American Gastroenterological Association Research Articles

Epigenetic Memory of Intestinal Epithelial Cells in Inflammatory Bowel Disease

Background: The pathogenesis of human Inflammatory Bowel Disease (IBD) is a multifactorial process including interaction between immune, epithelial, and environmental factors. Growing evidence suggests that epithelial cell defects play major role in the pathogenesis of IBD. Epigenetic memory involves lasting, cell-type specific modifications to chromatin at multiple scales, which impacts transcriptional programs required for normal cell functions. A major gap in knowledge are the mechanisms involved in establishing and maintaining memory in cell types and diseases of the intestine. The objective of this study was to determine if intestinal epithelial cells (IECs) retain a memory of altered chromatin architectures and resultant regulation following inflammation. The hypothesis was that the IECs would show lasting altered chromatin structure landscapes (epigenetic memory) in response to inflammation. Methods: We have developed a multicellular model system of IBD using adult stem cell derived organoids from humans with IBD, from regions of the colon with and without active inflammation. We performed ATAC-seq, bulk RNA-seq and single cell RNA-seq on these organoids derived from the uninflamed and inflamed tissues of IBD patients, specifically Ulcerative Colitis (UC). Results: Regions of increased chromatin accessibility are enriched in organoids derived from areas of inflammation in UC patients compared to organoids from patient-matched, uninflamed regions. These open chromatin regions are associated with proinflammatory genes, with modest transcriptional alterations, pointing to an epigenetic inflammatory memory. Motif analysis for accessibly peaks in UC showed an enrichment of the AP-1 family of transcription factors and chromatin remodelers (SMARCA4). This data is consistent with other studies of inflammatory memory from other epithelial cell types, but we show this for the first time in IECs in the context of IBD. Conclusions: This study presents a novel line of investigation and development of model systems to examine epigenetic memory of IECs in human IBD. We expect that our studies will identify new chromatin-based mechanisms of IEC function that are impacted by inflammation. This research was funded by American Gastroenterological Association Research Scholar Award and KL2 Scholar Career Development Award (KL2 TR002379, National Center for Advancing Translational Science). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

The association between score of plant-based diet and non-alcoholic fatty liver disease in adults

Plant-based diet (PDI) as resource of antioxidants and anti-inflammatory phytochemicals, that was considered to protect against onset and development of Non-alcoholic fatty liver disease (NAFLD). To investigate the association between plant-based diet and NAFLD in adults. The present case control study was conducted on 240 individuals (120 with NAFLD and 120 control) aged 20-69 years. Provided recommendations by the American College of Gastroenterology and the American Gastroenterological Association were used for NAFLD diagnosis. Dietary intake was assessed using 178-food item food frequency questionnaire (FFQ). Also, plant-based diet score was evaluated based on 18 food groups classified into animal foods, healthy and unhealthy plant foods. A multiple logistic regression model was used to examine the relationship between fatty liver disease and tertiles of PDI. The results of this study showed that we did not observe any association between tertiles of PDI and NAFLD in crude model (OR: 1.29, 95%CI:0.66-2.52, P:0.44) and after adjustment for confounders including age, energy intake, physical activity, body mass index (OR:0.76, 95%CI: 0.31-1.86, P:0.52). Also, there were not any association of tertiles of healthy PDI (hPDI) (OR:1.14, 95%CI: 0.50-2.60, P:0.74) and unhealthy PDI (uhPDI) (OR:0.89, 95%CI:0.36-2.18, P: 0.79) with NAFLD after full adjustment for potential confounders. There was not any association of PDI, hPDI, and uPDI with NAFLD in adults. More research needs to examine whether this specific diet may impact and improve NAFLD.

Antimicrobial prescribing in acute pancreatitis: Too much for too many?

BackgroundAcute pancreatitis (AP) is an inflammatory condition of the pancreas that varies widely in both clinical presentation and severity. Current international guidelines do not recommend the use of prophylactic antimicrobials in AP. AimTo review the compliance of antimicrobial prescribing in AP with international guidelines. MethodWe conducted a retrospective review of patients admitted with AP between 1st January 2021 and 31st December 2021, in Beaumont Hospital, Dublin, Ireland. For each case identified, the 2012 Revised Atlanta Criteria for AP were then applied on review of medical, laboratory and radiology records. ResultsThere were 98 patients, 52 % male (n = 51) with a median age of 53 years (range 18–88) who met the Revised Atlanta Criteria accounting for 1,032 hospital bed days inclusive of 82 critical care bed days. Gallstones were the most common aetiology; 48 % (n = 47). Antimicrobials were prescribed for 55 (56 %) patients with AP. Of those, only 38 % (n = 21) met the American Gastroenterological Association criteria for antimicrobials. The most common classes of antimicrobials prescribed were beta-lactams and carbapenems. Procalcitonin testing was conducted on just one patient (1 %). There were no cases of inpatient or 90-day mortality. ConclusionsOur findings are consistent with previously published reports of low mortality in mild acute AP and an excessive prescription of antimicrobials, highlighting this as an area for a targeted antimicrobial stewardship (AMS) intervention, including an increased use of procalcitonin as a biomarker.

Management of irritable bowel syndrome: a narrative review.

As our understanding of the pathophysiology of irritable bowel syndrome (IBS) has advanced, so too has the therapeutic landscape, offering a myriad of approaches to alleviate symptoms and enhance the well-being of patients. This review paper is dedicated to a comprehensive exploration of the diverse therapeutic modalities available for managing IBS. By delving into the complexities of IBS therapeutics, our aim is to contribute to the enhancement of patient care and the overall quality of life for patients grappling with this complex condition. This review utilized information from PubMed/MEDLINE using the key search term "irritable bowel syndrome" as well as the 2020 American College of Gastroenterology (ACG) and 2022 American Gastroenterological Association (AGA) society guidelines on IBS. The search was restricted to articles in the English language only and included peer-reviewed observational studies and randomized controlled trials (RCTs) in adult patients from April 22, 2020 to October 16, 2023. This review will start with an overview of the current guidelines for pharmacologic therapies for IBS as recommended by the ACG and the AGA, with an emphasis on clinical trials published after the most recent guidelines. It will then delve into the literature on dietary modifications, probiotics, fecal microbiota transplant, behavioral therapy, and complementary and alternative medicine approaches to IBS. It is evident that the management of IBS has transcended a one-size-fits-all approach. As the field of IBS management continues to evolve, it is imperative for physicians to stay informed and receptive to the array of therapeutic options available, ultimately providing patients with the most effective and personalized care.

Clinical Outcomes and Safety of Upper Endoscopy While on Glucagon-Like Peptide-1 Receptor Agonists

Glucose-like peptide-1-receptor agonists (GLP-1RAs) have become integral to the management of type 2 diabetes and obesity. GLP-1RAs work in part through delaying gastric emptying, raising concerns about retained gastric contents (RGC) during esophagogastroduodenoscopy (EGD).1 The American Society of Anesthesiologists currently recommends holding GLP-1RAs for 1 dosing cycle before elective procedures, however, the American Gastroenterological Association (AGA) advocates proceeding with endoscopy in asymptomatic patients adhering to standard perioperative protocols without medication withholding and suggests implementing a liquid diet the day before endoscopy in lieu of stopping the medication.2,3 This variability in recommendations stems largely from a lack of GLP-1RA outcomes data from which to draw evidence-based conclusions.

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.

A205 PRACTICE PATTERNS FOR EOSINOPHILIC ESOPHAGITIS IN ADULTS VARY WIDELY AMONG CANADIAN GASTROENTEROLOGISTS: INTERIM ANALYSIS OF A NATIONWIDE SURVEY

Abstract Background Eosinophilic esophagitis (EoE) is a chronic allergic, type 2 immune-mediated, condition of the esophagus with increasing prevalence in Canada. Practice patterns among Canadian gastroenterologists are not well described. Aims To identify practice variation among Canadian gastroenterologists who care for adults with EoE. Methods A cross-sectional, web-based survey was distributed to Canadian gastroenterologists through the Canadian Association of Gastroenterology as well as administrations at Canadian universities. Results Of 53 respondents, 68% currently work in an academic setting. 77% manage at least 6 patients with EoE per year, with 19% managing over 50 patients per year. 51% of respondents obtain biopsies in every new patient presenting with an acute food bolus, while 26% take biopsies in less than 50% of cases or never at all. 36% take less than 5 biopsies on initial endoscopy with 23% only taking biopsies from one location in the esophagus. 58% are either unaware of the EoE Endoscopic Reference Score (EREFS) or never use it in clinical practice. Most respondents (72%) prefer proton pump inhibitors as initial therapy while 17% prefer starting multiple treatment modalities. 9% use topical steroids initially. Only 6% keep their patients on topical steroids indefinitely, if started. Preferred dietary approach vary with 36% choosing 6-food elimination diet (FED), 23% 2-FED, 19% 4-FED, 13% milk-only elimination diet, 6% allergy test-directed diet, and 4% elemental diet. Only 17% feel very comfortable starting biologic therapies. When evaluating treatment effectiveness, 23% use improving patient symptoms alone, while 74% include repeat histological assessments. 42% do not regularly screen for adaptive behaviours, such as excessive chewing, or texture modification and avoidance. In those who perform repeat endoscopic evaluation, 13% do so in less than 3 months after starting therapy, 32% in 3-5.9 months, 28% in 6-11.9 months, and 8% after a year. 11% will only repeat endoscopic evaluation if a patient reports symptom recurrence. 64% do not regularly refer to an allergist. For guidance, 59% follow the American Gastroenterology Association 2020 guidelines, 34% American Society of Gastrointestinal Endoscopy 2022 guidelines, 4% British Society of Gastroenterology 2022 guidelines, while 21% do not use any guidelines. 83% feel Canadian guidelines would be useful in their practice. Conclusions EoE practice patterns among Canadian adult gastroenterologists vary widely, with management differing from the current consensus guidelines. Strategies aimed at decreasing these variations, such as the development of Canadian guidelines, are needed to standardize practice. Funding Agencies None

White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States–Removing Barriers and Embracing Opportunities

Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and IBD specialists limits patients access to high quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high quality, patient centered care. This position statement outlines the policy and advocacy goals that the AGA will prioritize for collaborative efforts with patients, providers, and payors.

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)

P1075 Outcomes in patients stopping biologic during the first trimester of pregnancy : a retrospective monocentric study

Abstract Background Both the American Gastroenterological Association (AGA) and the European Crohn's and Colitis Organisation (ECCO) recommend to continue biologic during the whole pregnancy and until the third trimester, respectively. However, these positions are associated with a baby's exposure to the drug and from our clinical practice are not necessarily in line with patients' wishes and fears. In patients in full clinical and biologic remission, stopping biologic before it is actively transported through the placenta (around the week 20) would be a possible approach to get around these drawbacks. We aimed to assess the outcome of disease activity and pregnancies in patients stopping biologic before the week 20. Methods We performed a retrospective monocentric study. All patients who gave birth between 2010 and 2023 were included. The following parameters were collected: clinical and demographic characteristics, biomarkers (CRP and faecal calprotectin before pregnancy and during the 3 trimesters), IBD treatment at time of pregnancy, whether it was stopped during pregnancy, when and in what circumstance (patient versus medical agreement). We also looked at the disease course, whether a relapse occurred (defined as the need to take corticosteroids, a biologic, or surgical resection), and the pregnancy outcome. Results A total of 185 pregnancies were reported in 143 patients (73.4% Crohn disease and 26.6% ulcerative colitis). Patient's characteristics are shown in Table 1. Among these women, 106 (74.1%), 32 (22.4%) and 5 (3.5%) reported one, two or 3 or more pregnancies, respectively. Figure 1 summarises the treatments during these reported pregnancies, disease activity outcomes and pregnancy outcomes. The biologic was stopped before conception for 9 pregnancies and 90 pregnancies started under biologics (anti-TNF, vedolizumab or ustekinumab). Of these, biologic was continued until delivery in 10 (11.1%) patients, whereas it was stopped before the week 20 for the others (88.9%). Among patients who stopped biologics before conception, before the week 20, and those who continued biologics through delivery: 3/9 (33.3%), 13/80 (16.3%; including 10/66 or 15.2% among those stopping on medical agreement) and 4/10 (40%) relapsed, respectively. Among the 10 relapses in patients who stopped in first trimester on medical agreement, 6 had normal biomarkers before cessation (unknown for the others). Conclusion Biologic discontinuation before week 20 on medical agreement was associated with relapse in 15.2% of cases. Fate of disease activity and pregnancies in patients stopping biologic before week 20 should be studied prospectively in a dedicated study.

DOP68 Natural history of isolated Crohn's Disease perianal fistula

Abstract Background Approximately 20% of patients with Crohn’s disease (CD) have perianal fistulizing CD, which are most often complex PAF. Studies have shown that 4-5% of patients with CD present with PAF without luminal disease, termed isolated perianal CD (iPCD). Little is known about their natural history. Methods We performed a retrospective cohort study of patients seen within the Mount Sinai Health System (New York) with an ICD-10 diagnosis code for PAF between 7/22/2008 and 7/22/2022. Medical record review was conducted to identify patients with PAF, considered as possible iPCD, who did not have evidence of luminal disease and had &amp;gt; 6 months of follow-up (Table 1). Demographics, comorbidities, imaging, endoscopy, surgeries, hospitalizations and medication data were collected. These patients were reviewed to determine progression to luminal disease, which was defined as any evidence of luminal ulcers, erosions, or strictures on endoscopy, histology, video capsule exam, or MRE. Descriptive and univariate analyses were performed. Complex PAF was defined by American Gastroenterological Association criteria. Complicated disease course was defined as a composite of any major CD-related surgery, PAF/IBD-related hospitalization or biologic use. Results Among 887 patients who presented with PAF, 62.2% (n=552) patients underwent luminal evaluation, of whom 80 patients (14.5%) were found to have no luminal disease and considered as having iPCD (Table 1). 57 of these 80 patients had &amp;gt;6 months follow-up. Luminal disease developed in 13 patients (23%) with a mean time to diagnosis of 4.2 +/- 3.8 years after PAF presentation. Patients who developed luminal CD were more likely to be &amp;lt;30 years old at PAF diagnosis (p=0.0225), had &amp;gt;2 fistulas on imaging (p=0.002), and have concomitant autoimmune conditions (p=0.046) (Table 2). During the follow-up period, the patients who developed luminal CD were more likely to receive biological therapy (77% vs 16%, p&amp;lt;0.0001) or undergo CD/PAF-related hospitalization (62% vs 30%, p =0.0356) (Table 2). Overall, patients who developed luminal CD had a more complicated disease course (31% vs 2.3%, p=0.007) than those who did not. Conclusion Approximately 1 in 4 patients who presented with possible iPCD developed luminal CD at follow-up. Patients who developed luminal CD were more likely to be younger at diagnosis, had more fistula tracts, and had concomitant autoimmune conditions.

Microbiota restoration therapies for recurrent Clostridioides difficile infection reach an important new milestone.

Microbiota restoration therapy has become a standard treatment for recurrent Clostridioides difficile infection (rCDI). In this article, we review the studies supporting the licensure of two live biotherapeutic products (LBPs) designed to prevent rCDI and to provide clinicians with a perspective on their differences. PubMed was reviewed on 1 October 2023, for all papers published concerning the current Food and Drug Administration allowance of the use of fecal microbiota transplantation (FMT) and the studies that led to the licensure of RBX2660 (REBYOTA™), generic name, fecal microbiota, live-jslm, and SER-109 (VOWST™), generic name, fecal microbiota spores, live-brpk. OpenBiome continues to produce fecal products for patients with rCDI at their treatment sites, and the American Gastroenterology Association has a National Registry focused on long-term safety of administering fecal microbiota products. The science behind the licensing of fecal microbiota, live-jslm, a consortium of fecal anaerobes found in stool augmented with strains of Bacteroidetes and fecal microbiota spores, live-brpk, a mixture of 50 species of purified Firmicutes spores is reviewed. Both products appear to be safe in clinical trials and effective in reducing rCDI episodes by mechanisms established for FMT, including normalization of α- and β-diversity of the microbiome and by increasing fecal secondary bile acids. The different makeup of the two LBPs suggests that rCDI responds to a variety of engrafting microbiota which explains why nearly all donors in FMT of rCDI are generally effective. Fecal microbiota, live-jslm has also been shown to successfully treat rCDI in elderly patients with advanced comorbidities. With the licensure of two novel LBPs, we are entering a new phase of microbiota replacement therapy. Having standardized manufacturing and proper monitoring of products, harnessing the microbiome to control and prevent disease has a new beginning.

The Incidental Pancreatic Cyst: When to Worry About Cancer.

Incidental pancreatic cystic lesions are a common challenge encountered by diagnostic radiologists. Specifically, given the prevalence of benign pancreatic cystic lesions, determining when to recommend aggressive actions such as surgical resection or endoscopic ultrasound with sampling is difficult. In this article, we review the common types of cystic pancreatic lesions including serous cystadenoma, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm with imaging examples of each. We also discuss high-risk or worrisome imaging features that warrant a referral to a surgeon or endoscopist and provid several examples of these features. These imaging features adhere to the latest guidelines from the International Consensus Guidelines, American Gastroenterological Association (2015), American College of Gastroenterology (2018), American College of Radiology (2010, 2017), and European Guidelines (2013, 2018). Our focused article addresses the imaging dilemma of managing incidental cystic pancreatic lesions, weighing the options between imaging follow-up and aggressive interventions.

The Wise Long-Term Use of Proton Pump Inhibitors PPIs among Adults in Hospitals, Health Centers and Clinics

Background: PPIs are frequently used in hospitals, primary health care centers and private clinics. The adverse effects and interactions are numerous so, physicians’ knowledge including accurate indications after confirmations of diagnosis, duration of use and follow-up are an essential part of the treatment process. Aim: The purpose of this review tis o help health care professionals to prescribe the PPIs wisely and appropriately. Objective: To undertake a review of the literature relating to the long-term use of PPIs Data Sources: United States, Food and Drug Administration [FDA], PubMed, Scopus, Science Direct, Wiley, Google Scholar, major clinical guidelines, and governmental agencies. Data Extraction: The 2 reviewers Musa Basheer Mansour and Sara Ahmedana [MBM and SEA] independently assessed the qualities of the extracted studies and summarized data of the studies for outcomes of interest and performed quality assessments based on review of published articles and the data sources. Results: We reviewed the available evidence and summarized the long-term use of PPIs as indicated by major clinical guidelines, governmental agencies, and published studies. For instance, United States, Food and Drug Administration, American Gastroenterological Association, American Academy of Family Physicians, British National Formulary, National Institutes of Health, Randomized controlled trials, Systematic review, Meta-analysis and Observational studies. Conclusion: This review will provide clinical practice with research evidence-based guidelines. Clinicians and physicians should follow the major clinical guidelines and governmental agencies to prescribe PPIs, follow their patients regularly to achieve the goals of treatment, to avoid adverse effects, drug interactions and reduce the costs. Keywords: Proton Pump Inhibitors, Food and Drug Administration, Gastrointestinal Acid Disorders, Gastro-Esophageal Reflux Disorder, and peptic ulcer disease

ADDRESSING BARRIERS TO A FULL RANGE OF EVIDENCE-BASED OBESITY CARE FOR OLDER ADULTS: A GSA ROUNDTABLE DISCUSSION

Abstract Obesity is identified as a chronic disease by the American Medical Association and several professional societies such as the American College of Cardiology, the American Heart Association, The Obesity Society, and the American Gastroenterological Association. These organizations have all established clinical guidelines on caring for individuals with obesity and overweight. However, there is a critical lack of appropriate and individualized treatment strategies for older adults with obesity. To address this issue, in June 2023 The Gerontological Society of America (GSA) convened 15 multidisciplinary leaders in a roundtable discussion on Addressing Barriers to Accessing a Full Range of Evidence-Based Obesity Care Options by Older Adults. Roundtable participants identified how to overcome obesity/overweight perceptions, communicate appropriately with older adults about their body size, address cultural differences in obesity care, provide care in conjunction with common comorbidities that are faced by older adults, collaborate with an interprofessional team to care for older adults with obesity, overcome barriers to implementation of lifestyle changes including diet and exercise, incorporate medical and surgical interventions, and align needs of older adults with community resources. This poster will illustrate key findings from this roundtable discussion.

Gastroesophageal reflux disease management and chronic use of proton pump inhibitors.

Proton pump inhibitors (PPIs) are one of the most commonly prescribed drugs worldwide and have changed the treatment of gastroesophageal reflux disease (GERD). However, these drugs have been associated with several potentially serious adverse reactions if used chronically. Guidelines from the American College of Gastroenterology in 2021 and the American Gastroenterological Association's 2022 clinical practice updates reflect the latest recommendations. This article reviews the management and treatment of GERD and the adverse reactions to long-term PPI use.

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.

Today and tomorrow: the use of biomarkers in inflammatory bowel disease

Biomarkers play important roles in clinical care for people with inflammatory bowel diseases (IBD). Biomarkers are also central to the development of new therapies and as endpoints in their evaluation.&#x0D; The recommendations from the STRIDE-II study emphasize the central role of clinical indices and biomarkers such as fecal calprotectin (FC) and C-reactive protein (CRP) in the management of Crohn’s disease (CD) and ulcerative colitis (UC).&#x0D; This review will focus on the established roles for FC and CRP, emerging roles for alternative and composite biomarkers, limitations of current biomarkers, and unmet needs in the field. This is an evolving area, with recent clinical practice guidelines from the American Gastroenterological Association in UC. In addition, updates are expected from the European Crohn’s and Colitis Organisation on their multi-society guideline for IBD monitoring.

Validation of AGA clinical care pathway and AASLD practice guidance for nonalcoholic fatty liver disease in a prospective cohort of patients with type 2 diabetes.

Recently, the American Gastroenterological Association and the American Association for the Study of Liver Diseases developed clinical pathways to evaluate populations at high risk for NAFLD. We assessed the diagnostic performance of the new guidance in a well-phenotyped cohort of patients with Type 2 diabetes mellitus (T2DM). This prospective study enrolled patients age ≥50 years with T2DM. Participants underwent a standardized clinical research visit with MRI and ultrasound-based assessment of liver fat and stiffness and Enhanced Liver Fibrosis (ELF) testing. Of 417 participants (36% men) with T2DM with FIB-4 and MRE data, the prevalence of NAFLD was 64% and 12% had advanced fibrosis (MRE≥3.63 kPa). Applying the American Gastroenterological Association pathway of FIB-4 and vibration-controlled transient elastography, the false negative rate was 3.3% and 18% would qualify for specialty referral. Applying the FIB-4 + ELF American Association for the Study of Liver Diseases pathway, the false negative rate was 4.5%, but 50% would qualify for specialty referral. Applying higher ELF cut points improved the pathway, yielding a similar false negative rate of 4.9% but decreased specialty referral to 27%. Validation of the American Gastroenterological Association clinical pathway in a prospectively recruited cohort with T2DM revealed a low false negative rate and avoided specialty referral in a large percentage of patients. The American Association for the Study of Liver Diseases pathway with FIB-4 + ELF resulted in a high rate of specialty referral, which improved with the utilization of higher ELF cut points and may serve as an alternative for primary care and endocrinology clinics without access to vibration-controlled transient elastography.

FRI661 Assessing The Current State Of Screening And Managementof Non-alcoholic Fatty Liver Disease In An Academic Endocrinology Clinic

Abstract Disclosure: K.M. Myers: None. C.D. Hendrickson: None. Background: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver disease and the second most common cause of liver failure leading to transplantation. NAFLD is strongly associated with factors of metabolic syndrome including diabetes mellitus (DM), with which it shares a strong bi-directional relationship. Up to 70% of patients with DM also have NAFLD, and DM is a risk factor for higher rates of NAFLD progression leading to steatohepatitis, fibrosis and cirrhosis. In September 2021, the American Gastroenterological Association published recommendations including endocrinology in the screening and management of NAFLD patients. Screening for NAFLD involves computing a FIB-4 score to risk-stratify patients into low, intermediate or high risk of having liver fibrosis. The FIB-4 score is calculated using patient age, AST, ALT and platelet count. Further management is determined by the level of risk identified, with some indeterminate-risk and all high-risk patients needing referral to hepatology clinic. Methods: Deidentified patient data was abstracted from an electronic health record registry associated with a large academic medical center. Patient qualifiers included: age over 18 years, diagnosis of type 2 DM, a prior visit within 5 years at one of two endocrinology clinic locations and having a primary care physician associated with the system. Of these patients, lab data was obtained for AST, ALT and platelet count. Additionally, the presence or absence of a prior hepatology clinic encounter was assessed. Two endocrinology clinics were analyzed, including one clinic at the main hospital campus and a second, smaller clinic located in an adjacent county. Results: Within the larger clinic, 16,398 patients met the above criteria; however, only 1797 (11.0%) had all lab components evaluated within 5 years to calculate a FIB-4 score, largely due to only 11.3% of total patients having platelet count data available. Of patients with a FIB-4 score, 342 had a score over 2.67, indicating high-risk for liver fibrosis. Of these 342 patients, 181 (53.0%) had an associated hepatology visit. Within the smaller clinic, 3844 patients met the above criteria; however, only 1055 (274%) had all lab components evaluated within 5 years to calculate a FIB-4 score, again largely due to only 30.0% of total patients having platelet count data available. Of the patients with a FIB-4 score, 148 had a score ≥ 2.67, indicating high-risk for liver fibrosis. Of these 148 patients, 47 (31.8%) had an associated encounter with hepatology. Conclusion: This study highlights a need for improved screening and risk-stratification of diabetic patients for NAFLD, including the increased awareness of screening with appropriate lab evaluation and subsequent referral to hepatology when appropriate. Presentation: Friday, June 16, 2023