ACG Clinical Guideline Research Articles

Continuing Medical Education Questions: July 2024

Article Title: ACG Clinical Guideline: Focal Liver Lesions

ACG Clinical Guideline: Diagnosis and Management of Biliary Strictures.

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

Know Your Guidelines Series: The ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease Review.

Know Your Guidelines Series: The ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease Review.

S1496 Addressing over Prescription of PPI in an Outpatient Underserved Population

Introduction: Long term use of PPIs has been associated with increased risk of mineral and vitamin deficiencies and in some studies with C. Difficile Colitis. It is estimated that 25%-70% of PPI prescriptions are without an appropriate indication. The aim of this study was to discontinue at least 10% of the patients on PPIs who do not have an appropriate indication for therapy over the course of a 6-week period. Methods: This study took place at a medically underserved resident clinic in Hartford Connecticut. Patients scheduled between 09/16/21 and 10/01/21 were pre-screened using EMR review. Any patient with a PPI on their medication list was included in the data set. Patients were stratified based on clinical need for PPI and potential for tapering using ACG Clinical Guidelines. Providers were educated on the clinical guidelines for PPI therapy. Patients on standard dosing were reduced to 50% dosing for 2 weeks and then discontinued. Patients were provided with as needed H2 Blocker for possible rebound symptoms. A total of 114 patients on PPI with appointments during the time window were identified. On the date of their visit, providers assessed individual patient PPI usage and discontinuation eligibility. Patients eligible for discontinuation of PPI were advised to dose reduce by 50% for 2 weeks and prescribed as needed H2 blocker. Providers also provided education on how to take PPI appropriately. Patients were called 2 weeks later for follow up. At that time if symptoms tolerated, PPI was discontinued. Results: Of the total population, 28% (32/114) were on long term PPI appropriately. Seventy-two percent (82/114) of the patients prescribed PPI lacked a true medical indication. Of these, 44 patients were seen and provided a taper plan. PPI was discontinued successfully in 22% (18/82) of the population of inappropriately prescribed PPI within the 6-week window. Conclusion: The aim of this study to achieve 10% population reduction in inappropriate PPI use was exceeded with roughly 22% discontinuation. Frequent medication reconciliation, patient education on proper PPI use and physician education with ACG Clinical Guidelines were simple changes to successfully improve clinically indicated PPI therapy. Many patients are aware of their triggers and use PPIs as a means of avoiding lifestyle and dietary change. When prescribing PPI, placing a “stop” time on the prescription may further reduce PPI burden.

S2943 Budd-Chiari Syndrome Diagnosis Achieved With High Clinical Suspicion Raised by EUS-Guided Portal Pressures and Liver Biopsy

Introduction: Budd Chiari syndrome (BCS) is a rare syndrome due to hepatic venous obstruction in the absence of cardiac cause, mostly secondary to thrombosis. As high as 80%of patients present with ascites. The diagnosis should be suspected in patient with acute or chronic liver disease without identified cause. Venous obstruction can be seen on Doppler ultrasound, CT, or MRI of the hepatic veins and inferior vena cava. In some cases, hepatic venogram is needed for its diagnostic and therapeutic advantages. We report a 50-year-old woman with BCS who underwent successful wire recanalization, angioplasty and thrombolysis of the right hepatic vein. Case Description/Methods: 50-year-old woman with no significant past medical history presented with abdominal distension and bilateral lower extremity swelling of two weeks duration. On exam, abdomen was distended with positive signs of fluid collection with +3 bilateral lower extremity edema. Labs revealed total bilirubin 3.3 direct bilirubin 1.4, ALP 477, ALT 38, AST 96, PT 14.4, INR 1.35. Ultrasound showed Heterogeneous appearance of liver and large volume ascites. Doppler study showed normal hepatic and portal venous flow. Abdominal MRI showed hepatic steatosis and caudate lobe hypertrophy. Large volume paracentesis was done with analysis showing SAAG of 3.1, WBC 364, Neutrophils 8. EGD revealed large esophageal varices. Viral hepatitis panel, ceruloplasmin, alpha-1antitripsin, ASMA, AMA antibodies were negative. EUS guided liver biopsy and portal pressure measurement was done showing venous pressure gradient of 13 consistent with portal hypertension. Liver biopsy showed grade 2 fibrosis and zone 3 congestion. Hepatic venogram showed chronically occluded right hepatic vein on which successful wire recanalization was done. Pt was worked up for hypercoagulable state and was found to have JAK 2 mutation and Protein C deficiency. Apixaban, Beta blocker and diuretics were started. Patient showed significant improvement with ascites and MELD score. Discussion: First line investigation for diagnosis of BCS is doppler ultrasound. Doppler US and MRI venography didn’t reveal the hepatic venous thrombosis in our patient. However, high index of suspicion, finding of elevated IVC pressure on EUS, and caudate lobe hypertrophy found on imaging as well as congestion liver biopsy findings led us to further investigate with hepatic venogram which confirmed the diagnosis and provided therapeutic advantages. Table 1. - Prothrombotic risk factors for BCS ACG Clinical Guideline A. Acquired thrombophilia B. Inherited thrombophilia C. Systemic factors D. Hormonal factors Myeloproliferative disorderPolycythemia veraEssential thrombocytosisIdiopathic myelofibrosisJAK 2 mutationPNH Hyperhomocysteinemia Factor V LeidenProthrombin gene G20210A mutationMTHFR C677T mutationThalassemiaPC deficiencyProtein C deficiencyAntithrombin deficiency SarcoidosisVasculitisBehcet’s diseaseConnective tissue diseaseInflammatory bowel diseases OCP usePregnancy Disorders of the Hepatic and Mesenteric Circulation Simonetto, Douglas A.; Singal, Ashwani K.; Garcia-Tsao, Guadalupe; Caldwell, Stephen H.; Ahn, Joseph; Kamath, Patrick S. Official journal of the American College of Gastroenterology | ACG115(1):18-40, January 2020. doi: 10.14309/ajg.0000000000000486

ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions.

ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions.

ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions.

Subepithelial lesions (SEL) of the GI tract represent a mix of benign and potentially malignant entities including tumors, cysts, or extraluminal structures causing extrinsic compression of the gastrointestinal wall. SEL can occur anywhere along the GI tract and are frequently incidental findings encountered during endoscopy or cross-sectional imaging. This clinical guideline of the American College of Gastroenterology was developed using the Grading of Recommendations Assessment, Development, and Evaluation process and is intended to suggest preferable approaches to a typical patient with a SEL based on the currently available published literature. Among the recommendations, we suggest endoscopic ultrasound (EUS) with tissue acquisition to improve diagnostic accuracy in the identification of solid nonlipomatous SEL and EUS fine-needle biopsy alone or EUS fine-needle aspiration with rapid on-site evaluation sampling of solid SEL. There is insufficient evidence to recommend surveillance vs resection of gastric gastrointestinal stromal tumors (GIST) <2 cm in size. Owing to their malignant potential, we suggest resection of gastric GIST >2 cm and all nongastric GIST. When exercising clinical judgment, particularly when statements are conditional suggestions and/or treatments pose significant risks, health-care providers should incorporate this guideline with patient-specific preferences, medical comorbidities, and overall health status to arrive at a patient-centered approach.

Know Your Guidelines Series: The ACG Clinical Practice Guideline on Upper Gastrointestinal and Ulcer Bleeding Review.

Know Your Guidelines Series: The ACG Clinical Practice Guideline on Upper Gastrointestinal and Ulcer Bleeding Review.

20-Year-Old Man With Elevated Liver Tests

20-Year-Old Man With Elevated Liver Tests

Continuing Medical Education Questions: January 2022

Article Title: ACG Clinical Guideline: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease.

P019 Not All Fecal Calprotectin is Specific for Inflammatory Bowel Disease.

Introduction:Fecal calprotectin is a known inflammatory marker used to evaluate patients with Inflammatory Bowel Disease (IBD). In fact, ACG Clinical Guideline for management of Crohn's disease recommend fecal calprotectin (FC) as a helpful test to distinguish IBD versus functional disorder such as Irritable Bowel Syndrome. Studies have also shown association of fecal calprotectin with colon cancer. Recent study proposed fecal calprotectin could be a reliable marker for ruling out organic disease with high negative predictive value. We present a patient case of a Caucasian, thirty-five years of age male with PMHx of GERD on Prilosec who presented due to acute abdominal pain, nausea, emesis and watery, nonbloody diarrhea of four days duration. Initially, patient had unknown family history of colon cancer which later was revealed that patient's father had a colon cancer diagnosis in his fifties. On admission, patient had stable vitals with routine labs showing leukocytosis, iron deficiency anemia, normal CRP, and elevated fecal calprotectin of 986mcg/gm. Abdominal imaging with CT abdomen with contrast showed diffuse dilation of ileum and thickening of the distal ileum up to the level of the ileocecal junction, suggestive of enteritis from infectious or inflammatory etiology such as Crohn's. Patient was managed conservatively, stool studies were negative otherwise and discharged with outpatient endoscopy due to high suspicion for Inflammatory Bowel Disease. Within one week, patient had a subsequent readmission for now partial small bowel obstruction at the level of ileum. Due to high suspicion of Crohn's, patient was empirically started on IV steroids. Decision for inpatient colonoscopy was made with colonoscopy showing completely obstructing, circumferential, large mass found in the cecum extending into ascending colon. Final pathology revealed invasive mucinous adenocarcinoma, moderately differentiated. Patient subsequently underwent right hemicolectomy with lymph node resection and adjuvant chemotherapy treatment for stage 3 colon. We present here a case where a common cancer was found in an otherwise healthy, young male with acute abdominal pain and altered bowel habits. While initial symptoms, imaging and laboratory findings pointed towards a biased high suspicion for Inflammatory Bowel Disease, patient's ultimate diagnosis was stage 3 adenocarcinoma of colon requiring surgical resection and chemotherapy. Fecal calprotectin is a known marker for colon inflammation and associated with both IBD and colon cancer. It is important to keep in mind that while fecal calprotectin may have elevated negative predictive value and be used to rule out organic disease, elevation of fecal calprotectin is not always specific for IBD. We want to emphasize the importance of considering colon cancer on the differential despite a patient's age and diagnostic bias. Lastly, we also want to highlight the importance of tissue diagnosis prior to long term therapy use.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

70-Year-Old Man With Chronic Nausea and Vomiting

70-Year-Old Man With Chronic Nausea and Vomiting

Correction to: ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections.

Correction to: ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections.

Continuing Medical Education Questions: October 2021.

Article Title: ACG Clinical Guidelines Management of Benign Anorectal Disorders.

Correction to: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

Correction to: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process

Continuing Medical Education Questions: June 2021.

Article Title: ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections.

ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections.

Clostridioides difficile infection occurs when the bacterium produces toxin that causes diarrhea and inflammation of the colon. These guidelines indicate the preferred approach to the management of adults with C. difficile infection and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations Assessment, Development, and Evaluation but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not the only, approach to clinical scenarios.

Continuing Medical Education Questions: May 2021.

Article Title: ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury.