ACG MAGAZINE | Vol. 5, No. 3 | Fall 2021 by AmCollegeGastro

ACG MAGAZINE Fall 2021

MEMBERS. MEDICINE. MEANING.

CURIOSITY-DRIVEN DISCOVERY Barry Marshall on The Discovery of H. pylori

ACG 2021 | A HYBRID CONFERENCE YOUR M E E T I N G, YOUR WAY

ANNUAL SCIENTIFIC MEETING & Postgraduate Course

OCTOBER 22–27, 2021 MANDALAY BAY • LAS VEGAS, NEVADA

WE’RE BACK!

Live and in -person!

Join us at the beautiful Mandalay Bay in Las Vegas where you can not only soak up some sun but also receive the best education on Clinical GI. Plus, enjoy everything you love about the ACG

REGISTRATION IS NOW OPEN!  acgmeetings.gi.org

Annual Scientific Meeting. We can't wait to see you! Seats may be limited.

CA L ELGOEG O AMERICAN COLLEGE OF GA AM SE T RRI O EN N TCEORL O YF G A S T R O E N T E R O L O G Y

FALL 2021 // VOLUME 5, NUMBER 3

FEATURED CONTENTS Conversations with Women in GI Dr. Christina Surawicz on paving the way for women in GI and empowering others to lead PAGE 31

ACG Perspectives Dr. Jennifer HorsleySilva provides a glimpse into Mayo Clinic's multidisciplinary approach for addressing the needs of patients with EoE PAGE 34

COVER STORY

CURIOSITY-DRIVEN DISCOVERY: Barry Marshall on the Discovery of H. pylori Prof. Barry Marshall shares how scientific curiosity played a role in the discovery of H. pylori and its subsequent diagnosis and treatment

PAGE 22

Attend an upcoming

ACG POSTGRADUATE COURSE ACG Weekly Virtual Grand Rounds

2021 ACG’s IBD School and ACG Southern Regional Postgraduate Course

 Nashville, TN  December 3–5, 2021

2022 ACG’s Functional GI Disorders School and ACG Board of Governors / ASGE Best Practices Course  The Aria | Las Vegas, NV  January 28–30, 2022

ACG/FGS Spring Symposia  Naples Grande Hotel | Naples, FL  March 11–13, 2022

ACG/LGS Regional Course  Hilton New Orleans Riverside | New Orleans, LA  March 18–20, 2022

ACG’s Hepatology School and Eastern Regional  The Seaport Hotel | Boston, MA  April 1–3, 2022

MORE INFO: gi.org/acg-course-calendar

FALL 2021 // VOLUME 5, NUMBER 3

CONTENTS

“Curiosity-driven research is the type of research that makes amazing discoveries and causes a paradigm shift.” —Barry J. Marshall, MD, FRACP, FACG, “Curiosity-Driven Discovery,” PG 22

6 // MESSAGE FROM THE PRESIDENT

22 // COVER STORY

Dr. Greenwald on the importance of quality in care and communication, and lifelong learning as a tenet of the profession

DISCOVERERS: HELICOBACTER PYLORI WITH PROF. BARRY MARSHALL Dr. Daniel Pambianco poses questions for Prof. Barry Marshall on his Nobel Prizewinning contribution to the discovery of Helicobacter pylori and its role in gastritis and peptic ulcer disease

7 // NOVEL & NOTEWORTHY New GI Eye photography feature, member book reviews, professional accomplishments & more

15 // TRAINEE HUB Dr. Judy Trieu shares tips on preparing for your first job in GI and determining your postfellowship priorities based on her experiences in a mock interview with ACG Past President Dr. Mark Pochapin

19 // GETTING IT RIGHT BUILDING SUCCESS Fatty Liver is Our Future: Setting Up a NAFLD Disease Management Program in Your Practice

40 ON GETTING OLD Reflections on how physician perceptions and perspectives change over time from Dr. Amnon Sonnenberg

41 // INSIDE THE JOURNALS

31 // ACG PERSPECTIVES

42 AJG ACG issues three new guidelines on C. difficile infection, upper GI and ulcer bleeding, and drug-induced idiosyncratic liver injury

31 CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos speaks with ACG Past President Dr. Christina Surawicz on mentoring, coping during the pandemic and her amazing career of firsts

43 ACGCRJ A Rare Case of the Jejunal Ectopic Pancreas Observed With an Endoscope by Yamauchi, et al., and introducing the 2021–2022 ACG Case Reports Journal editorial board

34 MULTIDISCIPLINARY EOE CLINIC AT MAYO Dr. Jennifer Horsley-Silva provides insights into the multidisciplinary approach that Mayo Clinic takes in meeting the needs of patients with EoE

43 CTG Low-Grade Endotoxemia and Thrombosis in COVID-19 by Oliva, et al.

36 CULINARY CONNECTIONS Reflections from ACG members whose cultural perspectives are key to their culinary views

45 // A LOOK BACK 50 YEARS AGO IN AJG In 1971, Farmer, et al., published an article on early experiences with ulcerative proctitis before its presentation and progression were well-understood

Photo by Frances Andrijich

ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG youtube.com/ACGastroenterology

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facebook.com/AmCollegeGastro Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant

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BOARD OF TRUSTEES President: David A. Greenwald, MD, FACG President-Elect: Samir A. Shah, MD, FACG Vice President: Daniel J. Pambianco, MD, FACG Secretary: Amy S. Oxentenko, MD, FACG Treasurer: Jonathan A. Leighton, MD, FACG Immediate Past President: Mark B. Pochapin, MD, FACG

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CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | gi.org

Past President: Sunanda V. Kane, MD, MSPH, FACG Director, ACG Institute: Neena S. Abraham, MD, MSc, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG Chair, Board of Governors: Patrick E. Young, MD, FACG Vice Chair, Board of Governors: Dayna S. Early, MD, FACG Trustee for Administrative Affairs: Irving M. Pike, MD, FACG

ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity

TRUSTEES Jean-Paul Achkar, MD, FACG William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Costas H. Kefalas, MD, MMM, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG John R. Saltzman, MD, FACG Nicholas J. Shaheen, MD, MPH, MACG Neil H. Stollman, MD, FACG Renee L. Williams, MD, MHPE, FACG

4 | GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 16,000 clinician members representing some 86 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.

CONTRIBUTING WRITERS Chau Che, MD Dr. Che is a gastroenterologist at Temple Health in Philadelphia, PA, with a passion for the intersection between cooking, eating, and GI, and is a member of the ACG Women in GI Committee. Jill K.J. Gaidos, MD, FACG Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program. David A. Greenwald, MD, FACG Dr. Greenwald is the 2020–2021 ACG President and is Director of Clinical Gastroenterology and Endoscopy at Mount Sinai Hospital and Professor of Medicine at Icahn School of Medicine at Mount Sinai in New York City. Magnus Halland, MD, PhD, MPH, FRACP Dr. Halland is a consulting gastroenterologist at Mayo Clinic with an interest in esophageal diseases and plant-focused nutrition. Jennifer Horsley-Silva, MD Dr. Horsley-Silva is Assistant Professor of Medicine and Senior Associate Consultant at Mayo Clinic, and is a member of the ACG Digital Communications and Publications and Educational Affairs Committees. Barry J. Marshall, MD, FRACP, FACG Professor Barry Marshall is a Nobel Laureate, Professor of Clinical Microbiology, and Brand Ambassador at The University of Western Australia, serving as Director of The Marshall Centre for Infectious Diseases Research and Training, founded in his honor. Edwin K. McDonald, IV, MD Dr. McDonald is Assistant Professor of Medicine at the University of Chicago Department of Medicine whose interests focus on improving the health through nutrition education. Richard L. Nemec, MD, FACG Dr. Nemec is a gastroenterologist practicing in Winchester, VA, at Winchester Gastro Associates.

Daniel J. Pambianco, MD, FACG Dr. Pambianco is a gastroenterologist and managing partner at Charlottesville Gastro Associates, has served in many ACG leadership and committee roles, and is the current ACG Vice President (2020–2021). Lawrence R. Schiller, MD, MACG ACG Past President Dr. Schiller is the Program Director of the Gastroenterology Fellowship Program at Baylor University Medical Center and chairs ACG’s Archives Committee. Amnon Sonnenberg, MD, MSc, FACG Dr. Sonnenberg is Professor of Medicine at Oregon Health & Science University in Portland, OR.

Christina M. Surawicz, MD, MACG Dr. Surawicz was ACG’s first woman president (1998–1999). In 2019 she retired from a long career at the University of Washington Harborview Medical Center where she served as Chief of Gastroenterology and Hepatology, among many roles. Judy A. Trieu, MD, MPH Dr. Trieu is third year GI and hepatology fellow at Loyola University Medical Center and will be pursuing a fourth year Advanced Endoscopy Fellowship at the University of North Carolina. She is also Co-Editor-in-Chief of ACG Case Reports Journal. Shifa Umar, MD Dr. Umar is a third year GI fellow at the Allegheny Health Network and incoming advanced pancreatology fellow at the Mayo Clinic. She serves on the ACG Digital Communications & Publications Committee. Bennie R. Upchurch, MD, FACG Dr. Upchurch is the Director of Gastroenterology at Adena Regional Medical Center in Chillicothe, OH, and a member of ACG’s Practice Management Committee.

MESSAGE FROM THE PRESIDEN

QUALITY WINS! QUALITY WINS!! That lesson applies universally—and most certainly it is true in gastroenterology. Sid Winawer has told us for years that the best colorectal cancer screening test is the one that gets done, and gets done with high quality. Larry Brandt has spent a career espousing the value of high quality communication skills. Irving Pike had the vision and wisdom to guide the formation of GIQuIC, the GI Quality Improvement Consortium, the registry that helped establish benchmarks for high quality performance in gastroenterology and with which participants can track their own quality. These three ACG Past Presidents have been significant career mentors for me; their focus on unyielding high quality and their promotion of exacting standards are a model for all of us. Let’s examine each area a bit more carefully. In the world of colorectal cancer screening, we now have solid evidence that screening for and removing adenomatous polyps leads to a reduction in colorectal cancer incidence and a decrease in mortality from colorectal cancer. But it’s not that easy! Towards this very important end, the quality of the chosen exam is critical. For colonoscopy to be an effective screening test, we need to visualize the entire colon clearly, and take adequate time to find those pre-cancerous polyps. While we all know this, putting these principles into practice on each and every exam is crucial—I hear Sid Winawer’s voice in my ear each time I’m doing a colonoscopy. Moreover, for a non-invasive stool based test to be effective, it must also be high quality, and that means that follow up is assured in a systematic way. We know, for example, that an abnormal stool based colorectal cancer screening test must be acted on within 6 months, and if not, outcomes are worse. Turning to high quality communication, I think that nothing is more important as we help our patients and our colleagues. Our patients approach us with a wide range of concerns—many are scared, frightened, and even downright terrified at the time of an office visit, hospitalization or procedure. How we approach patients, their families and their loved ones is what is remembered. Empathy, compassion and clarity of explanation must always be at the center of every interaction we have. All the time I hear Larry Brandt whispering in my ear the title of his Presidential Address, “Holding a hand is often as important as examining one.” For example, I urge

6 | GI.ORG/ACGMAGAZINE

you to approach each procedure in this fashion—fully appreciating that while for you this may be very much “what you do every day,” but for the patient it may be a once in a lifetime moment. It’s certainly scary for the patient. Those few moments of interaction before a procedure, or drawing down at the close of an office visit, or with a patient and their family in the hospital are crucial, impactful ones, and demand the highest quality at all times. Finding the best way to deliver complex clinical information in an understandable way that is both factually correct and attentive to the needs and fears of our patients is an art, but one that is so worth taking the time to improve. I always start my discussion with a patient post-procedure with “you don’t have cancer” (unless they do) because that immediately addresses their biggest fear, and then they can be attentive to the rest of the information I’d like to share. Communication with our colleagues done in a high quality way makes a big difference as well. We are lifelong learners, and we learn best when the material presented to us in journals, lectures and everyday interactions is of the highest quality. My advice…If you are delivering a lecture, teaching a student, or helping educate a patient and their family, pay attention to all the details—know the material— remind yourself of the personal details about the patient and the family—preparation of the highest quality is readily evident to those watching you and is always worth the time spent.

Finally, we can focus on quality in endoscopy and GIQuIC. This premier registry, which now houses data from over 12,000,000 colonoscopic and over 2,000,000 upper endoscopic exams, is testimony to the value that gastroenterologists place on quality. Simply measuring quality improves quality—that is known as the Hawthorne effect—but tracking quality robustly leads to better outcomes. Gastroenterologists who have higher adenoma detection rates, for example, have lower rates of interval colon cancers in the patients for whom they are caring. I hear Irving Pike whispering in my ear each time I see the endoscopic technician in our procedure suite set the clock to visibly display my time removing the colonoscope, a reminder to everyone that adequate withdrawal time is associated with better adenoma detection. Indeed, the entire team is showing a collective commitment to high quality. So yes, it has been a difficult last 18 months. COVID-19 continues to affect all of us personally and professionally. Ever resilient, the GI community has risen to every challenge that has come our way since March 2020, and we will continue to do so. As we continue to meet these challenges head on, our focus is providing high quality care, a beacon that shows us the clearest path to the best outcomes for our patients and for ourselves. Yep…high quality wins every single time!

—David A. Greenwald, MD, FACG

Note hy wor t INTRODUCING TWO NEW FEATURES! “GI Eye: Photography from ACG Members” is a place for the many GI clinicians whose hobby and passion is photography to share wellcomposed photos from your life and/or travels of any (non-endoscopic!) subject that captures your imagination. In this issue we also introduce a Book Review covering GI and general interest books reviewed by your peers. ACG MAGAZINE is proud to publish important professional achievements and welcomes your news, photos, and book ideas via ACGMag@gi.org.

Novel & Noteworthy | 7

N&N GI EYE: PHOTOGRAPHY FROM ACG MEMBERS

8 | GI.ORG/ACGMAGAZINE

PEACE in the ROCKIES INTRODUCING “GI EYE: PHOTOGRAPHY FROM ACG MEMBERS” a forum for the many GI clinicians whose hobby and passion is photography to share well-composed photos from your life and/or travels of any (non-endoscopic!) subject that captures your imagination.

About the Photo: This is Lake Agnes in Alberta, Canada. It is on the Tea House Trail which is 2.2 miles from the Fairmont Chateau Hotel at Lake Louise in the Canadian Rockies. The hike to the lake takes 1.5 hours, with an elevation of 1,312 feet. Composition and Challenges: I was amazed by the glacial elements in the background, which is mirrored by the pristine clear, rippleless water in the foreground. This serene composition is naturally framed by trees on both sides and accented by the greenery at the bottom. Shadows are absent as there was no direct sunlight. There were no signs of wildlife—nothing to disturb the peace that exists in one corner of this earth. This shot was taken in the month of June using a Nikon D90 (ISO 800, f/14, 1/125 sec), a Nikon 18-105 mm lens, and a tripod. On Photography: I owe my love of photography to my mother, who worked at Eastman Kodak for over 20 years. She taught me to think of each picture as a unique composition, a moment frozen in time. When I was 10, I was given a Pentax Spotmatic and used Kodachrome to take pictures at a wedding as a backup photographer. That was a lot of fun as a young kid. The subject I enjoy shooting most now is nature. A good photograph should evoke a strong emotion, which enables the observer to sense the mood of that moment. With each shot, one can imagine the earth speaking out to us, yearning to show its beauty. By sharing what my camera sees, we can be drawn toward protecting what we have on this fragile planet. —Dr. Immanuel Ho Immanuel K. H. Ho, MD, FACG is ACG MAGAZINE’s inaugural “GI Eye” Photographer. Dr. Ho is Director of Interventional Endoscopy at Pennsylvania Hospital and Clinical Professor of Medicine at the University of Pennsylvania School of Medicine. Novel & Noteworthy | 9

// N&N [BOOK REVIEW]

WORK CLEAN: THE LIFECHANGING POWER OF MISEEN-PLACE TO ORGANIZE YOUR LIFE, WORK, AND MIND by Dan Charnas (Rodale Press, 2016) Reviewer: Fazia A. Mir, MD, Presbyterian Medical Group, Rio Rancho, NM Work Clean by Dan Charnas is an excellent book that describes a system used in the culinary world called mise-en-place, which means putting in place. I found this book extremely useful in helping me avoid getting lost in the menial day-to-day administrative tasks. It can very well be applied to medicine and gastroenterology. It helps us deconstruct our day-to-day life and understand why it feels like some days there are not enough hours in the day. The book has several checklists to help us apply mis-en-place to our daily work life and this approach has helped me have a mental and physical clutter-free environment that enhanced productivity and improved my efficiency quotient. My key takeaways from reading this book were how to manage time effectively and how to minimize time spent in meetings—or not have meetings at all with effective email communication. I found it very helpful to see how planning and slowing down will in fact make me far more productive and efficient, and the importance of complete utilization—whether it’s equipment or staff—to their full potential. Other useful advice the book provides is always to have open eyes and ears in the kitchen, which in our world of GI could be translated to knowing what is happening in your entire institution, locally, and with colleagues nationally. I recommend this book be given at orientation to GI fellows so they can find their own mise-en-place. Alternatively, Work Clean can be read at any stage of one’s career to further enhance productivity.

[RESEARCH]

ACG SUMMER SCHOLAR SPOTLIGHT Darius WhitmoreCarter, a medical student at Morehouse School of Medicine, recently completed a summer research experience under the mentorship of Baha Moshiree, MD, MSc, FACG, through the ACG Summer Scholars program. The Summer Scholars program, chaired by Somaya Albhaisi, MD, offers an 8- to 10-week structured clinical research experience in GI and hepatology to medical students from groups underrepresented in medicine. At the culmination of his program, Mr. Whitmore-Carter co-authored an abstract for the project, Prevalence of Irritable Bowel Syndrome in an Underserved Community Internal Medicine Practice in Charlotte, North Carolina, which was accepted for presentation at the 2021 ACG Annual Scientific Meeting. [HONORS]

MICHAEL A. SAFDI, MD, MACG, received the American Jewish Committee (AJC) of Cincinnati 2021 Community Service Award at its Annual Human Relations Reception on May 25, 2021. Dr. Safdi served as president of AJC Cincinnati from 2012– 2013. He was a member of the ACG Board of Trustees from 1997 to 2001, and served as Governor for Southern Ohio twice, from 1988 to 1992, and again from 1994 to 1998. He became a Master of the American College of Gastroenterology in 2016.

[JOURNALS]

 NEW TWITTER HANDLES FOR CTG AND ACGCRJ The College is pleased to announce that Clinical & Translational Gastroenterology and ACG Case Reports Journal now have dedicated Twitter handles where the latest articles can be shared and discussed. With the addition of these accounts, all three of ACG’s scientific journals are represented on Twitter. Follow along to engage with the GI community on journal science.

CTG: @ACG_CTG CRJ: @ACGCRJ AJG: @AmJGastro

10 | GI.ORG/ACGMAGAZINE

[KEYNOTE]

DARRELL M. GRAY, II, MD, MPH, FACG, presented the keynote address at the American Board of Internal Medicine Virtual Summit on June 16, 2021, “Advancing Diversity, Equity and Inclusion in Health Care and Beyond.” Dr. Gray is Chair of the College’s DEI Committee; Co-Chair of the GI Intersociety Group on Diversity; and in August 2021 was appointed the first Chief Health Equity Officer at Anthem Health. [COVID-19 RELIEF]

NEELIMA G. REDDY, MD, FACG, of Gastroenterology Associates in Baton Rouge, LA, is ACG’s Governor for Louisiana and serves as a Board Member of Ekam USA, a non-profit committed to improving the health care of neonates, children, adolescents and mothers. Dr. Reddy and Ekam USA were active in raising funds to support urgent needs for COVID-19 relief in India during the worst of the crisis there.  ekamusa.org [LAURELS]

ALLON KAHN, MD, of Mayo Clinic, Scottsdale, AZ was recognized as Internal Medicine Residency "Teacher of the Year." Dr. Kahn is part of the 2020–2021 Cohort of the ACG Young Physician Leadership Scholars Program of the ACG Institute for Clinical Research and Education. [BOSS MOVES]

ANITA AFZALI, MD, MPH, FACG, was promoted to Professor of Medicine at The Ohio State University College of Medicine where she is the Director for the Advanced Inflammatory Bowel Disease Fellowship and Medical Director of the OSU IBD Center. She holds the Abercrombie & Fitch Endowed Chair in IBD.

BRIAN BOSWORTH, MD, FACG, was named Associate Chief Medical Officer at NYU Langone Health. He serves as Chief of Medicine at NYU Langone Tisch Hospital and is the College’s Governor for Manhattan.

ROTONYA M. CARR, MD, was named the new Chief of the Division of Gastroenterology at University of Washington. She is a hepatologist who has been Associate Professor of Medicine at the Hospital of the University of Pennsylvania.

MIGUEL REGUEIRO, MD, FACG, has been named chair of Cleveland Clinic’s Digestive Disease & Surgery Institute (DDSI). Dr. Regueiro served as chair of the Department of Gastroenterology, Hepatology, and Nutrition, and vice chair of DDSI, positions he held since 2018.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen: Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be Packaging and consumed. After breakfast, only clear liquids may be consumed until after the tablets not shown colonoscopy. Early in the evening prior to colonoscopy, open one bottle of actual size. 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury. Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185 See Full Prescribing Information and Medication Guide at SUTAB.com. References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020 3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

201-133-v1-A January 2021

Novel & Noteworthy | 11

! W! E NEW N

A NEW TABLET CHOICE A BOWEL NEW TABLET CHOICE IN PREPARATION IN BOWEL PREPARATION

• NO SODIUM PHOSPHATE1

• SAFE AND EFFECTIVE1,2 1 • NO SODIUM PHOSPHATE • ACG-RECOMMENDED1,2 SPLIT-DOSE REGIMEN3 • SAFE AND EFFECTIVE 1 – Two SUTAB doses are required for a complete preparation

Dose 1 consists of 12 tablets and 16 oz of water REGIMEN3 • ACG-RECOMMENDED SPLIT-DOSE Dose 2 consists of 12 tablets and 16 oz of water 1 – Two are required for a complete preparation EachSUTAB dose isdoses followed by two additional 16 oz of water Dose 1 consists of 12 tablets and 16 oz of water Dose 2 consists of 12 tablets and 16 oz of water Packaging and tablets not shown size. Each dose is followed by actual two additional 16 oz of water

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2† 1,2 ® 1,2‡ 92% OF PATIENTS IN TWO PIVOTAL TRIALSreported ACHIEVED SUCCESSFUL CLEANSING SUTAB * • 52% of all SUTAB and MoviPrep patients at least one selectedBOWEL gastrointestinal adverseWITH reaction • More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1%TO of these reports2† 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY CONSUME 2‡ Packaging and tablets not shown actual size.

considered severeand MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡ • 52% of all SUTAB

2† 78% OF PATIENTS ONE reported PIVOTALexperiencing TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE • More SUTAB IN patients nausea and vomiting than competitor, with ≤1% ofCOLONOSCOPY these reports

considered severe * Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope. OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2† † Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This * questionnaire has not undergone formal validation. Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; ‡ scores were assigned on withdrawal of colonoscope. Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion †of study drug, rating the intensity as mild, moderate, or severe. Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation. ACG=American College of Gastroenterology ‡ ® Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion is a registered trademark of Velinor AG. MoviPrep of study drug, rating the intensity as mild, moderate, or severe. ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG. IMPORTANT SAFETY INFORMATION 2‡

78%

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After IMPORTANT SAFETY INFORMATION breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required ® SUTAB (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG SUTAB.com. INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at SUTAB.com. From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

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THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

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ACG VIRTUAL GRAND ROUNDS Weekly on Thursdays at Noon EDT Live Presentation by an ACG Expert Plus Q & A #GIhomeschooling

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Even as all aspects of practice have changed due to COVID-19, your need to stay up to date on clinical GI does not stop. ACG is committed to your professional education and—until we can be together in person again—our goal is to help the GI community embrace #GIhomeschooling at this time. ACG has launched Virtual Grand Rounds weekly on Thursdays at Noon EDT. Each week an expert faculty member will present live on a key topic followed by Q & A.

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TRAINEE HUB Pearls & Perspectives from Dr. Judy Trieu

on ACG’s Workshop “Navigating, Networking and Negotiating Your First Job” An Interview with Dr. Shifa Umar

YOU SPEND ALMOST A DECADE LEARNING THE ART OF MEDICINE and most often follow a decisive path leading to what you always wanted to do and what makes you happy—your dream job. Your first job is important because it teaches you valuable skills and shows you what kind of work you enjoy, which can guide you through the rest of your career. The easiest way to find out your worth is by thorough preparation. In this Q&A, I asked Dr. Judy Trieu to share some “Do’s and Don’ts” when interviewing for your first job, drawn from her experiences at ACG’s recent workshop, “Navigating, Networking and Negotiating Your First Job,” in which she conducted a mock interview with ACG Past President Dr. Mark Pochapin. —Dr. Shifa Umar

Trainee Hub | 15

// TRAINEE HUB

Dr. Umar: What is the importance of this workshop overall for fellows-intraining—especially as we emerge from the COVID-19 experience? Dr. Trieu: ACG’s Navigating, Networking, and Negotiating Your First Job Workshop covered information that fellows do not really get during the years of training, such as how to network, how to negotiate a contract, and how to bill. These tips are coming from experienced gastroenterologists in the field who have interviewed countless fellows for their first job. What was unique about the workshop this past year was the discussion around the impact of the COVID pandemic on the job market. Although jobs became scarce during the peak of the pandemic, endoscopy demand appears to be increasing again, and as we become better prepared with personal protective equipment and point-of-care testing, there is hope that the job market will soon favor applicants. The workshop also highlighted how the virtual platform has become important in the interviewing process, and beyond the pandemic, it may not disappear completely.

Dr. Trieu’s Favorite Tips from Dr. Mark Pochapin for Virtual Interviews: • Look professional • Don’t be too casual just because it’s virtual • Maintain eye contact by looking at the camera • Have a white, non-distracting background, but if not possible, use a nice, professional virtual background • Avoid “um’s” and “uh’s”—the way you speak is more obvious during virtual interviews • Ramp up your verbal enthusiasm as it is more difficult for your passion to come across on video

What do you suggest should be a timeline for graduating fellows to follow? The exact timeline will vary depending on the field and type of practice the fellows want to pursue. However, based on the

16 | GI.ORG/ACGMAGAZINE

advice from Dr. Pochapin and other faculty speakers from the workshop, this is a general guide: • First year—learn how to be a good gastroenterologist and identify your passion • Second year, first half—figure out whether you want to practice in a private or academic setting and narrow down a few geographic regions • Second year, second half—start researching the job market and expressing interest to possible practices • Third year—apply and interview for positions What questions should you ask to assess if the job is right for you? This is going to be variable for each fellow interviewing for their first job. Prior to identifying the questions about the right fit, I believe what’s essential is identifying the elements of your ideal job. By defining the aspects of what you want for your first job, you can then prioritize your questions and determine whether the job is right for you. This may include geographic location, size of the practice, and scope of practice. Some important questions you may want to focus on include: • How can the practice support your short- and long-term career goals? • What does the practice offer for professional development (e.g., mentorship, additional training, research endeavors)? • What would work-life balance look like with the practice? Assessing the right fit is very important and as Dr. Pochapin mentioned, “you are as much in the driver’s seat as the person interviewing you.” What are some things to avoid during the interview? Dr. Pochapin mentioned several things that he considered “red flags.” His greatest pet peeve was asking for a leadership position or title for the first job. He commented further that it would be more prudent to

ask about professional development opportunities rather than requesting a leadership role. Other questions to avoid during the first interview include discussing call schedule, working weekends, vacation, and salary. These questions are best saved for the second interview, and it is best to frame the questions more subtly in order to delve into the topic. During the interview, it’s important to take your time to answer questions authentically. Avoid rehearsed responses—or “politician answers” as Dr. Pochapin labeled them—that only focus on what you want to relay instead of actually answering the questions thoughtfully. In a similar fashion, don’t answer questions with what you think the interviewer wants to hear. Lastly, avoid placing blame on your program for any deficiencies as it not only creates negativity, but it reflects poorly on your ability to overcome them. What was it like to do the interview with Dr. Pochapin? He was so easy to talk to and the time just flew by! I think what made it so easy was how genuine he was. He truly was invested in the interview and wanted to help prepare us fellows for the next steps in our careers. He is a true reflection of his take-away advice: “Be honest. [It’s about] honesty, transparency, sincerity, authenticity.” Throughout the interview, his enthusiasm really resonated. There were just so many pearls, not only for interviewing for our first job, but also for life! My favorite was his final piece of wisdom that should be incorporated into our daily perspectives: “there are only two outcomes in any endeavor— there’s success and there’s learning.” Talk about a mic-drop! What was your favorite session of the workshop (besides the one you presented!)? The best part of the session was the debate! This was new this past year with the goal of making the virtual platform feel more interactive and I think it’s here to stay for future workshops (I hope!). The faculty members were divided into teams of

academic versus private practice and they battled it out, discussing opportunities for professional development and work-life balance, among other topics. I know the faculty had a lot fun debating, so much so that we were going over the allotted time and there was still so much more to say! About Judy Trieu, MD, MPH Dr. Judy Trieu is a third year gastroenterology and hepatology fellow at Loyola University Medical Center and will be pursuing a fourth year advanced endoscopy fellowship at the University of North Carolina. Her area of clinical interests include pancreaticobiliary diseases and advanced tissue resection. She is interested in research and education, with plans on finding her first job in an academic setting. She is currently a Co-Editor in Chief of ACG Case Reports Journal and an AGA Editorial Fellow for Clinical Gastroenterology and Hepatology. In her personal time, she loves to work out on her Peloton bike and is currently training for the Chicago Marathon.

About Shifa Umar, MD Dr. Shifa Umar is currently a pancreatology fellow at Mayo Clinic, Rochester and will be pursuing an advanced endoscopy fellowship at the University of Chicago. She plans to develop an academic career with a focus in pancreatobiliary diseases and endoscopy. She is passionate about medical education and promoting diversity in gastroenterology. She currently serves on the ACG Digital Communications & Publications Committee and the ACG Diversity, Equity & Inclusion Committee. Outside of her life in GI, Dr. Umar volunteers for the philanthropic society of her medical school.

 RESOURCES  WATCH: Do’s and Don’ts of Interviewing for Your First Job (interview by a fellow for a fellow, in which Judy Trieu, MD, MPH, interviews ACG Past President Mark Pochapin, MD, FACG) bit.ly/NNN-Jan-2021-Pochapin-Trieu

 EXPLORE: 2021 Virtual ACG Navigating, Networking and Negotiating Your First Job Workshop bit.ly/NNN-Workshop-Jan-2021

 ABOUT THE WORKSHOP The ACG Women in GI Committee hosted a virtual program in January 2021, for both men and women, geared towards senior GI fellows and junior faculty, addressing the specifics of both the private practice and academic job search. Pre-recorded lectures and recordings of the live virtual workshop are available on the ACG website. Workshop highlights include a lively debate between panelists from both private practice and academics. This program was supported by Medtronic.

 PRE-RECORDED LECTURES • Welcoming Remarks (Kara De Felice, MD, and Judy Trieu, MD, MPH) • How to Search for a Job & ABC’s of Private Practice (Harish Gagneja, MD, FACG) • ABC’s of Academics (David Greenwald, MD, FACG) • Networking & Negotiating Skills (Amy Oxentenko, MD, FACG) • Achieving Success in Life after Training (Kara De Felice, MD)

• Finding a Job in the COVID-19 Era: Tips for Success (Vivek Kaul, MD, FACG) • What is an RVU? Billing and Coding Basics for New Graduates (Daniel Raines, MD, FACG) • Do’s and Don’ts of Interviewing for Your First Job (interview by a fellow for a fellow) (Mark Pochapin, MD, FACG, and Judy Trieu, MD, MPH)

 LIVE VIRTUAL SESSION RECORDINGS Private Practice versus Academics Debate Private Practice Debate Panelists and Private Practice Breakout Session • Samir Shah, MD, FACG • Harish Gagneja, MD, FACG • Margaret Schwiesow, DO, FACP • Ripple Sharma, MD, FACG

Academic Debate Panelists and Academics Breakout Session • Amy Oxentenko, MD, FACG • David Greenwald, MD, FACG • Vivek Kaul, MD, FACG • Mark Pochapin, MD, FACG

Q&A with Lecturers from Pre-recorded Sessions & Negotiation Tips • Mark Pochapin, MD, FACG • Harish Gagneja, MD, FACG • Daniel Raines, MD, FACG • Amy Oxentenko, MD, FACG • David Greenwald, MD, FACG • Vivek Kaul, MD, FACG

Trainee Hub | 17

Accessible. Relevant. Practical.

The information you need to improve your practice.

The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-lead clinical practices. Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Explore the 2021

PRACTICE MANAGEMENT TOOLBOX and LAW MIND insights!

ACG PRACTICE MANAGE Toolbox HigMENT

hlights Download the e-Book: bit.ly/PM21EBOOK AC nagement Comm ittee own “Fellows are asked to balance multiple concernsG Practionce Matop of their readiness for parenthood, including limited access to parental leave obscure policiesSuccess about potential impacts on their career. StartandBuilding Today. This often leads women, in particular, to delay child-rearing.” Brought to you

GI.ORG/TOOLBOX

18 | GI.ORG/ACGMAGAZINE

by the

GETTING IT

ACG Practice Management Toolbox

Fat(ty Liver) is Our Future:

Setting Up a Disease Management Program

in Your Practice

By Richard L. Nemec, MD, FACG and Bennie R. Upchurch, MD, FACG

HIGH-QUALITY DISEASE MANAGEMENT PROGRAMS are an excellent way for medical practices to distinguish themselves within their respective markets. Common examples of such programs for gastroenterologists include esophageal disease, inflammatory bowel disease, and hepatitis. Fatty liver disease may also represent a very promising opportunity.

Getting it Right | 19

// GETTING IT RIGHT

Some reasons why you should consider developing a fatty liver program in your practice: • Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver condition in the United States and will soon replace hepatitis C as the #1 reason for liver transplantation. • NAFLD is present in over 50% of adults with type II diabetes mellitus or metabolic syndrome. • The management and evaluation of these patients is rapidly evolving: • Multiple guidelines and/or guidance statements regarding the management of fatty liver have been released over the past four years. • Several drugs to treat advanced NASH are in Phase III trials in the therapeutic pipeline. • This is a slowly evolving disease that requires • Disease detection • Risk stratification • Therapeutic intervention in high-risk groups OVERVIEW NAFLD is thought to be present in about one-third of the US population. While most affected individuals have simple steatosis, which is not thought to progress to cirrhosis, a substantial portion (3-5%) have non-alcoholic steatohepatitis (NASH). This condition may progress to cirrhosis and even hepatocellular carcinoma in a small percentage of patients. As in most chronic liver conditions, the rate of progression is rather prolonged, causing disease to be clinically apparent only after it is well advanced. Fortunately, this long phase of progression provides us with an opportunity for disease assessment and risk reduction prior to development of end-stage liver disease. IDENTIFYING CASES IN YOUR PRACTICE Identifying the patients with fatty liver requires examining multiple sources. With approximately 30% of Americans classified as obese, abnormal transaminases are often identified in these individuals on routine laboratory tests for employment physicals or annual primary care visits. Fatty liver may be found incidentally on an abdominal ultrasound, or cross-sectional imaging performed for other reasons. Thus, primary care, endocrinology, cardiology, and orthopedics often refer patients to gastroenterologists for unexplained elevations in transaminases. Patients with no other definite cause for abnormal transaminases often have occult fatty liver disease. Risk factors for fatty liver

20 | GI.ORG/ACGMAGAZINE

such as diabetes, obesity, insulin resistance, and metabolic syndrome will identify which patients are at high risk for fatty liver. These should then be evaluated with abdominal ultrasound or other forms of screening.

“Identifying the patients with fatty liver requires examining multiple sources. With approximately 30% of Americans classified as obese, abnormal transaminases are often identified in these individuals on routine laboratory tests.”

RISK STRATIFICATION The following tests may be used to assess a patient’s risk for disease progression or the presence of advanced disease: • Simple serum markers (readily obtainable) • APRI: AST and platelet count • NALFD score: AST, ALT, albumin, platelet, age, BMI, DM • FIB-4 score: AST, ALT, platelet, age • Serum biomarkers (blood tests, more costly): • ELF (enhanced liver fibrosis) panel • FibroTest® • NASH-Fibrosure®. • Imaging techniques: • Vibration controlled transient elastography (VCTE), available commercially as FibroScan® • Magnetic resonance elastography (MRE) • Shear wave elastography • Histology: The ‘gold standard’ for diagnosis has long been liver biopsy. It is not feasible to perform liver biopsies in the large numbers of at-risk patients. Biopsy is usually reserved for patients with inconclusive or contradictory lab results. It is especially useful when patients have findings suggestive of other liver diseases that are treated differently. MANAGEMENT Currently, published clinical guidelines recommend diet and exercise to promote weight loss and delay disease progression. Although, none of the guidelines specifically address alternatives to manage obesity (pharmacologic, endoscopic, surgical). In the United States, there is currently no FDAapproved therapy for NASH as a primary indication. However, published guidelines and guidance statements have suggested that vitamin E and/or pioglitazone be considered. Studies to date have not been uniform in determining what endpoints correlate with real-world clinical outcomes, such as improvement in transaminases, NASH scoring, fibrosis, prevention of cirrhosis, or regression of advanced fibrosis. Given the unpredictable outcome of fatty liver in an individual patient, and the frequent comorbidities in this population, careful and close follow-up of these patients is necessary.

FOLLOWING RESULTS Success in any disease management program requires a process of data collection and review. We recommend this be kept as simple as possible while providing evidence that supports the program. This data will be essential when communicating with referring physicians, hospitals, involved colleagues, and patients. Demonstrating effectiveness in this program will distinguish your practice when negotiating contracts and marketing your practice. EXAMPLES OF DATA COLLECTED • Demographic data • Body measurements (height, weight, BMI) • Related co-morbidities (diabetes, hepatitis C) • Relevant social factors (alcohol intake) • Lab values such as transaminases and HgA1C • Measures of fibrosis • Weight loss interventions • Follow up • Patient-measured outcomes QUESTIONS 1. How should I provide patient and provider education regarding the potential significance of fatty liver? 2. Who and how will patients be risk stratified in your office? 3. To what extent are dietary and or lifestyle modifications going to be offered within your practice or outsourced? 4. How will you follow patients; who you will identify as low risk for progression? 5. How will you treat or manage patients who you identify as high risk for progression or those with advanced fibrosis or cirrhosis? 6. Is a fatty liver program financially viable? a. Risk assessment is through evaluation and testing that is not well reimbursed b. There are no current FDA-approved therapies c. Diet and lifestyle modification recommendations are not reimbursed 7. Can a fatty liver program be used to identify patients who need other care from your practice? a. Those who need screening for HCV b. Those with occult advanced liver disease/ cirrhosis or hepatocellular carcinoma c. Those who need colorectal cancer risk assessment and screening 8. How will the data be collected and maintained?

“Given the unpredictable outcome of fatty liver in an individual patient, and the frequent comorbidities in this population, careful and close follow-up of these patients is necessary.”

RECOMMENDATIONS FOR YOUR PRACTICE 1. Identify an individual, such as an advanced practice provider, to be your practice’s champion in the evaluation and management of these patients. 2. Review the current guidelines and obtain some consensus as to how these patients will be identified, risk-stratified, and treated by your practice. We suggest reviewing World J Gastroenterol 2018 August 14; 24(30): 3361-3373 which provides a recent summary of all the guidelines and guidance statements from the past three to four years. 3. Educate your patients and referring providers about fatty liver disease using widely available sources from guidelines or industry. 4. Use (or develop) a scripted intake protocol for historical risk assessment of these patients. See appendix A. 5. Develop a protocol to risk-assess these patients. AASLD guidance statements suggest NAFLD fibrosis score (NFS), FIB-4 score, and elastography (vibration [FibroScan] or magnetic resonance). See appendix B for a calculator. 6. Develop a recall system to follow low-risk individuals. Many guidelines/guidance statements are silent about this. See appendix C for an example. 7. Determine how your practice will provide dietary and lifestyle modification to all patients. For high-risk patients: See appendix D 8. Set up a database for this project. 9. Arrange monthly reports to involved colleagues. 10. Advertise the program to referral sources. 11. Provide periodic follow up to referring providers.

 View decision aids, additional guidance on setting up a disease management program, and more resources: bit.ly/ACG-PMToolbox-FattyLiver

Bennie R. Upchurch, MD, FACG Knox Community Hospital, Mount Vernon, OH

Richard L. Nemec, MD, FACG Winchester Gastro Associates, Winchester, VA

Getting it Right | 21

CURIOSITY-DRIVEN DISCOVERY Barry Marshall on The Discovery of H. pylori Barry J. Marshall, MD, FRACP, FACG, Marshall Centre, University of Western Australia, Perth, Australia interviewed by Daniel J. Pambianco, MD, FACG, Charlottesville Gastroenterology Associates

22 | GI.ORG/ACGMAGAZINE

About Professor Marshall

Professor Barry Marshall is a Nobel Laureate, Clinical Professor, and Brand Ambassador at The University of Western Australia (UWA). Professor Marshall and Professor Emeritus J. Robin Warren were awarded the 2005 Nobel Prize for Physiology or Medicine for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease. Professor Marshall returned to Perth and UWA in 1996 after a tenure at the University of Virginia. Today, Professor Marshall is the Director of The Marshall Centre for Infectious Diseases Research and Training, founded in his honour. In addition to Helicobacter pylori research, the Marshall Centre is at the forefront of infectious disease identification and surveillance, diagnostics and drug design, and transformative discovery. His research has expanded with his group to embrace new technologies, including third generation sequencing and genomic analysis. https://www. uwa.edu.au/marshall-centre/

staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria, they made them amenable to scientific study. In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies, and epidemiological studies. Thanks to the pioneering discovery by Marshall and Warren, peptic ulcer disease is no longer a chronic, frequently disabling condition, but a disease that can be cured by a short regimen of antibiotics and acid secretion inhibitors.” [Source: https://www.nobelprize.org/prizes/ medicine/2005/press-release/] About Dr. Pambianco

About the 2005 Nobel Prize in Physiology or Medicine

In 2005, the Nobel Assembly at Karolinska Institutet awarded the Nobel Prize in Physiology or Medicine to Barry Marshall and J. Robin Warren, “who, with tenacity and a prepared mind, challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver

Daniel J. Pambianco, MD, FACG is Vice President of the American College of Gastroenterology and serves on the College’s Executive Committee. He is President and Managing Partner of Charlottesville Gastroenterology Associates, Charlottesville, VA and serves on the Board of GI OnDEMAND. He is past president of

Image of the Nobel Medal used by permission ®© The Nobel Foundation.

the Virginia Gastroenterological Society and past Director of Gastrointestinal Endoscopy and Co-Director of Biliary Lithotripsy at the University of Virginia. Dr. Pambianco’s career intersected with Professor Marshall’s when they were both at the University of Virginia where Dr. Pambianco finished his GI fellowship training in 1987.

A Conversation with Professor Barry Marshall Professor Marshall: Today, I’m going to

do an interview with Dr. Dan Pambianco, who was the senior gastroenterology fellow when I first turned up at the University of Virginia in 1986. I’m very happy to be helping you, Dan, to produce an article for the American College of Gastroenterology Magazine. I’ve got a lot of loyalty towards the ACG because my first presentation was actually to the ACG conference in Atlanta in 1986, and after that I was really supported by the ACG and its members. I still think that they are a great society for networking and also for clinical gastroenterology in the United States and around the world. I know the ACG journal is a great journal.

Dr. Pambianco: Dr. Marshall, thanks for taking the time to answer some questions on your career. You probably had the most successful trainee research project ever.

That’s true. How did you come to meet Dr. Warren, a pathologist, and get involved in the study of gastric bacteria?

That’s a great question. The Australian College of Physicians requires a three-year clinical training course after you pass the exam, and so I was in the beginning of that training course. I was looking for an interesting project because each year they expect you to try and publish or produce a clinical research project of some sort. My boss, Tom Waters, who is an academic clinician at Royal Perth Hospital, said, “Barry, go down and have a talk to Dr. Warren. He’s got some bacteria that he saw under the microscope and maybe there’s something of some value in it.” I was interested in microbiology and anything

Cover Story | 23

// COVER STORY

related to the stomach and the puzzle was, how could bacteria live in the stomach when the stomach’s full of acid? The challenge for us was that all the medical books said the stomach was sterile. In fact, you can’t usually culture anything from gastric juice, so it started off as an interesting curiosity. We were hoping maybe we’d get a paper published out of it and one thing led to another, so I went down and had a talk with Dr. Warren. He convinced me the bacteria were real and that we should get started on that project. What made you think these organisms might be related to gastritis or peptic ulcer disease when review of the original cohort did not suggest a clear pattern?

Well, that’s true. Originally, Warren had 20 patients where he had seen spiral bacteria on the biopsies, some with gastric or duodenal ulcers. But he said to me, “Barry, when you’re doing this research, don’t take the biopsy from ulcers. Ulcer borders have such a mixture of different pathologies (metaplasia, inflammation, etc.) that you’ll always think there’s gastritis there, but we want to study gastritis, so take your biopsy away from ulcers. And that’s what I did, although patients, of course, did have ulcers in some cases; maybe 20 out of 100 patients had an ulcer. So, we had an interesting study where we had people with ulcers, and we had people without ulcers, and gastritis, and no gastritis, and bacteria, and we put all the information together blinded and did simple Fisher’s tests, chi-squared tests on them and proved the association between the bacteria and inflammation. And Dr. Warren’s calculation had some data like P=0.0000000001 or something for the association with gastritis and the p-value for the association with ulcers was about .001, is my recollection, so that’s how we got pretty excited about it and ultimately cultured the bacteria. So that’s why I say to people, curiosity-driven research is the type of research that makes amazing discoveries and causes a paradigm shift, which ultimately happened in gastroenterology, with peptic ulcers. One of the major themes of your career has been perseverance in the face of adversity. Although the organism could be recognized, it was hard to grow. How did you figure out the conditions needed to establish it in culture?

One thing that is particularly challenging: if nobody’s done it before, you might presume that it’s difficult to do. On the other hand, as

24 | GI.ORG/ACGMAGAZINE

“

“I was interested in

microbiology and anything related

to the stomach and the puzzle

was, how could bacteria live in the stomach when the stomach’s full of acid? The challenge for us was that all the medical books said the stomach was sterile. In fact, you can’t usually culture anything from gastric juice, so it started off as an interesting curiosity.” —Prof. Barry Marshall

soon as you figure out how to do something like culture bacteria, everyone says, “Oh, well, that was easy.” But it’s only easy if you know the answer, and Helicobacter was like that—people didn’t know what to do. Campylobacters had only just been cultured. So, we had a microaerophilic type of organism, but Campylobacter jejuni will culture in about two days on a petri dish whereas, we didn’t know it, but, Helicobacter took four or five days. And most people would say you couldn’t just grow Helicobacter from gastric juice because in the first one or two days you’ll get so many commensals from the mouth that they would overgrow any Helicobacter that was there, and so you’re going to fail. But it turned out that biopsies from patients with duodenal ulcer were pretty sterile because you’re taking that biopsy in an acid milieu. You’re taking it up through your scope and plating it out and, so, for many of these biopsies, the surface of them was sterile and they weren’t actually contaminated very much with oral flora. So, once we found out that you needed only to wait longer and then you would see the Helicobacter, even on non-selective media, that was the trick. Just waiting a bit longer. Ultimately, we used selective media once we knew the antibiotic sensitivities, so it’s much easier these days. Nowadays, everybody has a CO2 incubator, which is also very good for culturing H. pylori, but way back in 1982, you didn’t have those fancy incubators. You used to have to use special gas jars and so it was a bit more difficult. Reading the literature, we could see Campylobacters, we could see spiral bacteria that had been grown from different animals, particularly from the colon of mice, and we followed some of those publications. It was also difficult to develop an animal model of infection leading to gastritis. Explain what led up to experimenting on yourself.

To fulfill Koch’s postulates, you’ve got to go ahead and show that you can infect an experimental animal, usually a mouse, a rat, a guinea pig, or even pigs, cats, or dogs, etc. Then you want to see the same lesion develop in the animal. So, supposedly, you want to see ulcers and then you want to be able to show that the organism is present in the lesion, so we set off trying to do that. We failed in our experiments with mice, with rats, and with guinea pigs, and so I then tried to infect piglets with H. pylori. That was a difficult experiment because the piglets grew so quickly that after six months, I couldn’t endoscope them anymore. The body of the pig was longer than the endoscope that I had and so I was very frustrated by it all. And I said, “Well, the key question is can Helicobacter infect a healthy human?” And that was going to be me. So

that experiment was something I discussed and had written down in a proposal for a thesis a year before, so it wasn’t as if it was totally unplanned. I needed to move on with my life. It was becoming very draining to be hammering away at these animal experiments when, ultimately, it was going to be a human experiment that was needed. So, I did that experiment where I took a culture of Helicobacter pylori from a patient with gastritis. He actually didn’t have an ulcer and I made sure that it was sensitive to all the antibiotics I could think of, particularly metronidazole, and I even treated the patient with metronidazole and bismuth and showed that I could eradicate it. On that basis, I figured that if I did develop a severe duodenal ulcer, I’d probably be able to treat it with antibiotics and it’d be fine, so I didn’t need to worry too much about it. I went ahead and drank two petri dish cultures of H. pylori mixed up in beef broth and I felt okay for a couple of days. About three or four days later, I started to feel a bit full. I had bloating; my evening meal just seemed like it wasn’t digesting. I think, in retrospect, I was developing achlorhydria because for a few days I was vomiting each morning with no acid in the vomitus, so it wasn’t my previous night’s meal that I vomited, it was just clear fluid. So, there was something wrong with the stomach at that stage and, again, no acid in the vomit. We now know that the acute syndrome of Helicobacter pylori can cause lots of different symptoms, but mostly you develop achlorhydria related to the severe inflammation in the gastric mucosa, the result of immune system activation. Most people believe the stories that I actually developed an ulcer, but I didn’t develop an ulcer. On the 10th day, I had a biopsy. I just had a pretty normal stomach—a bit pinkish—but there was severe damage to the epithelium. A lot of polymorphs and eosinophils were present, so the biopsy showed “severe active gastritis” or “acute active gastritis.” There were not many mononuclear cells at that stage, but there was severe damage to the epithelium, which you could even see on light microscopy. The very short epithelial cells had very little intracellular mucus, and this was evident in the couple of EM biopsies taken at the same time. I went on for another four or five days, but my wife insisted that I was going to have to have

Professor Barry Marshall and Professor Emeritis J. Robin Warren celebrate their 2005 Nobel Prize in Medicine.

treatment with antibiotics and get rid of this bacteria before the whole family became infected. She was probably pretty wise in that, and so I said, “Well, let me hold out until next week, then I’ll have a further endoscopy and biopsy,” which I did have, but on that occasion, very surprisingly, the Helicobacter had gone. Although I did not develop antibodies, my innate immunity and the severe inflammation was enough to eradicate the Helicobacter. So, I then took antibiotics as well and had no further symptoms, no aftermath, my stomach returned back to normal, and everything was great. But it did tell us that not everybody who catches Helicobacter pylori is going to have a lifelong, chronic infection. Looking around at the epidemiology data around the world, we could say that in children, for example, it’s known that a proportion of them will lose the organism and then get it back again. So, presumably, each person might have their own particular strain of Helicobacter which is perfectly suited to them and will cause a lifelong infection. If you are

just having a Helicobacter infection once in your life from your partner or someone that you met, maybe you could easily have a temporary infection and not have a permanent infection. Alternatively, if you live in a country where you’re continually being exposed to Helicobacter, for example in Peru, every few days you might get another Helicobacter in the drinking water. Ultimately, you’re going to catch the one that’s perfectly suited for you, which means that 50% or more of the population in these places will end up being chronically infected. Did you feel you had made a horrible mistake when you became ill after ingesting live culture?

No, I was getting quite excited! I could see there was going to be some papers published about this. However, in some ways, the symptoms were quite subtle. You know when you see people with functional dyspepsia and their symptoms might be vague bloating, etc., you suspect that that could be that they’re overworked, or they’ve been eating the wrong food or something,

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// COVER STORY

What challenges had to be overcome to develop effective antibiotic regimens?

Professor Marshall and Professor Emeritus Warren won the 2005 Nobel Prize for Physiology or Medicine for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease.

and so it’s very easy to explain away a lot of cases of Helicobacter—and certainly some of them are going to be asymptomatic. So, it taught me a lesson. It wasn’t until I actually had the endoscopy and the biopsy that I was really certain that I was infected. The illness that I had was quite interesting; it wasn’t really painful, I was feeling tired, and had this vomiting going on—so it definitely brought me down, you know my productivity that week must have been pretty low—so I was a little surprised. But I know that a friend of mine in New Zealand took the Helicobacter and had a severe onset of abdominal pain. After about a week he was admitted to the emergency room. The surgeon wanted to take out his appendix because he was having severe abdominal colic. Luckily, however, with an H2 blocker or something he settled down, didn’t have to have a surgery, and he got better after about three days. So, this is what we think happens in most people. They have a severe abdominal syndrome of some sort—it might be epigastric pain, it might be vomiting, nausea, crampy pains, who knows—but that will usually improve after a few days. My experience with volunteers is that they will nearly always settle down just with a decent dose of H2 blocker. So, my early treatment studies supported the hypothesis that Helicobacter was responsible for the development of peptic ulcer, but it took another decade for more effective antimicrobial therapy to be developed and widely recommended.

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“Curiosity-driven research is the type of research that makes amazing discoveries and causes a paradigm shift.” —Prof. Barry Marshall

One of the problems with clinical trials in 1982 was that you couldn’t do a placebocontrolled trial in people with ulcers, because if the placebo didn’t work, a person could die from a bleeding ulcer. So, we always had to use an active control when we did clinical studies. We wanted to have an active control, so that was probably an H2 blocker, and then the active antibiotic treatment was going to be an H2 blocker plus some antibiotic treatment. We didn’t really have good antibiotic treatments to eradicate H. pylori. An H2 blocker and amoxicillin might give you a 20 percent cure rate, but it’s not really enough to do a clinical trial with. However, we noticed that one of the treatments people were taking for ulcers in Australia and in Europe was bismuth, a drug called De-Nol® or bismuth citrate, and in the United States you’ve got Pepto-Bismol®, which was bismuth subsalicylate. So, it looked like bismuth was interesting because in vitro we could show it killed Helicobacter. There was data out there that the relapse rate was much lower after people had their ulcers healed with bismuth, so the theory we had was that bismuth must be killing the Helicobacter in the stomach, as some people had complete eradication of Helicobacter and then would not relapse. So, one of the active treatments that I used was bismuth with an H2 blocker and tinidazole, which is a longer acting version of metronidazole, and we achieved about 80 percent eradication in that group when we did the double-blind study. So, by experimenting from trial and error, we did have a cure rate for Helicobacter. If the organism was sensitive, the cure rate was about 90 percent; if the organism was resistant to metronidazole, the cure rate was about 70 percent or so, enough to get going with clinical trials. Interestingly, Tom Borody in Sydney was experimenting with bismuth and different antibiotics and was seeing a lot of patients, so he ended up with the combination of bismuth, tetracycline, and metronidazole. So, he took my treatment and added tetracycline to it, and he was able to get 90 percent cure rate in Sydney. In the last few years, similar combination treatments based on that work have become available and are still getting 70 to 80 percent cure rate with bismuth, metronidazole, and tetracycline

in a combination tablet—so it’s still a good treatment regimen. Of course, H. pylori is becoming resistant to different antibiotics, notably macrolides, which is clarithromycin, and quinolones, so that’s a big issue for us at the moment. Helicobacter? You developed two diagnostic tests: the rapid urease test and the urea breath test. How did you come up with these inventions?

I saw the reports of Helicobacter producing urease and I was experimenting in the lab. I noticed that we could put a biopsy just in urea agar and see a change in color. Other people were working on this at about the same time, but we had the first patented use for it. So, we modified the gel and found that there were so many Helicobacters in the gastric mucosa that you could actually just put a biopsy in to see the red urease reaction. If I step back a bit, the previous year I had been doing work on urea concentrations in gastric juice, and we noted that in a normal person there was a level similar to the blood, with about one and a half to two millimoles of urea present in the gastric juice and saliva, but if you had Helicobacter, all the gastric juice urea had disappeared. So, we knew that the strong urease from the Helicobacter was really having the effect of destroying all the urea, so that led to the idea of the rapid urease test that could be done at the time of endoscopy. I understand that there are about 30 million rapid urease tests done per year for the diagnosis of Helicobacter, so I’m proud of that fact. I hope you remember that it did come from me. So, of course that’s all very well, but we wanted a non-invasive test that GPs could use and that caused the evolution of the breath test. So, I used C-14 urea, because that’s what I had handy, and we did our first tests with that. Lo and behold, based on this idea that there was no urea in the gastric juice, I knew that it should work, but we didn’t know the doses. So, we started off using 10 microcuries of urea because that’s the dose you would use if you were doing a metabolic study with labelled albumin, for example. But because the reaction with Helicobacter was so rapid, we saw there was labeled CO2 coming out in the breath in just three minutes, so over the next few years we tuned it and got it right down to one microcurie of urea, so you can diagnose Helicobacter pylori in 10 minutes with the C-14 urea breath test. The one that I developed was called PYtest and, again, 30 million or so breath tests per year are based

“We failed in our experiments with mice, with rats, and with guinea pigs, and so I then tried to infect piglets with H. pylori. That was a difficult experiment because the piglets grew so quickly that after six months, I couldn’t endoscope them anymore. The body of the pig was longer than the endoscope that I had and so I was very frustrated by it all. And I said, “Well, the key question is can Helicobacter infect a healthy human?” And that was going to be me.” —Prof. Barry Marshall

on Helicobacter and urease. Now almost in parallel with my studies, David Graham and Peter Klein, who were working in Houston doing metabolic studies of various kinds, realized that their technology, which was a stable isotope of carbon-13 urea, could be used in the same way. Carbon-13 urea takes a little longer to do, and sometimes it’s given with a meal and has a baseline, etc., but the people who had the equipment and could afford it would prefer to use the carbon-13 urea in the same way, so now it’s used around the world. I think the breath testing is about 50-50 carbon-14 vs. carbon-13. Now the carbon-14 has been approved without any restrictions in the United States. You can give it to anybody because, although it does contain a tiny amount of radioactivity, it’s about the same or less than you receive from background radiation in a single day, so it doesn’t make sense that you would worry about it or restrict it. The other example is that it’s less than you receive in a short plane flight—so if we restricted the carbon-14 urea breath test we’d really have to go ahead and restrict people from taking plane flights and keeping children off planes and pregnant women off flights. We don’t need to do that, so it doesn’t make sense that there should be any restrictions on the carbon-14 urea breath test, so it’s a continuing marketing battle between the carbon-13 and carbon-14. The carbon-13 doesn’t have that issue, so patients don’t have to worry, but the carbon-14 is so easy that with just a single breath sample, that means you can do it much quicker. We’ve had the whole family of seven people just sit there and do the breath test immediately just with a 15-minute time gap in the clinic, so it’s advantageous in that way. Anyway, it’s a good test because nowadays nearly every Western country has access to a breath test, and your general practitioner can follow-up to see if the H. pylori has been eradicated because the breath test goes from some positive value usually down to pretty close to zero. Your recent work focused on antibiotic resistance, which has become more of a problem. What do you see as potential solutions to this issue?

I think I’ve been giving the same talk on this for about 20 years, so just remember that the key to eradicating H. pylori is, number one, give a strong dose of proton pump inhibitor and now the new versions of the PPI are the P-CABs (potassium-competitive acid

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// COVER STORY

blockers), which seem to be even stronger than the regular PPIs, so the P-CABs might be the way to go. So, lots of acid blockade and a pH in the stomach of seven or so is where we want to start. Then you add an antibiotic or a combination which Helicobacter cannot become resistant to, and the drugs there are amoxicillin, bismuth, tetracycline, and maybe furazolidone, although that has more side effects, so you could add one or two of those, and you’ll start to get a pretty high eradication rate—maybe 60 percent or so. Then, if you go to a more personalized or precision medicine type therapy and can get sensitivity results, you might then add a quinolone or clarithromycin, if it’s sensitive. Or you might add rifabutin, I know that some treatments are based on that, so with this strategy, you can then usually steer around the resistances. In our clinic, even though I see so many patients who have been treated two or three times, I can still get 90 percent eradication using a precision medicine approach to each patient because, of course, we can do culture and sensitivity. One of the things I’m trying to do is bring in a bit more knowledge and a bit more expertise into the microbiology so that, once again, we can easily culture H. pylori and people will be culturing it all over the world pretty easily, even with using simple methods. Then do antibiotic sensitivities to guide the therapy; that is how we’re going to eradicate that last 10 percent or so of Helicobacter. Looking back 40 years to when you first started your investigations, did you anticipate the impact your discovery would have on a disease that affected 10 percent of the human population at one time?

Well, certainly, we didn’t expect that we were finding the cause of duodenal ulcer; although, by 1983, we started to be pretty confident and we published our first paper mentioning duodenal ulcer and gastritis caused by Helicobacter in The Lancet in 1984. So that is getting on towards 40 years ago—I think this year it’s going to be 40 years since I met up with Robin Warren and we first started looking down the microscope together. So, luckily, we’re both still alive and I can actually do these interviews so maybe it’ll still be a lot of fun. I think I’ve got 20 or 30 years to go because I heard that Nobel Laureates live a heck of a long time. So, getting back to this, we still know that Helicobacter affects at least 50 percent of the global population and, you know, you’ve got all of Asia, you’ve got India,

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“Most people believe the stories that I actually developed an ulcer, but I didn’t develop an ulcer. On the 10th day, I had a biopsy. I just had a pretty normal stomach—a bit pinkish—but there was severe damage to the epithelium.” —Prof. Barry Marshall

a lot of Russia, and South America—those countries are infected with Helicobacter—so, adding up that great population, you easily get to about 50 percent of the human race. Nowadays, people have stopped arguing about Helicobacter. It used to be, “Oh should you treat it? The patient’s asymptomatic, all those antibiotics are so toxic.” Well, hopefully, we’re not having that argument anymore. We just go ahead and eradicate the Helicobacter pylori. Usually, patients at least don’t feel any worse, but a lot of them will feel better after that and they can’t infect their family, and they’re not going to pass it on to the next generation, they’re not going to develop stomach cancer, except very rarely. What advice do you have for young investigators today who want to pursue clinical research?

My advice for clinical research: anything that is interesting, particularly in patients you haven’t cured and particularly if it’s a chronic disorder, any observation you make is worth pursuing. You don’t know which idea is going to be the successful one. You know, there are so many chronic diseases out there which we don’t have a cure for and, really, I haven’t seen much progress in my career of 40 years or more in medicine, particularly in autoimmune diseases. So, it’s great now that you’ve got the biologics and quite often you can suppress these diseases like rheumatoid arthritis, all kinds of arthritides, skin lesions, psoriasis, etc., but it’s still not to the stage that we know exactly what caused them. What was the antigen? What was the trigger that put that particular person into that disease process? So, as far as I’m concerned, medicine’s still wide open, and no matter what you say to people about a bedside manner and relationship with your patients, most patients just want to take a cure and get on with their life. So, if you have any idea which could possibly lead into a cure, save people a lot of time, get them back to their normal health, and save time for doctors, well, there’s a lot of value in it. So keep up with your clinical research. I’ll say once again, if it’s curiosity-driven research, it’s interesting, and you like to do it, I’m sure it’s got value.

ACG CLINICAL ACG CLINICAL RESEARCH AWARDS RESEARCH AWARDS

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DEADLINE: DECEMBER 3, 2021

APPLY: gi.org/research-awards

DEADLINE: December 3, 2021

THE ACG INSTITUTE FOR CLINICAL RESEARCH & EDUCATION ANNOUNCES EIGHT 2022 ACG CLINICAL RESEARCH AWARDS: The ACG seeks original, patient-oriented research in clinical gastroenterology and hepatology, defined as: 1. Research conducted with human subjects 2. Research on new diagnostic and therapeutic intervention 3. Research on material of human origin such as tissues and specimens 4. Research that is translational in nature; i.e., have direct applicability to clinical care NOTE: Studies involving animals will not be considered unless the work cannot be done in humans.

SUBMISSIONS OPEN: SEPTEMBER 2021

DEADLINE: FRIDAY, DECEMBER 3, 2021

ACG 2022 HEALTH EQUITY RESEARCH AWARD ACG recognizes the importance of equity in health and healthcare, and believes everyone should have a fair and just opportunity to achieve their full health potential. Unfortunately, many digestive diseases disproportionately burden certain minority groups, highlighting significant disparities in their evaluation, management, and clinical outcomes. The ACG Institute identified a critical need for targeted research funding to produce actionable science that will translate to reducing health and/or healthcare disparities, thereby promoting health equity.

 50k/ 1-year award  Research to produce actionable science that will translate to reducing health and/or healthcare disparities  Requirements: • ACG membership at time of submission • US or Canadian-based physicians • Full-time faculty position at university, med school or other healthcare institution at time of application OR practicing gastroenterologist/ hepatologist in a community practice • NOT for fellows-in-training • Pilot data required

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ACG 2022 ESTABLISHED INVESTIGATOR BRIDGE FUNDING AWARDS  300k/ 2-year award (150k/ year)  Experienced physician faculty in need of bridge funding  50% protected time  Requirements: • Complete Pre-Qualification Application by November 1, 2021 • ACG Member at time of submission • Physicians, full-time faculty (US or Canada) • > 8 years out of fellowship or terminal training program • Evidence of recently (within 2 years) concluded federal grant in clinical or translational GI or hepatology. NOTE: Career development awards are non-qualifying.

• Must demonstrate one of the following: 1) Evidence of ongoing application to renew federal funding OR 2) Evidence of new federal application to be re-submitted. • NOT for early career investigators or fellows-in-training

2022 ACG/ASGE EPIDEMIOLOGIC RESEARCH AWARD IN GASTROINTESTINAL ENDOSCOPY  50k/ 1- or 2-year award  Research using the GIQuIC registry  Requirements: • ACG or ASGE Member at time of submission • Letter of support from GIQuIC and any registries being utilized • Include cost of data extraction, cleaning and analysis in the proposal • Physicians (US or Canada) • Fellows are eligible to apply, but must include a letter of support from: 1. Research mentor 2. Division Chief confirming trainee's ongoing appointment and position for the duration of the grant. (If not guaranteed, a contingency plan is required)

FOR QUESTIONS: research@gi.org

FOR QUESTIONS: RESEARCH@GI.ORG | 29

ACG CLINICAL ACG CLINICAL RESEARCH AWARDS RESEARCH AWARDS APPLY: GI.ORG/RESEARCH-AWARDS DECEMBER 3, 2021 APPLY: gi.org/research-awards DEADLINE: DEADLINE: December 3, 2021

ACG 2022 JUNIOR FACULTY DEVELOPMENT AWARDS

ACG 2022 CLINICAL RESEARCH AWARDS

ACG 2022 CLINICAL RESEARCH PILOT AWARDS

 450k/ 3-year award (150k/ year)

 50k/ 1-year award

 15k/ 1-year award

 Research in clinical gastroenterology

 Requirements: • One investigator must be an ACG Member at time of submission

 Does not require pilot data

 Requirements: • ACG Member at time of submission • Junior Faculty: <7 years out of fellowship

• Open to US, Canadian, and International physicians

• Gastroenterologists and hepatologists (US or Canada)

• GI or hepatology fellows (with a mentor)

• Full-time faculty position (instructor or assistant professor in the GI or hepatology department)

• NOT for residents or medical students

 50% protected time & career development

The purpose of these awards is to recognize and support promising trainees as they develop a career in clinical research in gastroenterology and hepatology. Successful applicants will have the opportunity to travel to the ACG Annual Scientific Meeting in October 2022.

SUBMISSIONS OPEN: SEPTEMBER 2021

• GI or hepatology fellows (with a mentor) • NOT for residents or medical students

ACG 2022 RESIDENT CLINICAL RESEARCH AWARD

ACG 2022 MEDICAL STUDENT RESEARCH AWARD

 10k/ 1-year award

 5k/ 6-10 week research project

 Requirements: • US & Canadian Residents

 Requirements: • US & Canadian Medical Students

• 1st or 2nd year internal medicine or pediatric residents

• 1st, 2nd or 3rd year medical or doctor of osteopathy students

• Patient-oriented research: QI projects, retrospective cohort studies, meta-analysis, etc.

• Short-term research experience in GI and hepatology

• Mentor must be an ACG Member at time of submission

DEADLINE: FRIDAY, DECEMBER 3, 2021

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• Open to US, Canadian, and International physicians

• Pilot data required

• NOT for established investigators

MEDICAL RESIDENTS AND MEDICAL STUDENTS RESEARCH AWARDS

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• Mentor must be an ACG Member at time of submission

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LEARN MORE ABOUT THE ACG INSTITUTE LEARN MORE ABOUT THE ACG INSTITUTE The The Clinical Research Awards are a project of the ACG Institute and is supported by charitable contributions to the G.U.T. Fund. Clinical Research Awards are a project of the ACG Institute and is supported by charitable contributions to the The G.U.T. G.U.T.Fund. Fund The is the Institute’s whose missionwhose is to Grow, Uplift, Transform GITransform Research GI and Education. Visit G.U.T. Fund iscampaign the Institute’s campaign mission is to and Grow, Uplift, and Research gi.org/gutfund for more information. and Education. Visit gi.org/gutfund for more information.

30 | GI.ORG/ACGMAGAZINE

Conversations with Women in GI Christina M. Surawicz, MD, MACG on “A Career of Firsts” In conversation with Jill Gaidos, MD, FACG

MORE THAN A YEAR AFTER WE WERE LAST TOGETHER at the “ACG Bridging the Leadership Gap in GI” Conference in January 2020, Dr. Surawicz and I finally have a chance to catch up over Zoom to talk about mentoring, coping during the pandemic, and her amazing career of firsts. Dr. Jill Gaidos: In preparation for our conversation, I found a biography of you published in 1981 where I learned that you were the first female faculty member in the University of Washington Gastroenterology division, you were initially the Director of GI Endoscopy at Harborview Medical Center (the county hospital) then, you were the Section Chief of Gastroenterology there for 20 years and the first Assistant Dean for Faculty Development. You were the first female president of the American College of Gastroenterology from 1998 to 1999. Did you strive for these leadership positions? Were these leadership positions part of your 5-year or 10-year career plans? Dr. Christina Surawicz: No, it just happened organically. I never planned more than one or two years ahead and had not really thought about doing academic medicine. It was always, “Well, let’s just give it a try and if it doesn’t work out, I can always go into private practice.” But I did end up staying. When I took that first job, I did not negotiate for anything, though I did at least get an office.

ACG Perspectives | 31

// PERSPECTIVES

I learned some leadership on the fly in my job, but the most important was becoming involved in the College. I met Dr. David Graham when he was a visiting professor at UW. He introduced me to the College and gave me opportunities such as speaking at the annual postgraduate course, and later serving as the course director. Being on ACG committees was important too. You know the saying that committees are the little hands and feet of an organization? Committees are a great way to get involved in ACG: you have tangible products, you meet people, many of whom become colleagues and friends. If you are in academics, committee members can write letters for your promotion because they know you but have not worked with you academically. I want to highlight the ACG Women in GI Committee that you have also chaired. It was started by Dr. Jamie Barkin when he was president, and the first chair was Dr. Robyn Karlstadt. It was an exciting committee as it was high energy with lots of new projects. We were the first to ensure the College offered free childcare at the Annual Scientific Meeting, even if only one child showed up. We did white papers addressing issues like leave policies for pregnant fellows and radiation exposure. We organized symposia for the Annual Meeting on topics relevant to women. But, of course, these topics are relevant to men as well. I am so proud of the work this committee has continued with new ideas – such as these interviews which were your idea. I also learned a lot serving on the Board of Trustees, watching other leaders. Sometimes, I felt more positive feedback from my College work than I did in my job. You know the saying, “You’re never a prophet in your own land.” JG: Exactly! CS: Some of my leadership opportunities at UW started with our Women in Medicine committee, which was very embryonic. A survey at that time showed that women were not

32 | GI.ORG/ACGMAGAZINE

getting as much mentoring as men and were less satisfied at work. That committee, which I ended up chairing, started doing workshops for women faculty on various topics as well as networking events. We sent women to leadership programs, like AAMC and ELAM programs. Then in 2002, I was appointed as the first Assistant Dean for Faculty Development. JG: You mentioned the survey results showing that women were less likely to have mentors. What were your steps to improve mentoring for women? CS: A lot was focused on supporting mentoring in departments and divisions, and on learning about mentoring. We stressed the need for multiple mentors. In my experience as a junior faculty, I could not look to the men in my division to advise me on combining work and family when I had twins. We also emphasized that your mentor should not be your boss, as each of your goals may be different. Workshops on topics such as promotions, giving presentations, and unconscious bias, among others, were open to all faculty and were very popular, especially having half day or all-day programs at a nice site off campus with free breakfast, lunch, and parking. We started a Women Faculty day that was very popular. I felt it was also important to find speakers from outside of medicine, such as from the business school, to teach topics like negotiating skills and conflict resolution. JG: Right! What do you think about sponsors compared with mentors? In talking with other women, many have not heard of the term sponsor. CS: I only heard of this concept a few years ago. It comes from business, right, from the whole idea of the C-suite? JG: Yes. The business world is way ahead of medicine in regard to leadership training. CS: Having a sponsor is important. Originally the mentor was supposed

to do it all, but the sponsor’s job is to promote someone without necessarily having that intense mentoring relationship but just providing opportunities. Tell me your thoughts on sponsorship. JG: There is a book called Forget a Mentor, Find a Sponsor: The New Way to Fast-Track Your Career that talks about the importance of having a sponsor. It is great to have a mentor to help you with your career goals, but you really need someone who is going to open doors including being first author on reviews and book chapters, speaking opportunities, helping to get you on committees, etc. I agree that it seems like a mentor should be able to do both, but I do not think that happens very often, at least in my experience. It is hard to get promoted without a national reputation and you need those opportunities, you need those doors to be opened. Speaking of opportunities, did you face any major obstacles as the first female President for the ACG? CS: Not at all. I had a great year. I am proud of the things we accomplished. It was satisfying to be involved in the Annual Scientific Meeting. One thing I am especially proud of resulted from our recognition that if we wanted disadvantaged young people to consider a career in medicine, we needed to reach out to them before college. So, we started the first “Prescription for Success: Careers in Medicine and Science” program by choosing a high school with many minority students. Anne-Louise Oliphant organized our first visit to Alhambra High School when the ACG Annual Scientific Meeting was in Phoenix, Arizona in 1999 during my ACG presidential year. A group of us went to make our presentations. I remember Dr. Yvonne Romero (from Mayo Clinic) telling the students that if she, as a Latina teen from an underprivileged background in Las Vegas, could end up at Harvard for undergrad and then go to medical school, that they could too. I am happy that this program continues to this day. In my Presidential address, I spoke on women in medicine, and addressed my tips for combining work and family— maybe the best advice I gave was to lower

your standards at home—I had 3 young boys at home and after being fired by the Maid Brigade cleaning service for having a house too messy to clean I bought an ugly brown couch so that if one of my children spilled milk or juice on it the next day I wouldn’t care. I am proud to have been part of the College, but even more proud of those who have followed me, and their incredible contributions over the decades. JG: In addition, to your research career on recurrent infection with Clostridioides difficile, you took an early interest in burnout, including raising awareness of physician burnout in gastroenterology. Was there a particular incident to lead to your interest in burnout? CS: I did not know much about burnout at the time when then-ACG president Dr. Ron Vender asked me to give the Berk/Fise Lecture on burnout at the Annual Meeting. As I read and prepared the talk, I realized I had survived burnout. As a midcareer faculty, I felt like I had a lack of control at work. I became the section chief then, realizing that if I was going to be happy, I was going to have to be in charge and not feel like a victim. [Dr. Surawicz’s 2018 lecture, “Recognizing Burnout” is available at bit.ly/SurawiczBurnout-2018] JG: During the pandemic, there have been essentially two movements on how to handle the changes brought on by COVID: one group was promoting the idea that we should be trying to finish everything you have been putting off and/or learning some new skills. I heard that the GI journals were flooded with submissions because people were trying to finish up projects now that they were seeing fewer patients and endoscopy centers were closed. The other group was pushing for us to just give ourselves time to deal with the changes in our society and our lifestyles due to COVID. Which camp would you be in? CS: Those are two different approaches. It has got to be individual, and maybe a mix of the two approaches works for some. But I have the luxury of being retired and free of patient care responsibilities. It has been a really tough year and I am in awe of the work you have all been doing.

“...when an opportunity comes up, assume that you CAN do it because the tendency may be more to think, ‘Oh, I don’t know if I’m ready for that.’ You would not have been asked if they did not think that you could do it. Just believing in yourself as much as others believe in you, that is the main thing.” —Dr. Christina Surawicz

Jill K.J. Gaidos, MD, FACG Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

JG: You gave an amazing talk at the ACG “Bridging the Leadership Gap” conference called “Tips on Breaking the Glass Ceiling” where you discussed lessons you have learned on how women can reach their highest potential. From someone with a lot of firsts in her professional bio, what advice do you give women who can be a first at something or have an opportunity to do something new? CS: A few things: First, when an opportunity comes up, assume that you CAN do it because the tendency may be more to think, “Oh, I don’t know if I’m ready for that.” You would not have been asked if they did not think that you could do it. Just believing in yourself as much as others believe in you, that is the main thing. Second, make sure it is something you really want to do. Finally, if you do not fail sometimes, you are probably not taking enough risks. Twice I applied for positions that I didn’t get. I felt bad about not being chosen. Yet in both cases, those chosen were better suited, did a better job, and were happier in those roles than I would have been. Other opportunities came up for me, such as the Assistant Dean position. As Helen Keller said, “when one door of happiness closes, another opens but often we look so long at the closed door that we do not see the one which has been opened for us.” Helping to advance women and groups underrepresented in medicine and GI has been a passion for me. There are still fewer in leadership (for a variety of reasons), but I am gratified to see that it is heading in the right direction and that the College members and leaders remain at the forefront of the work that needs to be done.

ACG Perspectives | 33

// PERSPECTIVES

Eosinophilic Esophagitis: Creating Access to a

Patient-Centric Model of Care By Jennifer Horsley-Silva, MD

OPPORTUNITIES FOR PERSONALIZED THERAPY Eosinophilic esophagitis (EoE) is a food-driven disease characterized by symptoms of esophageal dysfunction with tissue eosinophilia which has increased in incidence and prevalence since its discovery two decades ago. As our understanding of the pathogenesis has evolved endotypes and phenotypes of the disease as well as various targets for treatment have started to emerge. This creates opportunities for personalization of EoE therapy. Studies have also shown that patients have better outcomes with longitudinal care. The requirement of multiple endoscopic procedures for evaluation makes patient-centric shared decision making important. Patients with EoE often have comorbid atopic disorders and are cared for by both gastroenterologists and allergists. Given the diversity in treatment options, there is a need to streamline care management and avoid unnecessary delays. When I started on staff here at Mayo Clinic in Scottsdale, Arizona, 34 | GI.ORG/ACGMAGAZINE

none of the gastroenterologists were specializing in EoE. I had completed an advanced esophageal diseases fellowship and during that time I spent elective time with Dr. Evan Dellon at University of North Carolina and Dr. David Katzka and Dr. Jeffrey Alexander at Mayo Clinic in Rochester, Minnesota, focusing on EoE. As I started caring for EoE patients, it was apparent there was a need for coordination of care with our allergy and nutrition departments. Patients sometimes received differing opinions regarding their diagnosis or care plan depending on the provider(s) or that provider’s specialty. For those choosing to pursue food elimination as a treatment for EoE, nutritional counseling and dietary adherence was challenging. COORDINATING CARE IN EOE: A UNIFIED PLAN After discussing with my colleague in Allergy/ Immunology, Dr. Benjamin Wright, we decided to implement a multidisciplinary clinic where

patients with a new diagnosis of EoE or complex/refractory EoE could be seen by a gastroenterologist, an allergist/ immunologist, and a dietician. Dr. Wright is a member of the Consortium of Eosinophilic Gastrointestinal disease Researchers (CEGIR) and leads a translational research program focused on food allergy and EoE. He is one of several faculty in our basic science laboratory focused on allergic disease and eosinophil biology. We involved one of our registered dietitians who had a special interest in food allergies and diet elimination. Michelle Sharpe, RDN, has extensive experience in counseling for diet elimination and has attended ASPEN Nutrition Science and Practice conferences with lectures focused on EoE. It took some time to set up this endeavor, but it has been extremely rewarding as patients receive a unified plan and comprehensive medical evaluation for allergic and gastroenterological diseases. Both Dr. Wright and I have been able to bill for our services during the clinic, and, when needed, Ms. Sharpe provides same-day dietary counseling. When a patient comes to clinic for the first time, we take a complete history of both their GI symptoms and allergy symptoms. In addition to symptoms, we review and assess the following: 1. Prior diagnoses 2. Testing including endoscopies with dilations and pathology 3. Prior therapies and reasons for treatment failure or discontinuation 4. The patient’s baseline knowledge of their atopic diseases We provide a thorough explanation of disease pathophysiology and symptoms and then discuss treatment options we both feel might be beneficial. We review pros and cons of proton pump inhibitors (PPIs), topical steroids (with various preparations), and diet therapy in the context of the patient’s preferences and medical history. During our assessment we also discuss ongoing clinical trials and translational research studies to gauge patient interest and assess eligibility.

“As I started caring for EoE patients, it was apparent there was a need for coordination of care with our allergy and nutrition departments.”

AN APPROACH TO ELIMINATION DIETS IN EOE If a patient wishes to pursue diet elimination, we review options of stepup versus step-down therapy and the details involved with food exclusions and reintroductions. We then request a 1:1 visit with Ms. Sharpe to review practical considerations for dietary management of EoE including how to read food labels, recognize hidden allergens, and identify suitable food replacements. She ensures nutritional adequacy, especially if patients are already eliminating foods due to IgEmediated food allergies or intolerances and provides access to resources. Resources can include meal planning for diet eliminations, additional snack ideas, sources where suitable supplements and vitamins can be purchased that are allergen free and even a phone app called AllergyEats which can help identify restaurants that will accommodate their needs. This coordinated multi-disciplinary approach enhances EoE care. It saves our patients time by consolidating multiple appointments. It improves communication and fosters collaboration among specialists. Finally, it increases access to ancillary services (e.g., dietitian). We have observed that this reduces unnecessary procedures, improves outcomes, and increases patient satisfaction.

it had to be compounded, refrigerated, and refilled frequently. After reviewing all the options, he was not happy with swallowed topical steroid or diet elimination therapy. Due to a co-morbid diagnosis of moderate persistent asthma, he qualified for dupilumab which was prescribed by Dr. Wright. His EoE and asthma are now both in remission on this medication and he is doing well.  A Caucasian gentleman in his 30’s, presented with EoE, allergic rhinitis, and mild peripheral blood eosinophilia. He had symptoms of mild dysphagia and heartburn. His symptoms seemed to worsen when his allergic rhinitis flared. He had previously not responded to high-dose PPI therapy. He underwent allergic skin prick testing and was found to have significant aeroallergen sensitivities and mild asthma. He was started on Flonase and prescribed albuterol for pre-treatment before to physical activity. His dysphagia improved and we continued PPI therapy due to suspected GERD. Repeat upper endoscopy showed resolution of active eosinophil inflammation after optimizing control of his reflux, allergic rhinitis, and asthma.

LESSONS LEARNED FROM A MULTIDISCIPLINARY EOE CLINIC While we are not the first to develop a multidisciplinary EoE clinic, this model is less commonly employed in adult EoE centers. As a budding gastroenterologist, I have found this clinic to be most helpful because it facilitates collaboration amongst colleagues. Group visits may not be possible in most clinics, but this emphasizes the need for improved communication amongst clinicians and providers involved in the care of the same patient. In areas where a combined clinic is not possible, it is important for allergists and referring gastroenterologists to have an open line of communication. It is also important to have nutrition support which can be difficult and sometimes costly to find. The website www.eatright.org can help locate a dietitian who may specialize in food allergies. In my experience, dietary counseling can be helpful throughout the elimination process; prior to starting the diet elimination for education and resource purposes, during treatment to assess adherence, and at the end to review correct diet after food triggers have been identified. As medicine becomes increasingly complex and subspecialized, I hope there are more opportunities for multidisciplinary collaborative clinics in our practices.

THE PATIENT EXPERIENCE Examples of patients who have benefitted from our multidisciplinary approach:  A young Caucasian male in his 20’s presented with EoE, childhood eczema, moderate intermittent asthma, and IgE-mediated food allergies to nuts and corn as well as allergic rhinoconjunctivitis. He had failed high-dose PPI and responded to twice daily oral viscous budesonide but felt as though it was causing side effects of insomnia and fatigue. He also found taking budesonide cumbersome because

Dr. Jennifer Horsley-Silva, Mayo Clinic Gastroenterologist, specializes in EoE and is a key member of the EoE multidisciplinary clinic.

Photo page 34: The EoE multidisciplinary clinic one afternoon which includes Dr. Horsley-Silva, Dr. Wright, Michelle Sharpe, RDN, and Dr. Diana Snyder, advanced esophageal disease fellow. Photo this page: Dr. Horsley-Silva and Dr. Wright discussing a patient in clinic.

Dr. Benjamin Wright, Mayo Clinic Allergist and Immunologist, has a special interest in food allergy and EoE and is a key member of the EoE multidisciplinary clinic.

Ms. Michelle Sharpe, RDN, Mayo Clinic Dietitian, has a special interest in food allergies and diet elimination, and is a key member of the EoE multidisciplinary clinic.

ACG Perspectives | 35

// PERSPECTIVES

CHAU CHE, MD

Temple Health

Culinary Connections:

Cultural Perspectives to Inform Your Palate  FALL IS A SPECIAL TIME OF THE YEAR. The days become shorter, the air crisper, and the summer greenery transforms into a kaleidoscope of colors in the plants around us. It is a time for harvest, traditions, and gatherings filled with delicious food. As we all have different experiences and backgrounds, the foods we eat with our families at our celebrations reflect this. In this issue, we are excited to share the stories (and recipes!) of three gastroenterology colleagues from diverse backgrounds within the American College of Gastroenterology. They each have focused on nutrition and incorporate different plants and flavors into their cooking. They also advocate for a healthy lifestyle for their own families and patients. Food nourishes us

Food is the centerpiece of any culture. My parents immigrated from Vietnam to the United States before I was born. They worked tirelessly to preserve their culture and instill it in our family. Although we ate everything growing up, my childhood was filled with Vietnamese food. My mother made a three-course dinner every night: soup, protein, and vegetables. My job was to prep the garlic, onions, and shallots because every meal would include these ingredients. It explains my affinity for cooking with these items! Dinner would end with my mom peeling fruit at the table for dessert. She is an amazing cook so my standards for eating were set high at an early age. As a gastroenterologist, I play an important role in helping patients improve their lifestyle. Food is a big part of this. I recognize the importance of eating in moderation and that is the approach I take with my patients. Food makes up a culture and if you don’t understand the culture, it’s hard to counsel patients. When a culture’s diet primarily consists of white rice, telling a patient to not eat white rice, the very

and brings us together.

AU CHE)

VEGETABLE GRATIN (DR. CH  Ingredients

• Sweet potatoes • Yukon gold potatoes • Turnips • Shallots (finely chopped) • Salt • Pepper • Heavy cream • Toasted panko breadcrumbs

36 | GI.ORG/ACGMAGAZINE

sted Panko 4. Continue repeating step  Toa Breadcrumbs #3 with the potatoes, 1. Preheat oven to 375 F. 1. Set pan on medium-high sweet potatoes, and use or ly thin heat. gies veg in. 2. Slice turnips aga a mandoline. 2. Add olive oil and 5. Cover baking dish with breadcrumbs. 3. In a baking dish, arrange foil. Place in the oven on tly sligh s, t. the turnip slice top of a baking shee 3. Stir until breadcrumbs are overlapping in a single , golden brown. 6. Cook for 30 minutes layer. Sprinkle salt, 45 then covered, and pepper, and shallots onto minutes uncovered. ugh eno r this layer. Pou heavy cream so it slightly 7. Top with panko breadcrumbs. covers the turnips.

 Gratin

essence of their diet, is not practical advice. Instead, I try to offer a sustainable solution, like mixing white and brown rice together. The best diet is a sustainable one. Small changes can have big impacts. A lifetime of small changes can have a tremendous impact over time. If I were not a gastroenterologist, I would be a chef. My love of gastronomy has only grown. To marry these interests, I am pursuing my certification in culinary medicine. These days, I am a chef to my personal party of five. A home-cooked meal was so important to my childhood that I wanted to continue that tradition with my family. I am consumed with eating and finding the best possible foods. What we put in our body matters and it should be the best, most flavorful food possible, whatever that may mean for each person. At my house, nothing is off-limits, but I strive toward feeding my family a balanced diet that is heavy in vegetables. Like in my childhood, I want to give my

children the opportunity to learn about different cultures through food. I may not be able to cook three courses nightly like my mom did, but our meals are well-rounded. Every night, we have dessert like I did growing up; homemade chocolate chip cookies for dessert may be followed by nights of fruit to balance things out. As a working mom, it is hard to get dinner on the table in a timely manner! Since my medical training began, I always wanted to share my cooking with the world and recently started on Instagram (@drchautime). My goal is to show that a healthy, balanced, homemade meal can be done nightly. Many of us are planners and, with a busy schedule, that same mindset needs to occur when it comes to feeding our families. With planning, practice, and foresight, a homecooked dinner is within everyone’s grasp. Since starting my endeavor, I have received an outpouring of support from colleagues. We have been able to share our collective experiences as gastroenterologists and lovers of gastronomy.

ROASTED SWEET POTATO (DR. MAG NUS  Ingredients

• 2 sweet potatoes or 1 whole pumpkin (butternut squash works well) • Spices: 1 Tbsp paprika, 1 tsp smoked paprika, ½ tsp cayenne, ½ tsp ground oregano, ½ tsp garlic powder • Lemony white miso tahini chickpea topping: • 1 can chickpeas • 2 Tbsp white miso paste • 2 Tbsp tahini • 1 tsp of white vinegar • 1 clove of garlic • 1 lemon • Greens: • Fresh herbs – parsley and coriander work well • Sliced cucumber or steamed broccoli • Sesame seeds for topping

For four of the past five years, we have hosted Thanksgiving dinner for our families. I am sharing one of my favorite side dishes with you. As someone who cannot eat cheese, I love this dish because I can finally enjoy a gratin! It only has a few ingredients, including shallots—a family favorite! Shallots are essential in infusing flavor throughout the dish. Use this recipe as a guide; any root vegetable can work as a substitute. Bon appétit!

MAGNUS HALLAND, B.MED, B.MED.SCI, MPH, PHD, FRACP

Mayo Clinic, Rochester

As a gastroenterologist and avid cyclist with an interest in swallowing medicine and nutrition, food is at the forefront of my mind, both at work and at home. While all living beings require nutrients for survival, food and shared meals represent so much more than a mere supply of energy. It is not by chance that food features prominently in nearly all social events, family gatherings, and celebrations!

HALLAND)

 Steps 1. Pre-heat oven to 375F. 2. Mix spices with either lemon juice or olive oil. 3. Cut the sweet potatoes in half. If using pumpkin, cut this in half and remove seeds – carefully “Hasselback” the pumpkin by cutting thin slices almost, but not completely through – leave the skin on. 4. Paint the sweet potatoes with spices and bake – time will vary depending on size – but 35 min to 55 min is a rough guide.

5. Make the topping: a. Mix the miso paste and tahini— add a few Tbsp of water until smooth. b. Add finely chopped garlic and juice from ½ the lemon, along with the vinegar. c. Rinse the chickpeas and add to the mixture. 6. Serve up: a. Place the baked sweet potato on a plate. Gently pierce with a fork so the topping will soak in. b. Add a generous amount of miso chickpea topping. c. Add greens: fresh herbs and lemon zest go on top— chopped cucumber or steamed broccoli goes well on top as well. I add some chili-flakes and sesame seeds for extra flavor as well.

ACG Perspectives | 37

// PERSPECTIVES

My personal journey with food started in Norway, growing up in a family that encouraged participation in the kitchen from an early age. This was fortunate as I was a very picky eater, but by actively making food, my courage to introduce more fruits, vegetables, and flavors grew over time. I don’t think anyone who knew me 30 years ago would have predicted that I would end up eating a predominantly whole-food plantbased diet. The change was gradual but was kicked into gear a few years back when I recognized how little I knew about nutrition, despite being a gastroenterologist, and how profound the impact of food choices we make have on health. From there I avidly starting learning about and integrating evidence-based nutrition into my personal life, as well as patient care. My number one tip for people who would like to move towards a wholefood plant-based lifestyle is to focus on flavors and colors. By eating a variety of colored fruits, wholegrains,

“I hope you will take the time (perhaps on a weekend) to make this roast dinner of sweet potatoes. If your current insurance plan requires pre-authorization for sweet potato, the lower-tier pumpkin can be prescribed as a substitute.” —Dr. Magnus Halland

WITH FENNEL ROMAINE AND ARUGULA SALAD  Ingredients

Buttermilk Dressing • 1/2 cup buttermilk (can use pea milk for vegans) • 1 Tbsp dijon mustard • 2 Tbsp apple cider vinegar • 2 Tbsp plant-based mayo, mayo, or creme fraiche • 2 Tbsp olive oil • 1 tsp agave nectar • 1⁄4 tsp garlic powder • Kosher salt • Freshly ground black pepper

beans/lentils, and vegetables you obtain a diverse amount of nutrients and colorful plates are also way more appetizing! Many people also have to re-train their tastebuds! Processed and fast foods typically contain too much salt, sugar, and fat. Such foods distort the baseline of flavor perception. When eaten frequently, we lose the ability to detect many of the flavors and nuances in healthier foods— thankfully, this process is reversible. I hope you will take the time (perhaps on a weekend) to make this roast dinner of sweet potatoes. If your current insurance plan requires pre-authorization for sweet potato, the lower-tier pumpkin can be prescribed as a substitute. When using pumpkin, you can even go fancy and cut them Hasselback-style. This type of preparation takes a bit of time and knife skills, but nothing an endoscopewielding gastroenterologist can’t handle, and the result is totally worth it! I have included a recipe for one of my favorite toppings, but many other variations will work—be creative!

AND A BUTTERMILK DRESSING

Salad • 1.5 oz arugula (~2 cups) • 5 oz. romaine lettuce, torn into bite-sized pieces (~4 cups) • Salt and pepper, to taste • 1⁄2 cup cherry tomatoes, diced • 1⁄4 red onion, thinly sliced • 1⁄2 small bulb fennel, halved lengthwise, cored and thinly sliced • 10 basil leaves, thinly sliced or chiffonaded • Grated Parmesan cheese

(DR. EDWIN MCDONALD)

 Steps

To make the dressing: small bowl 1. Whisk all the ingredients in a and salt until combined. Season with . side the to pepper to taste. Set For the salad:

lettuce 2. Place the arugula and romaine leaves. the Mix l. bow ing in a large serv and salt with ce lettu the on Seas Add freshly ground pepper to taste. Mix el. fenn and ns, the tomatoes, onio with salad the s Dres ts. the ingredien grated the dressing. Serve with freshly ns, vega For Parmesan cheese on top. sed t-ba plan a nutritional yeast or cheese are a good substitute.

a ¼ cup of 3. teaspoon salt. If desired, add water while cooking until 4. Cook for another 5-8 minutes softened

pepper to 5. Add beans (and crushed red red) desi if , taste

38 | GI.ORG/ACGMAGAZINE

EDWIN K. MCDONALD, IV, MD

University of Chicago

Many of my favorite memories from childhood involve food. Unlike many children, I enjoyed Thanksgiving more than Christmas. There was something magical about sharing a delicious meal with friends and family. I vividly remember helping my grandmother in the kitchen— breaking the ends of snap peas and preparing the dining room table for Thanksgiving dinner. I treasure these memories much more than a toy truck or video game I received as a Christmas gift. Celebrating with food profoundly impacted my appreciation for cooking by highlighting the connections between food, love, and culture. These connections inspired me to work in restaurants, host barbecues, and attend culinary school. Despite the joy that food gave me in my youth, my childhood was also replete with numerous examples of the negative impact of food on health. While attending churches on the south side of Chicago, I vividly remember hearing pastors implore congregations to pray for church members struggling with diabetes, kidney disease, and heart attacks. As I aged, my awareness of the relationship between food and these chronic diseases gradually increased. Embracing the joy of food and witnessing deleterious results of unhealthy eating motivated me to become the nutrition-focused gastroenterologist I am. I am currently the Associate Director of Adult Nutrition at the University of Chicago. I also am board-certified in obesity medicine and teach culinary medicine to medical students, residents, patients, and community members. As much as I love treating patients with gastrointestinal problems, my focus on nutrition provides extra satisfaction. Helping patients navigate food deserts, food swaps, and the taste preferences associated with living in these environments gives me an additional sense of purpose. Teaching healthy eating also allows me to put my culinary training to use.

“Celebrating with food profoundly impacted my appreciation for cooking by highlighting the

Now that I am a culinary-trained physician in charge of preparing Thanksgiving dinner for my family, my perspective on Thanksgiving has evolved. Previously, I solely tried to pay homage to my grandmother's recipes and make the food as tasty as possible. Now I juggle these efforts with incorporating new flavors/techniques and cooking a healthy meal. My diet is predominantly plant-based, unlike many of my family members. Being mindful of my family’s preferences, I cook a variety of dishes. These dishes include traditional Thanksgiving items such as turkey, mac & cheese, and sweet potatoes. But I also cook a variety of vegetable-based dishes. I frequently take a multicourse meal approach by starting the Thanksgiving meal with a soup or salad. This salad with arugula, romaine lettuce, fennel, and a homemade buttermilk dressing is one of my Thanksgiving favorites. I love it because it incorporates multiple vegetables and flavor profiles. Fennel’s freshness and the dressing’s creaminess and acidity balance the arugula’s bitterness.

connections between food, love,

 Have a personal connection with GI

and culture.”

and gastronomy? Contact ACG at acgmag@gi.org to share your story with the ACG community.

—Dr. Edwin McDonald

ACG Perspectives | 39

On Getting Old: The Sounds of Silence By Amnon Sonnenberg, MD, MSc, FACG

I HAVE KNOWN RICHARD (ASSUMED NAME) FOR MANY YEARS. Richard recently retired from his academic position, but still works part-time as a gastroenterologist. He and I share similar interests in clinical epidemiology and see each other at medical conferences once in a while, chitchatting about work and exchanging academic gossip. The last time I ran into Richard was at Digestive Disease Week when we both headed for the exit after a lecture and started talking about the presentation. Richard was critical of the elderly presenter, whose talk appeared poorly structured, overly long, and lacking in new information. Once he became older and lost his mental acuity, Richard said, he wished that someone would take him aside and tell him to stop engaging in academic pursuits and clinical work before he made a fool of himself. As we are getting older, don’t we all wish for some benevolent and insightful friend, who would provide us with such guidance? But if he or she really existed, would we listen to them? Would we believe them or just become offended and angry? We harbor a natural tendency to kill the messenger of bad news. Even without resentment towards the messenger, we may still try to downplay the severity of the critique, question its overall relevance, and find exceptions to its general applicability. We would ask ourselves whether in spite of some agerelated decline we were, nevertheless, still capable of pursuing our clinical, educational, research, or administrative responsibilities. What if the advice was wrong or just biased by our nominal rather than biologic age? There is a good chance that any suggestion would go unheeded and be of no consequence.

40 | GI.ORG/ACGMAGAZINE

Out of empathy and good intentions not to hurt us, close friends may phrase their critique ever so carefully and make such subtle allusions that we would be hard pressed to notice them at all. And why should others besides family even expose themselves, make the effort, and take the risk of incurring our wrath with no benefit to themselves and little chance of affecting our behavior? As outlined above, a short mental simulation already leads to the inevitable conclusion that any such benevolent, objective, and reliable outside guidance on when to curtail or stop one’s professional activity represents mostly wishful thinking and would in reality be difficult to come by. Listening to Richard talking, I was wondering why Richard hadn’t reached such conclusions on his own. Would a young bright Richard from 30 years ago have even voiced such half-baked idea? I was reminded of a paradox. Did the very fact that he expressed such unrealistic wishes indicate his own loss in cognitive function and that he himself had already crossed the point of no return? I was also wondering whether Richard was driven by yet another motivation to express this idea. Did he make his remark

because it sounded seemingly selfeffacing and modest, but provided him at the same time with the comfort and assurance of still being detached from the mental decline that he had noticed and admonished in the presenter? In essence and in an unspoken way, Richard told me, “fortunately, I am still sharp, and I don’t need anyone as yet to tell me otherwise.” A revealing negation constitutes a common pattern of speech, when the speaker negates the truth and thereby inadvertently reveals it. Upon his forced resignation President Nixon famously revealed himself by stating: “I am not a crook.” In using such revealing negation, the speaker tries to conceal what is obvious to himself but may still be unclear to his listeners. Only by hearing his remark was I made aware of Richard’s concerns and struggle with his own age-related decline. I listened to him and nodded my head but didn’t say anything.

Amnon Sonnenberg, MD, MSc, FACG Portland VA Medical Center and Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon

Inside the

JOURNALS

AC RTS EPO CASE RO J URN L G OM I.OR TS.C TS.G POR POR ERE ERE CAS CAS ACG ACG

VOLUME 6

ed by orts edit e Rep ed by nal of CasRep orts edit ne Jour ows An Onli nal of Case atology Fell ne Jour ows An Onli ology & Hep atology Fell Gastroenter ology & Hep Gastroenter

PUBLISHING CLINICALLY

APPLICABLE, EVIDENCE-BASED GUIDELINES IS A MAJOR OBJECTIVE OF THE AMERICAN JOURNAL OF GASTROENTEROLOGY. In 2021, the Red Journal has offered several important updates to ACG guidelines that integrate new evidence and changes in the clinical landscape for upper GI and ulcer bleeding, drug-induced liver injury, and C. difficile infection. Clinical research on COVID-19 has been so critical to advancing understanding of the virus and its impact. Clinical and Translational Gastroenterology published findings from Italy on endotoxemia in patients with COVID-19 and its association with thrombotic events. ACG welcomes the new 2021–2022 Editorial Board for ACG Case Reports Journal, an online, open-access, peer-reviewed journal edited by GI fellows-in-training.

Inside the Journals | 41

// INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

ACG Clinical Guideline: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections Colleen R. Kelly, MD, FACG; Monika Fischer, MD, MSc, FACG; Jessica R. Allegretti, MD, MPH, FACG; Kerry LaPlante, PharmD, FCCP, FIDSA; David B. Stewart, MD, FACS, FASCRS; Berkeley N. Limketkai, MD, PhD, FACG (GRADE Methodologist); Neil H. Stollman, MD, FACG

 THESE GUIDELINES ARE INTENDED TO BE COMPLEMENTARY to the recently updated Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiologists of America (SHEA) guidelines. The goal of the authors was to provide an evidencebased, clinically useful guideline for the diagnosis, management, and prevention of C. difficile infection (CDI). They chose to expand on areas of particular interest to gastroenterologists, including diagnostic issues around diarrhea and distinguishing C. difficile colonization from active infection, and the evaluation and management of CDI in the setting of inflammatory bowel disease and also addressed the current evidence and best practices around fecal microbiota transplantation.

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

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

Loren Laine, MD, FACG; Alan N. Barkun, MD, FACG; John R. Saltzman, MD, FACG; Myriam Martel, MSc; Grigorios I. Leontiadis, MD, PhD

Naga P. Chalasani, MD, FACG; Haripriya Maddur, MD; Mark W. Russo, MD, MPH, FACG; Robert J. Wong, MD, MS, FACG (GRADE Methodologist); K. Rajender Reddy, MD, FACG

 THIS DOCUMENT CONSIDERS PATIENTS with manifestations of

 DESPITE ITS LOW INCIDENCE IN THE GENERAL POPULATION,

overt upper GI bleeding (UGIB), which include hematemesis (vomiting of red blood or coffee-grounds material), melena (black, tarry stool), or hematochezia (passage of red or maroon material per rectum). The authors consider the initial management of the overall population of patients with UGIB up to and including the time of endoscopic evaluation. They restrict their recommendations regarding endoscopic therapies and postendoscopic management to patients with ulcer bleeding, the most common cause of UGIB and the diagnosis for which most randomized controlled trials of therapy have been performed.

gastroenterologists must always consider the possibility of drug-induced liver injury (DILI) in patients with unexplained acute and chronic liver injury as well as when prescribing certain gastrointestinal medications (e.g., azathioprine, anti–tumor necrosis factor agents, and sulfonamides). Many herbal and dietary supplements (HDS) can cause DILI, and thus, they must be considered as a cause for DILI. For the purposes of this guideline, the term DILI will refer to liver injury from HDS as well as prescription or the over-the-counter drugs. This guideline is limited to the wider array of idiosyncratic DILI that is more difficult to diagnose and treat. In addition, characterizing the injury by latency, pattern of injury (e.g., R-value), mortality risk (Hy's law), and outcome (resolution vs. chronic) is critical in evaluating and managing DILI in clinical practice.

 READ: bit.ly/ACG-UGIBleed-Laine-etal  LISTEN: bit.ly/Podcast-Laine

 READ: bit.ly/ACG-Cdiff-Kelly-etal  LISTEN: bit.ly/Podcast-Colleen-Kelly Colleen Kelly, MD, FACG in conversation with AJG Co-Editor-in-Chief Brian E. Lacy, MD, PhD, FACG

[ACG CASE REPORTS JOURNAL]

A Rare Case of the Jejunal Ectopic Pancreas Observed With an Endoscope Yamauchi, et al.  ENTEROSCOPY SHOWED a 20mm elevated lesion that looked like a submucosal tumor on 20 cm distal from the ligament of Treitz. Observing closely with an endoscope, the lesion was slightly faded and had a dimpling on

Loren A. Laine, MD, FACG in conversation with AJG Co-Editorin-Chief Brennan M. R. Spiegel, MD, MSHS, FACG

 READ: bit.ly/ACG-DILI-Chalasani-etal  LISTEN: bit.ly/ACG-Guideline-DILI-Podcast K. Rajender Reddy, MD, FACG in conversation with AJG Co-Editor-in-Chief Brian E. Lacy, MD, PhD, FACG

the top (indicated by an arrow), from which serous liquid was discharged. A biopsy confirmed acinar tissue on the submucosa. The acinar tissue was positive for chymotrypsin staining.

Read the Case: bit.ly/CRJ-Yamauchi-Ectopic-Pancreas

Figure 1. text

42 | GI.ORG/ACGMAGAZINE

[ACG CASE REPORTS JOURNAL]

Welcome, ACG Case Reports Journal Co-Editors-In-Chief, Katherine A. Falloon, MD & Judy A. Trieu, MD, MPH!  THE AMERICAN COLLEGE OF GASTROENTEROLOGY IS PLEASED TO ANNOUNCE the appointment of Katherine A. Falloon, MD and Judy A. Trieu, MD, MPH as the 2021–2022 Co-Editors-in-Chief of ACG Case Reports Journal, the College's openaccess, peer-reviewed journal edited exclusively by GI fellows. This longstanding fellow-run journal represents the College’s commitment to supporting gastroenterology trainees by promoting academic and professional growth. ACG Case Reports Journal provides a platform for medical students, residents, and fellows interested in gastroenterology and hepatology to contribute to medical literature.

 acgcasereports.com |  Follow ACGCRJ on Twitter @ACGCRJ

2021-2022 EDITORIAL BOARD Katherine A. Falloon, MD Co-Editor-in-Chief Cleveland Clinic Judy A. Trieu, MD, MPH Co-Editor-in-Chief Loyola University Medical Center

Anthony Horton, MD Associate Editor Duke University Health System Nicholas McDonald, MD Associate Editor University of Minnesota

Abhishek Agnihotri, MBBS, MD Associate Editor Thomas Jefferson University Hospital

Fredy Nehme, MD, MS Associate Editor University of Texas - MD Anderson Cancer Center

Amporn Atsawarungruangkit, MD Associate Editor Brown University

Malav Parikh, MD Associate Editor SUNY Downstate Health Sciences University

Divya Chalikonda, MD Associate Editor Thomas Jefferson University Hospital Phillip Gu, MD Associate Editor Cedars-Sinai Medical Center

Hirsh Trivedi, MD Associate Editor Beth Israel Deaconess Medical Center

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Low-Grade Endotoxemia and Thrombosis in COVID-19 Alessandra Oliva, MD; Vittoria Cammisotto, MSc; Roberto Cangemi, MD; Domenico Ferro, MD; Maria Claudia Miele, MSc; Massimiliano De Angelis, PhD; Francesca Cancelli, MD; Pasquale Pignatelli, MD; Mario Venditti, MD; Francesco Pugliese, MD; Claudio Maria Mastroianni, MD; Francesco Violi, MD, Sapienza University of Rome, Rome, Italy

 THE STUDY REPORTS FOR THE FIRST TIME that low-grade endotoxemia is detectable in patients with COVID-19 and is associated with thrombotic events. The coexistence of low-grade endotoxemia with enhanced levels of zonulin may suggest enhanced gut permeability as an underlying mechanism. The authors write: “Previous studies reported that patients with community-acquired pneumonia (CAP) display enhanced levels of lipopolysaccharides (LPS) coincidentally with an ongoing prothrombotic state, suggesting that low-grade endotoxemia may be implicated in the thrombotic complications occurring in CAP. This hypothesis has been recently corroborated in an experimental model of thrombosis where low-grade endotoxemia enhanced thrombus growth through Toll-like receptor 4 (TLR4). Based on this, we analyzed the interplay between endotoxemia and thrombotic events in SARS-CoV-2 patients followed-up during the intrahospital stay; furthermore, we investigated whether changes in gut permeability may account for low-grade endotoxemia.” They conclude: “low-grade endotoxemia coexists and is associated with thrombotic events in COVID-19, providing a new insight into the mechanism eliciting inflammation and eventually thrombosis in COVID-19. Further study is necessary to investigate whether changes of gut permeability play a role in eliciting low-grade endotoxemia.”

 READ: bit.ly/CTG-Oliva-Endotoxemia-COVID19

Mike Wei, MD Associate Editor Stanford University

Inside the Journals | 43

// INSIDE THE JOURNALS

New Book Reflects on New Book Reflects on Time to Integrate New Book Reflects on

It’s (History of Medicine) (History of Medicine) Genetic Testing into (History of Medicine) from the Pages of from the Pages ofof from the Pages The American Journal of Gastroenterology Your GI Practice The American Journal of The American Journal ofGastroenterology Gastroenterology T TT

he latest book by Robert E. Kravetz, MD, MACG, “A Look Back – he latest book by Robert E. Kravetz, MD, MACG, “A Look Back – Reflections on Medical HistoryE.&Kravetz, Artifacts from the Pages ofBack The American he latest book by Robert MD, MACG, “A Look – Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology ” is available at athe special of $25 for Reflections on Medical Historyfor & purchase Artifacts from Pagesrate of The American Journal of Gastroenterology ” is available for purchase at a special rate of $25 for Journal of Gastroenterology” is available for purchase at a special rate of $25 for College members. CollegeCollege members. members. With a keen eye for fascinating images and a gift for vivid and erudite descriptions, With aWith keenaeye fascinating images and aand gifta for vivid andand erudite descriptions, keenforeye for fascinating images gift for evolution vivid erudite descriptions, Dr. Robert Kravetz reflects on artifacts and trends in the of modern Dr. Robert Kravetz reflects on artifacts and trends in the evolution of modern Dr. Robert Kravetz reflects on artifacts and trends in the evolution of modern medicine and finds lessons and insights from medical antiques that remain medicine and finds lessons and insights fromfrom medical antiques that remain medicine finds today. lessons and insights medical antiques remainare fascinating and and relevant His appreciation for the past and histhat curiosity fascinating and relevant today.today. His appreciation for the past andand his his curiosity are fascinating and relevant His appreciation for the past curiosity both evident in each essay in “A Look Back: Reflections on Medical History & are both evident in each in “A in Look Back:Back: Reflections on Medical History & & both evident in essay each essay “A Look Reflections on Medical History Artifacts from the Pages of The American Journal of Gastroenterology.” Artifacts from the Pages of TheofAmerican Journal of Gastroenterology.” Artifacts from the Pages The American Journal of Gastroenterology.”

learn from the mistakes, sacrifices and advances of bygone eras. We learn the mistakes, sacrifices advances of bygone eras. ““ We We “ learn fromfrom the mistakes, sacrifices andand advances of bygone eras. History also teaches us to pay homage to our predecessors in the History also teaches to pay homage to our predecessors History also teaches us touspay homage to our predecessors in in thethe medical profession who paved the way for us. medical profession paved the way medical profession whowho paved the way for for us. us. ”” ”– Dr.– Dr.Kravetz Kravetz – Dr. Kravetz Dr. Kravetz is a healer and and historian whose humanistic sensibility shines Dr. Kravetz is a healer historian whose humanistic sensibility shinesthrough throughininthis this Dr. Kravetz is a healer and historian whose humanistic sensibility shines through in this elegant volume. Illustrated withwith vividvivid color photographs and short reflections elegant volume. Illustrated color photographs and short reflectionsbybyDr. Dr.Kravetz, Kravetz, elegant volume. Illustrated with vivid color photographs and short reflections by Dr. Kravetz, this curated selection of medical antiquities andand rare objects, many this curated selection of medical antiquities rare objects, manyfrom fromhis hispersonal personal this curated selection of medical antiquities and rare objects, many from his personal collection, comes to life. As aAs champion of medical history, anan avid collector collection, comes to life. a champion of medical history, avid collectorofofmedical medical collection, comes to life. As a champion of medical history, an avid collector of medical antiques and artifacts, and a consummate educator, Dr. Kravetz shares his passion with antiques and artifacts, and a consummate educator, Dr. Kravetz shares his passion with antiques and artifacts, and a consummate educator, Dr. Kravetz shares his passion with readers interested in gastroenterology medicine. readers interested in gastroenterology andand medicine. readers interested in gastroenterology and medicine.

OrderOnline Online ( Order ( ( ( Order Online (members.gi.org/store ( members.gi.org/store members.gi.org/store The book has a retail value of $60 and is available for purchase through The book has a retail value of $60 and is available for purchase through The book has website a retail to value of $60 andmembers is available forspecial purchase the ACG current ACG at the pricethrough of $25. the ACG website to current ACG members at the special price of $25. the ACG website Email to currentUs ACGto members at the special price of $25. Learn How This cost covers shipments to addresses in the United States only. This cost covers shipments addresses in the United States only. For information on orderingto the U.S., please contact info@gi.org. This cost covers shipments tooutside addresses in the United States only. GENETICS@GIONDEMAND.COM For information on ordering outside the U.S., please contact info@gi.org. For information on ordering outside the U.S., please contact info@gi.org.

44 | GI.ORG/ACGMAGAZINE

A Look Back

50 YEARS AGO... from the pages

of The American Journal of Gastroenterology By Lawrence R. Schiller, MD, MACG for the ACG Archives Committee

Ulcerative Proctitis

r. Richard G. Farmer, then a staff member in the Department of Gastroenterology at the Cleveland Clinic, and Dr. Charles H. Brown, head of the Department, reported on the Cleveland Clinic’s experience with ulcerative proctosigmoiditis in 193 patients from 1950–1966.1 At that time it was unclear whether proctosigmoiditis was an early stage of ulcerative colitis that inevitably would extend proximally with time or a discrete entity. In part, this was due to technical limitations: the only available diagnostic tests were rigid sigmoidoscopy and barium enema. The diagnosis was made on the basis of presentation (rectal bleeding), abnormal sigmoidoscopic findings typical of colitis (diffuse mucosal granularity and friability, edema, loss ERATIVE C OLITIS of the mucosal vascular pattern, and superficial ulceration with purulent exudates), and normal barium contrast radiography. Patients were followed arthritis, U C-related thropathie over ar time. gative and s

At the time of diagnosis 88 patients had a clear upper limit with transition to normal mucosa on sigmoidoscopy; 105 had disease extending at least 15 cm from the anal verge (the limit of routine visualization by rigid sigmoidoscopy). Most responded to the therapies available at the time, but mild recurrences were common. Of 120 patients initially seen from 1950–1963 and available for follow-up after an average of 6.2 years, 21 had extension into the distal colon (6) and the entire colon (15) visualized by barium enema. Eleven of these patients required surgery, 5 had toxic megacolon, and 2 had carcinoma (one in the transverse colon which had been involved with extended colitis, and one in an area not involved with colitis thought to be incidental). Of the 63 patients initially seen from 1964–1966 and followed for an average of only 2.6 years, 5 had extension into the distal colon (2) and the entire colon (3). Two patients required surgery, and one died. Of the entire

are nonerosive. 41 ial arthriti s can prese n t as ankylos litis or sa ing croiliitis. T hese cond ult in sign itions ificant mor bi dity but ca found inci n dentally on matic patie imaging in nts. When sy atients w mptomatic ill require , trea ent he inflamm to atory proce 39tm ,4 2, 43 ss . ema nodos um and p yoderma ga (PG) are nthe 2 mos t common ogic skin lesions in UC. Both y follow th cone activity of the luminal t PG can al so occur in FIGURE 1. dependentl activity. 36-39 Diagnostic y Although ev colitis on usually re erythema colonoscop idence of ulcerative sponds to y, showing co lo ni c inflammatio the therap continuous minal disea n starting in y se, PG of the rectum ten requir . injections es and can be associated ant morbid ity when la discrete ce rge ulcers cal patch can be pre is an area sent. 47 Th of isolated sclerosing is erythema cholangitis seen most th at may be co (P m SC does not m ) o is n ly ar ceal orifice parallel th ound the e luminal appendibut may ex mmation. tend into It has an This “skip the cecum es le si ti on m approximat ated nos ” does not . ely 5% in change the is and is st ill consisten UC. 45 diagsing cholan t gitis is mor w In 48 it h UC. most case e comand often s, patholo reveals dis diagnosed gic examin ease that is between ation 0 years. 46 limited to layers (ie, Most patie the mucosa not transm nts are t the time l u ra m l) et of diag with P aplasia

group of patients, extension of disease always occurred within three years after diagnosis. Only one patient was reclassified as having Crohn’s disease after developing a rectal stricture. Farmer and Brown concluded that ulcerative proctosigmoiditis was a milder disease and had a more benign prognosis than colitis involving the entire colon, and that progression of ulcerative proctosigmoiditis to pancolitis occurred in less than 10 percent of cases. When it did progress, it often occurred rapidly and aggressively. These observations largely have held up over the last half century, although proximal extension seems to be somewhat more likely now with longer follow-up and better diagnostic tests.2 Dr. Farmer went on to an illustrious career in gastroenterology and internal medicine, serving as Chief of Gastroenterology at the Cleveland Clinic for 10 years and as Chair of Internal Medicine for 16 years. He later practiced at Georgetown University and the University of Rochester. He served on the National Commission on Digestive Diseases, and he was elected to the Institute of Medicine of the National Academy of Sciences. Dr. Farmer was ACG President in 1979, after serving as Governor and Trustee. He was awarded Mastership in the College and received the prestigious Samuel S. Weiss Award for his efforts to modernize the ACG.

References: 1. Farmer RG, Brown CH. Course and prognosis of ulcerative proctosigmoiditis. Am J Gastroenterol. 1971;56(3):227-34. 2. Wu XR, Liu XL, Katz S, Shen B. Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis. Inflamm Bowel Dis. 2015 Mar;21(3):703-15.

Clockwise from left: Richard G. Farmer, MD; Ulcerative Proctitis image courtesy of Feuerstein JD, Moss AC & Farraye FA, Ulcerative Colitis, Mayo Clin Proc. 2019 Jul;94(7):1357-1273; used with permission of Mayo Foundation for Medical Education and Research, all rights reserved; Proctoscope. Source: Kravetz, Robert E., “Reflections on Medical History and Artifacts from the Pages of The American Journal of Gastroenterology.” Bethesda, Maryland, American College of Gastroenterology, 2020

Inside the Journals | 45

AboutIrritable Irritable Bowel Syndrome (IBS) About Syndrome (IBS) About Irritable Bowel Syndrome (IBS) Information from the American College of Gastroenterology

Information from the American College of Gastroenterology Information from the American College of Gastroenterology

#1 PAIN

5% PREVALENCE OR 1 IN 20

QUALITY OF LIFE

Abdominal pain is the Abdominal painof is IBS the major symptom #1 PAIN major symptom ofthe IBS Abdominal pain is major symptom of IBS

IBSof is the common and affects about 5% population in theOR U.S. 5% PREVALENCE 1orINabout 20 1 in 20 people of the in the U.S. or about IBSpopulation is common and affects about 5% of the population in the U.S. or about 1 in 20 people 1 in 20 people

$1.5 BILLION TO $10 BILLION PER YEAR $1.5 $1.5BILLION BILLIONTOTO$10 $10BILLION BILLION PER PER YEAR YEAR 10 TO 15 YEARS OF LIFE

A majority of IBS patients would give up10 10 TO to 1515 years of lifeOF expectancy YEARS LIFE A majority of of IBS patients would give formajority an instant cure for their condition A IBS patients would give up up 10 10 to to 15 15 years ofoflife years lifeexpectancy expectancy forfor an an instant cure forfortheir instant cure theircondition condition

10 TO 15 YEARS OF LIFE

IBS greatly reduces IBS greatly patients’ quality of life QUALITY OFreduces LIFE IBS greatly reduces patients’ quality of life patients’ quality of life

Direct medical costs of IBS are high, not including Rx or over-the-counter medications Direct medical costs of IBS are high, not Direct medical of IBS are high,medications not including Rx orcosts over-the-counter including Rx or over-the-counter medications

EQUAL OPPORTUNITY

IBS is not just found in women, it’s an “equal opportunity” EQUAL OPPORTUNITY IBSisisnot notand just foundinmen inwomen, women, disorder impacts too IBS just found it’san an“equal “equalopportunity” opportunity” it’s disorderand andimpacts impactsmen men too disorder too

EQUAL OPPORTUNITY

TYPES OF IBS

IBS is considered a

DISORDER OF is considereda a IBSIBS is considered GUT-BRAIN DISORDEROF OF DISORDER INTERACTION GUT-BRAIN

BLOATING

 IBS-C: IBS with constipation  IBS-D: with diarrhea TYPES OFIBS IBS  IBS-C: IBS-Mixed: IBS with mix IBS-C: IBS IBS with with constipation  constipation constipation and diarrhea  IBS-D: IBS-D: IBS IBS with with diarrhea  diarrhea  IBS-Mixed: IBS-Mixed: IBS IBS with  with mix mix constipation and constipation and diarrhea diarrhea

The sense of bloating is BLOATING a common The sense of of The sense symptom bloating isofisIBS bloating a common a common symptom of of IBSIBS symptom

TYPES OF IBS

GUT-BRAIN INTERACTION INTERACTION

HOPE symptoms can be frustrating HOPEIBS HOPE and discouraging, but there is hope

IBS symptoms can be frustrating and discouraging, but there is hope and there are treatment options: IBS symptoms can be frustrating  anddiet discouraging, but there is hope  medications andover-the-counter there are treatment options: and options: there prescription medications diet are treatment  diet gut-directed therapies like over-the-counter medications  over-the-counter medications cognitive behavioral therapy prescription medications  prescription medications and hypnotherapy gut-directed therapies like  gut-directed therapiestherapy like cognitive behavioral and hypnotherapy cognitive behavioral therapy

and hypnotherapy

QUALITY OF LIFE

#1 PAIN

5%IBSPREVALENCE OR 1 about IN 205% is common and affects

BLOATING

When you

TALK TOWhen YOUR DOCTOR, you

make sure you bring your list of When you symptoms and questions TALK TO YOUR DOCTOR, make sure you bring your list of , make sure you bring your list of symptoms and questions

TALK TO YOUR DOCTOR symptoms and questions

DO NOT SUFFER IN SILENCE! DO NOT SUFFER IN SILENCE!

DO NOT SUFFER IN SILENCE!

 Learn More:  gi.org/irritable-bowel-syndrome Learn  More: gi.org/irritable-bowel-syndrome

Learn More: gi.org/irritable-bowel-syndrome





Find a gastroenterologist near you:  gi.org/find-a-gastroenterologist Find a gastroenterologist near you:  gi.org/find-a-gastroenterologist

Read ACG 2021  IBS Guidelines: Read ACG bit.ly/ACG-Guideline-IBS  2021 IBS Guidelines: Read ACG 2021 bit.ly/ACG-Guideline-IBS

Read ACG 2018 Monograph  on IBS Guidelines: Read ACG 2018 Monograph bit.ly/ACG-2018-IBS-Monograph on IBS Guidelines: Read ACG 2018 Monograph bit.ly/ACG-2018-IBS-Monograph

Find a gastroenterologist near you: gi.org/find-a-gastroenterologist

IBS Guidelines: bit.ly/ACG-Guideline-IBS

on IBS Guidelines: bit.ly/ACG-2018-IBS-Monograph

American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro

American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro 46 | GI.ORG/ACGMAGAZINE

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ACG MAGAZINE ARCHIVE 2021 ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity

Vol. 4 No. 1 // Spring 2021

Vol. 4 No. 2 // Summer 2021

2020 ACG MAGAZINE Spring 2020

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Summer 2020

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Fall 2020

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Winter 2020

MEMBERS. MEDICINE. MEANING.

Pivot to

Virtual ACG 2020 & Leadership Lessons in the Time of pandemic

Evolution of an Idea

The Discoverers: development of the Colon Prep

From Functional GI Disorders To Disorders of Gut-Brain Interaction

Feeling fine with fear:

Mastering Risk Perception and Decision Making in Medical Practice

Vol. 4 No. 1 // Spring 2020

Vol. 4 No. 2 // Summer 2020

Vol. 4 No. 3 // Fall 2020

Vol. 4 No. 4 // Winter 2020

2019 ACG MAGAZINE

ACG MAGAZINE

Spring 2019

Winter 2019

MEMBERS. MEDICINE. MEANING.

Profiles in Courage IN The Fight Against Colorectal Cancer

Beyond City Limits:

GI Practice in Rural America

Vol. 3 No. 1 // Spring 2019

Vol. 3 No. 2 // Summer 2019

Vol. 3 No. 3 // Fall 2019

Vol. 3 No. 4 // Winter 2019