American Gastroenterological Association Guidelines Research Articles

500. Finding AP Gap: An Assessment of Antibiotic Use in Acute Pancreatitis

Abstract Background American Gastroenterology Association (AGA) guidelines recommend against the use of prophylactic antibiotics for acute pancreatitis. Antibiotic therapy is recommended for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (e.g. gas in collection, bacteremia, sepsis, or clinical deterioration). Carbapenems, metronidazole, third or fourth generation cephalosporins, and fluoroquinolones are preferred agents. Data to support use of piperacillin/tazobactam also exists. There is limited data evaluating adherence to these guidelines.Table 1:Baseline Characteristics Methods This was a retrospective cohort study of adult patients hospitalized in The MetroHealth System from January 1, 2021 through December 31, 2022 who received antibiotics for a diagnosis of acute pancreatitis. Exclusion criteria included multiple indications for antibiotics or antibiotics given in the emergency department (ED) only. Only the first hospitalization per patient was included. The primary outcome was the percentage of encounters for which antibiotic use was adherent to AGA guidelines. Secondary outcomes included descriptions of antibiotic choice/duration and microbiologic results.Table 2:Antibiotic Use Results Of 538 inpatient encounters with a diagnosis of acute pancreatitis, antibiotics for any indication were prescribed in 322 (60%). For the 83 unique patient encounters meeting inclusion criteria, antibiotic use was not adherent to AGA guidelines in 49 (59%). Table 1 compares characteristics of patients in whom antibiotic therapy was adherent vs non-adherent. Carbapenems, piperacillin/tazobactam, cephalosporins, and vancomycin were prescribed for pancreatitis during 42%, 51%, 41%, and 25% of encounters respectively (table 2). The average duration of antibiotics for all study patients was 8.5 days. Microbiologic testing was performed in 64 (77%) patients with no MRSA isolated in any cultures (Table 3).Table 3:Microbiologic Results Conclusion Antibiotic use in more than half of patients was not adherent to AGA guidelines. Carbapenems, piperacillin/tazobactam, and cephalosporins were commonly used. Vancomycin was often used, although no MRSA was isolated. Significant opportunities for antimicrobial stewardship for acute pancreatitis exist. Disclosures All Authors: No reported disclosures

Exploring thenew Kyoto guidelines for managing pancreatic cysts: an overview and comparison with previous guidelines.

The rising use of diagnostic imaging has led to an increase in the incidental detection of pancreatic cysts, with reported incidences of 1.2-2.6% on Computed Tomography and 2.4-49.1% on Magnetic Resonance Imaging. While many of these cysts are asymptomatic and benign, the enhanced imaging techniques have also revealed malignant and premalignant lesions. Mucinous neoplasms, including intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms, are particularly concerning due to their potential for malignant transformation. Recent studies highlight significant variations in dysplasia across IPMN types, with main duct IPMNs showing a higher likelihood of high-grade dysplasia or invasive carcinoma compared to branch duct IPMNs. Management and follow-up of these lesions remain controversial due to inconsistent guidelines. This article reviews and compares six major guidelines: the 2015 American Gastroenterological Association guidelines, the 2017 International Association of Pancreatology (IAP/Fukuoka) guidelines, the 2017 American College of Radiology guidelines, the 2018 American College of Gastroenterology guidelines, the 2018 European Study Group guidelines, and the newly released, 2024 Kyoto guidelines. We summarize key differences in risk factors, surveillance protocols, and surgical referral criteria, with a focus on the updated 2024 Kyoto guidelines and the implications of recent research advancements.

Clostridioides difficile infections: Update and therapeutic guidelines

Clostridioides difficile infection (CDI) represents a significant challenge due to its increasing incidence, severity, and treatment difficulty. Effective management requires a multifactorial approach that includes preventive strategies, prudent antibiotic use, and adapted therapeutic options. Ongoing research and innovation offer promising prospects for improving ICD management, making vigilance and informed practices essential among healthcare professionals. Two main complications of ICD are pseudomembranous colitis (PMC) and toxic megacolon. PMC involves severe colonic inflammation due to C.difficile toxins, leading to pseudomembrane formation. Diagnosis relies on clinical criteria, microbiological tests, and endoscopy. Toxic Megacolon is characterized by severe colonic dilation and systemic toxicity, requiring immediate medical intervention. ICD diagnosis combines clinical signs and microbiological tests. These tests include toxin tests, GDH antigen detection, PCR for toxin genes, and stool culture. Imaging techniques assess colonic inflammation and complications. Combined diagnostic criteria from the American Gastroenterological Association (AGA) and European guidelines emphasize integrating clinical and laboratory findings for accurate diagnosis. ICD treatment involves stopping the implicated antibiotics and starting specific antimicrobial therapy. Common treatments include mainly fidaxomicin and oral vancomycin. Fecal microbiota transplantation (TMF) is recommended for recurrent cases unresponsive to standard treatments. Bezlotoxumab, an antibody targeting C.difficile toxin B, is used to prevent recurrence in high-risk adults. ICD poses a major challenge due to its increasing incidence, severity, and difficulty in treatment. A multifactorial approach involving rigorous preventive strategies, prudent antibiotic management, and adapted therapeutic options is essential for controlling the infection. Ongoing research and innovations in treatment offer promising prospects for improving patient management. Healthcare professionals must remain vigilant and informed to ensure effective practices in combating this infection and utilizing available resources optimally.

Comparative accuracy of four guidelines to predict high-grade dysplasia or malignancy in surgically resected pancreatic intraductal papillary mucinous neoplasms: Small nuances between guidelines lead to vastly different results.

The guidelines regarding the management of intraductal papillary mucinous neoplasms (IPMNs) all have slightly different surgical indications for high-risk lesions. We aim to retrospectively compare the accuracy of four guidelines in recommending surgery for high-risk IPMNs, and assess the accuracy of elevated CA-19-9 levels and imaging characteristics of IPMNs considered high-risk in predicting malignancy or high-grade dysplasia (HGD). The final histopathological diagnosis of surgically resected high-risk IPMNs during 2013-2020 were compared to preoperative surgical indications, as enumerated in four guidelines: the 2015 American Gastroenterological Association (AGA), 2017 International Consensus, 2018 European Study Group, and 2018 American College of Gastroenterology (ACG). Surgery was considered "justified" if histopathology of the surgical specimen showed HGD/malignancy, or there was postoperative symptomatic improvement. Surgery was postoperatively justified in 26/65 (40.0%) cases. All IPMNs with HGD/malignancy were detected by the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines. The combined ("high-risk stigmata" and "worrisome features") 2017 International guideline missed 1/19 (5.3%) IPMNs with HGD/malignancy. The 2015 AGA guideline missed the most cases (11/19, 57.9%) of IPMNs with HGD/malignancy. We found the features most-associated with HGD/malignancy were pancreatic ductal dilation, and elevated CA-19-9 levels. Following the 2015 AGA guideline results in the highest rate of missed HGD/malignancy, but the lowest rate of operating on IPMNs without these features; meanwhile, the 2018 ACG and the combined (absolute and relative criteria) 2018 European guidelines result in more operations for IPMNs without HGD/malignancy, but the lowest rates of missed HGD/malignancy in IPMNs.

Practice Trends among US Gastroenterologists following the 2020 American Gastroenterological Association Guidelines on Gastric Intestinal Metaplasia: Data from a Tertiary Care Center.

Studies show variability in gastroenterologists' management of gastric intestinal metaplasia (GIM) in the United States. In 2020, the American Gastroenterological Association published GIM guidelines, recommending physician-patient shared decision-making on GIM surveillance based on risk factors. We compared gastroenterologists' communication trends of a GIM finding and surveillance recommendations before and after 2020 and evaluated patient and provider factors associated with a surveillance recommendation. A sample of patients diagnosed with GIM on biopsies from upper endoscopies performed in 2018 (cohort A) and 2021 (cohort B) were included. Logistic regression analysis assessed the association between patient/provider characteristics and surveillance recommendations in the overall cohort and over time. In all, 347 patients were included: 175 in cohort A and 172 in B. Median age was 65.7 (56.0, 73.4), and 54.5% were females. Communication to patients about GIM findings and surveillance recommendations increased from 24.6% <2020 to 50% >2020 ( P <0.001) and 20% <2020 to 41.3% >2020 ( P <0.001), respectively. Overall, endoscopy >2020, family history of gastric cancer, autoimmune gastritis, female providers, and gastroenterologists with 10 to 20 years of experience were associated with a surveillance recommendation. The effect of family history of gastric cancer and the effect of the patient's female sex on surveillance was significantly different between both cohorts [Odds ratio (OR): 0.13, 95% (Confidence interval) CI: 0.02, 0.97 and OR 3.39, 95% CI: 1.12, 10.2, respectively). Despite a 2-fold increase in surveillance recommendations after 2020, there was no meaningful effect of any of the patients' factors on a recommendation for surveillance over time, which raises the question as to whether surveillance is being offered to both average and high-risk patients without thorough risk stratification.

UPADACITINIB RESOLVES DIARRHEA AND FECAL CALPROTECTIN ABNORMALITIES IN BUDESONIDE-DEPENDENT MICROSCOPIC COLITIS

Abstract BACKGROUND Current American Gastroenterological Association guidelines are devoid of recommendations for steroid and biologic refractory microscopic colitis (MC). Upadacitinib (UPA) is a small molecule that selectively inhibits janus kinase-1 (JAK1). Evidence pertaining to its utility in the management of steroid and biologic refractory MC remains limited. Herein, we report efficacy and safety of UPA in medically refractory MC. METHODS Three patients presenting with severe MC refractory to budesonide and biologic therapy (vedolizumab, Table 1) were treated with standard UPA therapy. UPA was initiated at standard induction of 45 mg/day for 8 weeks. All patients had their UPA reduced to 30 mg/d for maintenance. Therapeutic response was assessed using Hjortswang’s criteria (HC), and serial fecal calprotectin measurements. HC defines clinical remission as &amp;lt; 3 bowel movements (BM)/day and &amp;lt; 1 watery stools/day. Active disease was defined as ≥ 3 BM/day or ≥1 watery stool/day. FC &amp;lt; 150 ug/g was deemed normal. RESULTS Three patients (Table 1) were included in this study. Overall, our cohort had 2 cases of collagenous colitis and 1 case of lymphocytic colitis. Two patients had an association with diagnosis of celiac disease. All patients failed steroid and biologic therapy (Table 1) with an average of 5 failed medications. At the end of UPA induction, all patients attained &amp;lt; 3 BM/day (% reduction: -79%±6). Resolution of abdominal pain, nocturnal stooling, fatigue and fecal urgency were observed. As per HC, 1 patient displayed clinical remission and two achieved significant symptomatic improvement (Table 2). All patients displayed significant reductions in FC (-71%±1.5). At 16 weeks, none of the patients experienced LBM (-100%±0) and all resolved abdominal pain, nocturnal stooling, fatigue and fecal urgency (Table 2). FC normalized (-93%±6.4) in all three patients (Table 3). No serious infections, cardiovascular events or thromboembolic events occurred. One patient experienced gout and required further UPA dose reduction to 15 mg/day. This patient continues to maintain remission at 15 mg/day. DISCUSSION UPA is a novel JAK1 inhibitor with a favorable pharmacokinetic profile. It’s rapid onset of action and relative safe profile compared to chronic steroid use makes it an ideal treatment for refractory MC. The pathophysiology of MC remains poorly elucidated. It is postulated that JAK1 is involved in IL-2, IL-4, IL-6, IL-15 and IFN signaling. UPA-inhibited JAK-STAT ameliorates IFN-γ and IL-6, implicated in MC pathogenesis. Data here supports UPA use in steroid and biologic refractory MC. Further large-scale studies are warranted to delineate long term efficacy and safety of UPA in MC. Table 1 Demographics and Baseline Disease Characteristics. Table 2 Trends in clinical parameters at baseline versus Weeks 8 and 16 Table 3 Percentage reduction in loose bowel movements (LBM) and fecal calprotectin (FC)

A Shift Toward Early Oral Feeding in Acute Pancreatitis.

The 2018 American Gastroenterological Association (AGA) guidelines strongly recommended early oral feeding as tolerated in patients with acute pancreatitis (AP). We compare early oral feeding rates in AP patients hospitalized in the periods before (2013-2016, Period A) and after (2019-2020, Period B) publication of the AGA guidelines, hypothesizing increased adherence in Period B. We performed a retrospective cohort study of AP patients presenting to the emergency department during each period. Early oral feeding was defined as diet initiation within the first 48 hours of presentation. The cohort included 276 AP cases in period A and 104 in period B. A higher percentage of patients were offered early oral feeding during period B as compared to period A (70.2% vs. 43.5%). Similarly, more patients in period B were started on solid diet as compared to period A (34.6% vs. 20.3%). On multivariable regression analysis, the independent predictors of delayed oral feeding included early opioid analgesics use (OR 0.37), presence of pancreatic necrosis (OR 0.14), and organ failure (OR 0.33). More AP patients were initiated on early oral feeding in the period following the publication of the AGA guidelines. Opioid analgesics use, pancreatic necrosis, and organ failure were associated with delayed oral feeding.

S1880 Communication and Surveillance Recommendations on Gastric Intestinal Metaplasia by US Gastroenterologists Before and After the 2020 American Gastroenterological Association Guidelines: Data From a Tertiary Care Center

S1880 Communication and Surveillance Recommendations on Gastric Intestinal Metaplasia by US Gastroenterologists Before and After the 2020 American Gastroenterological Association Guidelines: Data From a Tertiary Care Center

Acute Pancreatitis Review.

Acute pancreatitis, a prevalent illness with devastating consequences, poses a grave threat to those affected. There has been a steady increase in the occurrence of acute pancreatitis at about 3% per year from 1961 to 2016. There are 3 main guidelines on acute pancreatitis, including the American College of Gastroenterology, the International Association of Pancreatology/American Pancreatic Association guideline in 2013, and the American Gastroenterological Association guideline in 2018. However, several milestone studies have been published since then. We hereby reviewed the current acute pancreatitis guidelines with an update on clinical practicechanging literature. The aggressive or moderate fluid resuscitation in acute pancreatitis (WATERFALL) trial recommended fluid resuscitation with lactated Ringer's solution at a moderate aggressive rate. All guidelines did not recommend prophylactic antibiotics use. Early enteral feeding reduces morbidity. A clear liquid diet is no longer recommended. Nutrition with nasogastric or nasojejunal feeding does not have a difference. The upcoming high vs. low-energy administration in the early phase of acute pancreatitis (GOULASH) trial will provide more information on the impact of calorie intake. Pain management should be individualized based on the degree of pain and severity of pancreatitis. In patients with moderate to severe and severe acute pancreatitis, a step-down approach with epidural analgesia can be considered for moderate to severe pain. The management of acute pancreatitis has evolved. New research on the impact of electrolytes, pharmacologic agents, the role of anticoagulants, and nutrition support will provide scientific and clinical evidence to improve patient care and decrease morbidity and mortality.

An Overview of Emerging Trends and Technologies in Ulcerative Colitis

&#x0D; This report provides an overview of the evolving therapeutic landscape for moderate to severe ulcerative colitis (UC), including recent changes to clinical practice guidelines, key trends in therapeutic strategies, and new or emerging treatment options, with a focus on biologics and small-molecule therapies.&#x0D; Recent guidelines on the medical management of patients with UC include those of the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and European Crohn’s and Colitis Organisation (ECCO), which were published in 2019, 2020, and 2022, respectively. These guidelines provide an accurate reflection of how clinical practice has changed to incorporate newer therapies that have entered the market and newer evidence that has been published since the release of the Canadian guidelines in 2015. The ACG, AGA, and ECCO guidelines all recommend use of a tumour necrosis factor (TNF) antagonist, vedolizumab, or tofacitinib for induction of remission in patients with moderate to severe UC; the AGA and ECCO guidelines also recommend ustekinumab as an option and recommend vedolizumab over adalimumab, whereas the AGA guidelines recommend early use of biologic drugs over a step-up approach after failure of 5-aminosalicylates.&#x0D; Two important trends in therapeutic strategies for UC include changes in the use and definition of treatment targets and recommendations regarding therapeutic drug monitoring (TDM).&#x0D; &#x0D; The 2021 Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) guidelines provide contemporary consensus recommendations for using new and updated targets throughout an individualized treatment timeline in patients with inflammatory bowel disease (IBD). Although histologic remission is not considered a formal UC treatment target in STRIDE-II, it is acknowledged as an adjunctive measure to endoscopic remission to represent a deeper level of healing and is the focus of many current studies.&#x0D; The use of TDM emerged from challenges associated with the use of older biologics (primarily TNF antagonists), which posed difficulties related to immunogenicity and dosing. The relevance of TDM for newer biologics with different mechanisms of action, reduced immunogenicity, and fixed dosing (e.g., vedolizumab and ustekinumab) is a topic of ongoing debate. Although AGA guidelines on TDM in IBD and expert consensus statements support the use of reactive TDM for patients with UC who lose response to a TNF antagonist, evidence gaps remain regarding appropriate use of proactive TDM, utility of TDM for small molecules and biologics outside of the TNF antagonist class, and consistent target concentration thresholds to guide dose changes.&#x0D; &#x0D; &#x0D; There is a substantial pipeline of new and emerging drugs for the treatment of adults with moderate to severe UC, with many in phase IIb or III of clinical development; several notable trends of emerging pharmacotherapies exist, including an increasing number of Janus kinase inhibitors, several therapies with biologic targets that are new in UC (e.g., interleukin-23 antibodies, TNF-like ligand 1A inhibitors), an increasing number of oral therapies, and the first combination of 2 biologic therapies in UC.&#x0D; The Canadian health care system should be prepared to adapt to the rapidly evolving treatment landscape and potential clinical practice changes in moderate to severe UC. Drugs with new mechanisms of action in the treatment area and the new paradigm of combination therapy with multiple biologics of different classes may lead to improved patient outcomes but can also further complicate the treatment decision-making process. Therefore, it is important for health care providers to stay up to date on new and upcoming treatment options, which may require educational initiatives for both providers and patients as well as updates to the Canadian treatment guidelines. Overall, potential changes on the horizon may have substantial implications for the health care system given the prevalence of UC in Canada, the costs of advanced therapies, and the increasing number of available treatment options.&#x0D;

Multicentre Analysis of Cost, Uptake and Safety of Canadian Multidisciplinary Pancreatic Cyst Guidelines.

Pancreatic cystic lesions (PCLs) are common, with several guidelines providing surveillance recommendations. The Canadian Association of Radiologists published surveillance guidelines (CARGs) intended to provide simplified, cost-effective and safe recommendations. This study aimed to evaluate cost savings of CARGs compared to other North American guidelines including American Gastroenterology Association guidelines (AGAG) and American College of Radiology guidelines (ACRG), and to evaluate CARG safety and uptake. This is a multicentre retrospective study evaluating adults with PCL from a single health zone. MRIs completed from September 2018-2019, one year after local CARG guideline implementation, were reviewed to identify PCLs. All imaging following 3-4 years of CARG implementation was reviewed to evaluate true costs, missed malignancy and guideline uptake. Modelling, including MRI and consultation, predicted and compared costs associated with surveillance based on CARGs, AGAGs and ACRGs. 6698 abdominal MRIs were reviewed with 1001 (14.9%) identifying PCL. Application of CARGs over 3.1 years demonstrated a >70% cost reduction compared to other guidelines. Similarly, the modelled cost of surveillance for 10-years for each guideline was $516,183, $1,908,425 and $1,924,607 for CARGs, AGAGs and ACRGs respectively. Of patients suggested to not require further surveillance per CARGs, approximately 1% develop malignancy with fewer being candidates for surgical resection. Overall, 44.8% of initial PCL reports provided CARG recommendations while 54.3% of PCLs were followed as per CARGs. CARGs are safe and offer substantial cost and opportunity savings for PCL surveillance. These findings support Canada-wide implementation with close monitoring of consultation requirements and missed diagnoses.

Diagnostic accuracy of the AGA, IAP, and European guidelines for detecting advanced neoplasia in intraductal papillary mucinous neoplasm/neoplasia

BackgroundFollow-up in patients with intraductal papillary mucinous neoplasm (IPMN) aims to detect advanced neoplasia (high-grade dysplasia/cancer) in an early stage. The 2015 American Gastroenterological Association (AGA), 2017 International Association of Pancreatology (IAP), and the 2018 European Study Group on Cystic tumours of the Pancreas (European) guidelines differ in their recommendations on indications for surgery. However, it remains unclear which guideline is most accurate in predicting advanced neoplasia in IPMN. MethodsPatients who underwent surgery were extracted from a prospective database (January 2006–January 2021). In patients with IPMN, final pathology was compared with the indication for surgery according to the guidelines. ROC-curves were calculated to determine the diagnostic accuracy for each guideline. ResultsOverall, 247 patients underwent surgery for cystic lesions. In 145 patients with IPMN, 52 had advanced neoplasia, of which the AGA guideline would have advised surgery in 14 (27%), the IAP and European guideline in 49 (94%) and 50 (96%). In 93 patients without advanced neoplasia, the AGA, IAP, and European guidelines would incorrectly have advised surgery in 8 (8.6%), 77 (83%) and 71 (76%). ConclusionThe European and IAP guidelines are clearly superior in detecting advanced neoplasia in IPMN as compared to the AGA, albeit at the cost of a higher rate of unnecessary surgery. To harmonize care and to avoid confusion caused by conflicting statements, a global evidence-based guideline for PCN in collaboration with the various guidelines groups is required once the current guidelines require an update.

S3438 Malignant Gastrointestinal Neuroectodermal Tumor of the Small Intestine: A Rare Cause of Iron Deficiency Anemia

Introduction: Gastrointestinal neuroectodermal tumors (GNET) are a type of high-grade sarcoma of the gastrointestinal (GI) tract that share features with clear cell carcinoma of tendon sheaths and aponeuroses. Patients typically present with clinical signs and symptoms of small bowel obstruction, intussusception or abdominal mass. These tumors can arise in the stomach, colon, as well as metastasis to liver or regional lymph nodes. We present a case of ileal GNET in an otherwise asymptomatic patient with Iron-deficiency Anemia (IDA) diagnosed using video capsule endoscopy (VCE). Case Description/Methods: A 58-year-old Hispanic male with a past medical history of GERD and obesity presented for evaluation of chronic microcytic anemia. Workup revealed: hemoglobin 8.6 g/dl, MCV 62.2, iron saturation 2.6%, transferrin 307 mg/dl, ferritin < 5 ng/ml, reticulocyte index of 1.34; serum folate, vitamin B12 and TSH levels were within normal limits. He was taking oral ferrous sulfate and vitamin C for IDA. He reported heartburn but denied melena, hematochezia, hematemesis, weight loss and had an unremarkable colonoscopy four years prior. Upper endoscopy revealed mild erosive esophagitis and mild chronic active gastritis with negative biopsies. Colonoscopy was unremarkable in the setting of optimal bowel preparation. VCE revealed an ulcerated mass occupying 35% of the ileal lumen. CT of the abdomen noted asymmetric wall thickening with enhancement of the small bowel. The patient underwent laparoscopy-assisted enteroscopy with rendezvous technique allowing direct visualization of a 3 cm proximal ileum mass requiring open segmental resection with primary anastomosis. Pathology suggested malignant GNET or clear cell sarcoma-like tumor of the GI tract. Immunohistochemistry was positive for neural crest markers (S100, SOX10) and Vimentin; negative for CD117, DOG1, HMB45, MART1, MAA, chromogranin, and synaptophysin. Fluorescence in-situ hybridization was positive for EWSR1 (22q12) rearrangement. Given the clear surgical margins, absent regional lymph node spread and lack of standard guidelines for this rare pT1N0M0 tumor, surveillance imaging every three months without adjuvant radiation or systemic chemotherapy was recommended. (Figure) Discussion: This case highlights the importance of VCE for small bowel assessment after negative bidirectional endoscopy to identify the etiology of IDA per American Gastroenterology Association guidelines. In this case, an ulcerated GNET was the etiology of IDA persisting despite iron supplementation.Figure 1.: A-Luminal view of small bowel tumor on Video Capsule Endoscopy (VCE) B–Close up view of ulceration of small bowel tumor on VCE C–Histopathology slide showing epithelioid cells with eosinophilic cytoplasm, pleomorphic nuclei with prominent nucleoli and vesicular nucleoli. Scattered mitotic figures identified.

Confocal Laser Endomicroscopy Is a Useful Alternative “Optical” Biopsy Modality in Diagnosis of Gastric Intestinal Metaplasia

A recently published American Gastroenterological Association (AGA) guideline supported endoscopic surveillance of gastric intestinal metaplasia (GIM) for patients at higher risk of gastric cancer (GC).1 However, the optimal surveillance endoscopic modality for GIM is yet solidified in the United States. Although the updated Sydney System, a comprehensive endoscopic biopsy protocol, has been advocated for GIM mapping,2 the challenges are the heterogeneous distribution of GIM, suboptimal diagnostic accuracy of high-definition white light (HDWL) endoscopy to detect GIM, and the cost burden and safety of multiple biopsies.

Application of Artificial Intelligence in the Management of Pancreatic Cystic Lesions.

The rate of incidentally detected pancreatic cystic lesions (PCLs) has increased over the past decade and was recently reported at 8%. These lesions pose a unique challenge, as each subtype of PCL carries a different risk of malignant transformation, ranging from 0% (pancreatic pseudocyst) to 34–68% (main duct intraductal papillary mucinous neoplasm). It is imperative to correctly risk-stratify the malignant potential of these lesions in order to provide the correct care course for the patient, ranging from monitoring to surgical intervention. Even with the multiplicity of guidelines (i.e., the American Gastroenterology Association guidelines and Fukuoka/International Consensus guidelines) and multitude of diagnostic information, risk stratification of PCLs falls short. Studies have reported that 25–64% of patients undergoing PCL resection have pancreatic cysts with no malignant potential, and up to 78% of mucin-producing cysts resected harbor no malignant potential on pathological evaluation. Clinicians are now incorporating artificial intelligence technology to aid in the management of these difficult lesions. This review article focuses on advancements in artificial intelligence within digital pathomics, radiomics, and genomics as they apply to the diagnosis and risk stratification of PCLs.

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

AGA Institute Quality Measure Development for the Management of Gastric Intestinal Metaplasia With Helicobacter pylori

A178 BIOLOGIC THERAPY DURING PREGNANCY AS PER GUIDELINE RECOMMENDATIONS REDUCES ADVERSE PREGNANCY RELATED OUTCOMES

BackgroundInflammatory bowel disease (IBD) disease activity during pregnancy is associated with adverse neonatal and pregnancy-related outcomes. Biologics are used to suppress disease activity but crosses the placenta in the third trimester. Conflicting studies and guidelines on the timing of biologic dosing in pregnancy persist as we try to balance the risk of disease flare and possible adverse drug effects. The American Gastroenterology Association (AGA) recommends timing the final dose according to the half-life and dosing regimen of each biologic agent.AimsTo compare neonatal and pregnancy-related outcomes in early versus late dosing of biologics.MethodsThis was a single-center retrospective cohort study conducted at Mount Sinai Hospital from 2016–2021. We included patients with an established diagnosis of IBD before pregnancy who were at least 18 years of age at the time of conception. All patients must have been treated with an IBD-specific biologic agent and had a documented final dose during the pregnancy. The early group received their last biologic dose earlier than the AGA recommendations and the late group received it within the recommended interval. A patient was considered to have a flare based on the overall clinical impression of their gastroenterologist informed by reported symptoms, investigations (fecal calprotectin, endoscopy), and response to treatment. Neonatal and pregnancy-related outcomes were compared amongst the two groups using the student’s t-test (for continuous variables) and Fischer’s exact test (for categorical variables) using SPSS Version 27.ResultsOf 322 patients who had a completed pregnancy at Mount Sinai Hospital, 107 were included in this study. 67 (62.6%) were in the early and 40 (37.4%) were in the late groups. Baseline characteristics including age, comorbidities, IBD phenotype and disease activity were similar between the two groups. The late group had significantly later gestational ages (37.4 vs 38.7 weeks, p=0.006), higher 5-minute Apgar scores (8.7 vs. 9.0, p=0.042), fewer NICU admissions (25.4% vs 5.0%, p=0.036), and fewer IBD flares (28.3% vs 11.1%, p=0.039) in the 6-month post-partum period. There were no significant differences in the rates of premature birth, caesarian sections, infections, and congenital abnormalities. Results are displayed in figure 1.ConclusionsOur study suggests that late dosing of biologics according to the AGA guidelines was associated with favourable outcomes. However, this is an unadjusted analysis based on retrospective data and findings should be confirmed in a prospective manner to account for confounders. Funding AgenciesNone

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus

Подбор антикоагулянтной терапии пациентам с циррозом печени

Patients with liver diseases have a higher risk of hemostatic disorders. Meanwhile, despite a well-established opinion on a low risk of thromboses in cirrhosis, thromboembolic events cannot be totally ruled out in these patients. Increased risks of thrombotic events and venous thromboembolism in cirrhosis are accounted for by external (immobilization, surgeries, infections, comorbidities) and internal factors (reduced synthesis of anticoagulants, increased levels of estrogens). Practically, the selection of anticoagulant therapy in cirrhosis is difficult because of divergent hemostatic disorders and requires continuous and careful monitoring of hemostasis. In 2019, the American Gastroenterological Association (AGA) released guidelines on anticoagulant therapy in patients with cirrhosis and pulmonary embolism. We describe a patient with cirrhosis and pulmonary embolism. A management strategy was tailored to the AGA guidelines, the Russian Society on Liver Research guidelines, and the Russian Gastroenterological Association on Fibrosis and Cirrhosis and Complication Diagnosis and Treatment guidelines. This example of successful selection of anticoagulant therapy, multidisciplinary approach, and dynamic evaluation of all available methods of hemostasis control will be useful for practitioners. KEYWORDS: cirrhosis, hemostasis, thrombosis, hemorrhage, venous thromboembolism, pulmonary embolism, thromboelastometry, anticoagulant, low-molecular-weight heparin. FOR CITATION: Arykan N.G., Shestopalov A.E., Khvorostinina E.E. et al. Selecting anticoagulant therapy in patients with cirrhosis. Russian Medical Inquiry. 2022;6(5):286–292 (in Russ.). DOI: 10.32364/2587-6821-2022-6-5-286-292.

Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management.

Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.