up and manage functional abdominal pain. She reviewed a diagnostic algorithm that is evidence based and uses characteristics of the abdominal pain, coexisting warning signs, and a diagnostic work-up. A patient must be diagnosed with functional abdominal pain only after careful medical history, physical examination, and adequate consideration of competing etiologies.

Physical examination can be helpful in differentiating abdominal wall pain from that of visceral pain (Carnett’s sign) although some patients with functional abdominal pain may exhibit positive Carnett’s sign. Managing a patient with suspected functional abdominal pain includes careful attention to warning signs for organic disease (for example, unintended weight loss, hematochezia, abnormal labs, fever, or family history of serious GI disorders), avoiding unnecessary diagnostic testing, consideration of mental health consultation and pharmacotherapy as appropriate.

Dr. Chang reviewed the role of various pharmacologic agents for irritable bowel syndrome (IBS) with diarrhea (alosetron, rifaximin, and loperamide), IBS with constipation (linaclotide, lubiprostone, and polyethylene glycol) and agents such antispasmodics, tricyclic antidepressants, and SSRIs (reviewed extensively in the AGA Technical Review and Guidelines for Pharmacotherapy for IBS published in Gastroenterology. 2014 Nov;147[5]:1149-72.e2). It is important to establish a strong patient-provider relationship and to incorporate behavioral therapies into management of patients with recurrent or chronic functional abdominal pain.

Dr. Peter Gibson at Monash University in Melbourne discussed non–celiac gluten sensitivity and low-FODMAP diet in managing food sensitivity and functional bowel disorders. He pointed out that recent dietary strategies have changed from patient-initiated, whole-food strategies to avoiding specific dietary components such as FODMAPs and gluten and wheat products. FODMAPS (fermentable oligo-, di-, and monosaccharides and polyols) are foods that are generally high in fructose, lactose, oligosaccharides (e.g., beans, onions, garlic, complex carbohydrates) and polyols (e.g., mushrooms). FODMAPs are generally osmotic and lead to fermentation and diarrhea, bloating, and flatulence. General principles in offering a low-FODMAP diet are the selection of appropriate patients; correct education about FODMAP diets, preferably by a trained dietitian; and a step-down approach in which a strict diet is slowly liberalized. Dr. Gibson pointed out that there are a subset of IBS patients who are gluten sensitive but recent data suggest that wheat protein sensitivity may not be as common as it has been suggested and, in fact, FODMAPs may indeed be the major inducers of symptoms in individuals with supposed wheat intolerance. The potential risks of dietary manipulation such as creation of a dietary cripple or induction of an eating disorder should be kept in mind.

Dr. Anna Mae Diehl at Duke University Medical Center in Durham, N.C., spoke about the diagnosis, role of the microbiome, and the treatment of nonalcoholic fatty liver disease (NAFLD). It was pointed out that most patients with NAFLD have benign progression although individuals with nonalcoholic steatohepatitis (NASH), especially those with significant fibrosis, are at risk for developing cirrhosis, liver failure, and liver cancer. Therapeutic investigations undertaken to date have not sufficiently focused on improving fibrosis although several ongoing clinical trials are directed at this goal. Gut microbiome might be a new NAFLD diagnostic/therapeutic target because several recent animal studies have shown that gut microbiome may play a role in conferring susceptibility to liver injury, fibrosis, and cancer.

Dr. Lawrence J. Brandt at Albert Einstein College of Medicine, New York, gave an update on fecal microbiota therapy (FMT). He highlighted that FMT has historic roots going back to the 4^th century when Ge Hong described use of human fecal suspension to treat food poisoning or severe diarrhea. He made it clear that FMT should be offered only to those with recurrent Clostridium difficile infections (CDI), meeting selected criteria such as severe illness and prior treatment failures. The protocol for FMT in recurrent CDI includes careful selection of donor (may range from any healthy person, universal donor, or stool-bank product) and testing stool and blood of potential donors for any transmittable agents. A recent systematic review showed that the success rate for FMT in individuals with CDI is generally quite high (greater than 80%) but it may depend on the site of FMT – for example, if FMT is administered to duodenum/jejunum, the success rate is 86%, whereas if it is delivered to right colon/cecum, then the success rate can be as high as 93%. He highlighted the efficacy of FMT in severe, complicated CDI, which generally carries high morbidity and mortality. Practitioners offering FMT should carefully review the FDA guidance that was issued in March 2014. He noted that long-term consequences of FMT are not well understood and thus, risks versus benefits of FMT on a patient-by-patient basis must be carefully weighed.

Dr. Naga P. Chalasani is the David W. Crabb Professor and director of the division of gastroenterology and hepatology, Indiana University, Indianapolis. He has consulting agreements and receives research support from several pharmaceutical companies but none represent a conflict of interest for this activity.

This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2015.

Dr. Lin Chang at the University of California, Los Angeles, discussed how to work-up and manage functional abdominal pain. She reviewed a diagnostic algorithm that is evidence based and uses characteristics of the abdominal pain, coexisting warning signs, and a diagnostic work-up. A patient must be diagnosed with functional abdominal pain only after careful medical history, physical examination, and adequate consideration of competing etiologies.

Physical examination can be helpful in differentiating abdominal wall pain from that of visceral pain (Carnett’s sign) although some patients with functional abdominal pain may exhibit positive Carnett’s sign. Managing a patient with suspected functional abdominal pain includes careful attention to warning signs for organic disease (for example, unintended weight loss, hematochezia, abnormal labs, fever, or family history of serious GI disorders), avoiding unnecessary diagnostic testing, consideration of mental health consultation and pharmacotherapy as appropriate.

Dr. Chang reviewed the role of various pharmacologic agents for irritable bowel syndrome (IBS) with diarrhea (alosetron, rifaximin, and loperamide), IBS with constipation (linaclotide, lubiprostone, and polyethylene glycol) and agents such antispasmodics, tricyclic antidepressants, and SSRIs (reviewed extensively in the AGA Technical Review and Guidelines for Pharmacotherapy for IBS published in Gastroenterology. 2014 Nov;147[5]:1149-72.e2). It is important to establish a strong patient-provider relationship and to incorporate behavioral therapies into management of patients with recurrent or chronic functional abdominal pain.

Dr. Peter Gibson at Monash University in Melbourne discussed non–celiac gluten sensitivity and low-FODMAP diet in managing food sensitivity and functional bowel disorders. He pointed out that recent dietary strategies have changed from patient-initiated, whole-food strategies to avoiding specific dietary components such as FODMAPs and gluten and wheat products. FODMAPS (fermentable oligo-, di-, and monosaccharides and polyols) are foods that are generally high in fructose, lactose, oligosaccharides (e.g., beans, onions, garlic, complex carbohydrates) and polyols (e.g., mushrooms). FODMAPs are generally osmotic and lead to fermentation and diarrhea, bloating, and flatulence. General principles in offering a low-FODMAP diet are the selection of appropriate patients; correct education about FODMAP diets, preferably by a trained dietitian; and a step-down approach in which a strict diet is slowly liberalized. Dr. Gibson pointed out that there are a subset of IBS patients who are gluten sensitive but recent data suggest that wheat protein sensitivity may not be as common as it has been suggested and, in fact, FODMAPs may indeed be the major inducers of symptoms in individuals with supposed wheat intolerance. The potential risks of dietary manipulation such as creation of a dietary cripple or induction of an eating disorder should be kept in mind.

Dr. Anna Mae Diehl at Duke University Medical Center in Durham, N.C., spoke about the diagnosis, role of the microbiome, and the treatment of nonalcoholic fatty liver disease (NAFLD). It was pointed out that most patients with NAFLD have benign progression although individuals with nonalcoholic steatohepatitis (NASH), especially those with significant fibrosis, are at risk for developing cirrhosis, liver failure, and liver cancer. Therapeutic investigations undertaken to date have not sufficiently focused on improving fibrosis although several ongoing clinical trials are directed at this goal. Gut microbiome might be a new NAFLD diagnostic/therapeutic target because several recent animal studies have shown that gut microbiome may play a role in conferring susceptibility to liver injury, fibrosis, and cancer.

Dr. Lawrence J. Brandt at Albert Einstein College of Medicine, New York, gave an update on fecal microbiota therapy (FMT). He highlighted that FMT has historic roots going back to the 4^th century when Ge Hong described use of human fecal suspension to treat food poisoning or severe diarrhea. He made it clear that FMT should be offered only to those with recurrent Clostridium difficile infections (CDI), meeting selected criteria such as severe illness and prior treatment failures. The protocol for FMT in recurrent CDI includes careful selection of donor (may range from any healthy person, universal donor, or stool-bank product) and testing stool and blood of potential donors for any transmittable agents. A recent systematic review showed that the success rate for FMT in individuals with CDI is generally quite high (greater than 80%) but it may depend on the site of FMT – for example, if FMT is administered to duodenum/jejunum, the success rate is 86%, whereas if it is delivered to right colon/cecum, then the success rate can be as high as 93%. He highlighted the efficacy of FMT in severe, complicated CDI, which generally carries high morbidity and mortality. Practitioners offering FMT should carefully review the FDA guidance that was issued in March 2014. He noted that long-term consequences of FMT are not well understood and thus, risks versus benefits of FMT on a patient-by-patient basis must be carefully weighed.

Dr. Naga P. Chalasani is the David W. Crabb Professor and director of the division of gastroenterology and hepatology, Indiana University, Indianapolis. He has consulting agreements and receives research support from several pharmaceutical companies but none represent a conflict of interest for this activity.

This is a summary provided by the moderator of one of the spring postgraduate course sessions held at DDW 2015.