Rumblings FALL 2020
PENNSYLVANIA SOCIETY OF GASTROENTEROLOGY / NEWSLETTER
President’s Message / Ravi K. Ghanta, MD, PSG President
Dear Colleagues, Fall is officially here, and we can appreciate the beautifully changing and vibrant landscape of our great state of Pennsylvania. With this change of season, the rapid changes that have been occurring can be seen by us as regular citizens and as healthcare providers. Not only are we dealing with a worldwide pandemic, we are also in an election year leading to further uncertainty.
Now months into the COVID-19 pandemic, we are getting accustomed to a new way of life which in many ways has led so many to feel isolated and lonely. One of the wonderful things about PSG is the Annual Scientific Conference that is held yearly in the fall. This year’s conference was scheduled to be on September 1113. For the safety of our members, we had to make the difficult decision to cancel the Annual Meeting. As I mentioned previously, this was only the second time in PSG’s history that the conference had to be cancelled. The last time it was cancelled was in September 2001 in light of the 9/11 terrorist attacks.
It was sad to not have the meeting since it is a well-attended gathering where colleagues and family can get together in a relaxed environment. Connecting with colleagues means something totally different now. Instead of meeting in person, we are meeting virtually via our computer. While virtual meetings have tremendous value, the human connection one gets with meeting in person is lost. Hopefully, we will be able to get back to a time when we can meet in person. Just a few months ago, most of our practices and endoscopy centers had seen a significant drop in patient volumes. Currently, most practices have seen a significant increase in volumes with some even having volumes higher than the PreCOVID time period. It is nice to see that practices have been able to recover to some degree. However, the fear of having to shut down again because of another increase in infections is certainly looming. The economic impact has been devastating leaving continued on page 2
2 President’s Message
6 L egal Corner
10 Ins and Outs Medicine
3 PSG SoMe Update
8 Practice Mgmt Update
4 FIT Update
9 Featured Apps
19 CME Updates
continued from page 1
no practice immune. Large hospital systems and even large private practice groups may have weathered the storm better than smaller groups, but the impact on them has also been quite harsh. We have a long way to go but we will get through this pandemic as stronger and more resilient healthcare providers. We are learning more about this infection daily and we need to work collaboratively with each other and with our patients to get through this storm.
I cannot believe it has been one year since I took the role of President of this great organization. I am honored and humbled to be able to work with such great people on the PSG Board. These have been unprecedented times and I am grateful to navigate this course with all of you. We have all struggled in one way or another during this pandemic, but we need to stay strong since there are a lot of people depending on us. At PSG, we continue to advocate for our patients and the interests of our specialty. I look forward to a time that we can all meet up again, as one of the goals of our organization is to embrace the values of camaraderie and collegiality. If you are already a member of the PSG, we thank you for your support. If not yet a member, please consider becoming a member and joining our family. The application process
is very streamlined and should take no more than a few minutes and the membership fees are nominal. For trainees, the membership is complimentary. Remember, we are the PSG, your organization and professional family. We look forward to working with you and hopefully seeing you soon. Please stay safe! Respectfully, Ravi. K. Ghanta, MD President
Ravi Ghanta, MD President Pennsylvania Society of Gastroenterology
PSG SoMe Update
by Samantha Dougherty
Since the Since the advent of the PSG Social Media Ambassador program in March, our SoMe Ambassador’s have been working hard to generate meaningful content on our social channels for PSG members and other physician’s. Engagement on our social channels have increased exponentially since the launch of the Ambassador program and continues to improve as we push out more meaningful content. We are excited to continue that trend headed into 2021. We will be posting frequent board review questions for followers to get involved in the conversation, more takeovers like Dr. Kesavarapu’s in September, and other exciting new content ideas provided by our creative and intelligent ambassador’s! Keep your eye out for these great new content features and be sure to let us know what you want to see on our social pages by commenting, liking, retweeting or direct messaging us. Remember to follow @PAGastroSoc on Facebook, Twitter and Instagram to see what our Ambassador’s are up to! #PAGastro
FIT Update: Top Tips for New GI Fellows Sunny Patel, MD You take on a more prominent role as an educator as you now have a team of residents and students looking for guidance. Your attendings expect you to keep the pace of morning rounds and keep the team focused. As the saying goes, “everything comes in time”, and this is no different---be patient and prepare to work hard. Learn to triage. Under your new title of gastroenterology fellow, you will be overwhelmed at times with consults to see, procedures to complete, and/ or research to finish. @SunnyPatelGI
Welcome to our incoming gastroenterology fellows!
You have recently embarked on a ride of a lifetime training in this field is exciting, rewarding, challenging, and most definitely, characterbuilding. It was only a few months ago that you had gained a sense of accomplishment as you proudly read the correspondence proclaiming your match to the field of gastroenterology. As July inched closer, you may remember that feeling of accomplishment diminishing into a mixture of excitement, cluelessness, and fear. Your first year of fellowship is, without a doubt, the most challenging of your three-years of training. You are faced with learning a new language and procedural skill set from day one. Overnight, you transform from an internal medicine resident to an “expert” in gastroenterology (at least that’s how the rest of the hospital sees it). You are spread thin between learning the basics of endoscopy, managing consults, and learning to prioritize and coordinate procedures.
1. Learning to triage and prioritize your tasks will be a key survival tool. Chart review and evaluate your sickest patients first, anticipating the need for a procedure sooner rather than later. If they require a procedure, you need to decide who will be performing it and where it should be done (i.e. operating room, endoscopy suite, or bedside). Do not forget to communicate your plan with all those involved including the endoscopy team, primary care team, and of course, your attending. This can be a very stressful period but if you learn to prioritize and work efficiently, each month will be better than the prior. 2. L earn basics of endoscopy. Early in your first year, spend time with the endoscopy technicians and nurses. They will show you how to set up equipment correctly and troubleshoot common problems. Take every opportunity to perform bedside endoscopies outside of the comforts of the endoscopy suite—this will make you more efficient and test your knowledge. While on consults you will likely be taking overnight call where you will be confronted with emergent
overnight procedures. I urge you to anticipate your equipment needs during these encounters. For example, if called to perform an endoscopy on a foreign body or GI bleed, try to prepare equipment needed to complete the task and have it ready to be used. It may seem unnecessary, but when seconds count, you will be grateful. This not only helps maintain a smooth case, but also makes you look like a rock star. 3. Learn to accept criticism. Frequently, we receive positive criticism from our mentors and peers, boosting our morale and confidence. Try your best to focus on evaluations which provide more constructive criticism. In my opinion, one constructive comment is significantly more valuable than ten “you’re doing great!” reviews. 4. If you do not know, ask for help. You have spent countless hours studying and trying to be the best, but do not forget, you are not expected to know everything. However, you are expected to identify what you do not know. Many of us try to “figure it out,” but there will always be a time when you need to seek help. This not only applies to your first year, but to the rest of your career. Remember,
patient safety comes first! Second year of fellowship will start before you know it and you will surprise yourself on how much you have learned over the past year. The new first year fellows will be coming to you for advice. Take this opportunity to become a better teacher and mentor. 5. Identify your weaknesses. Take your time in endoscopy to identify your weaknesses. Ask those who are more experienced for “tricks of the trade.” Veteran attendings were once in your shoes too! There is something to take away from every case if you look for the opportunity. There is always a lesson you have not learned or a technique you have yet to master. 6. As you continue to build your knowledge base, seek out attendings who are experts in their own subspecialties. Not every attending will be the best at managing every disease, but they will have expertise in specific subspecialties of gastroenterology, for example, IBD, GI motility, advanced therapeutics, etc. You will even see different ways of managing the same disease-- this is why medicine is an art!
7. Engage in research. When it comes to research it may seem like a mountainous task. Learn to ask yourself “why.” This is the best way to start a research project of your own. When you have an idea, run it by a mentor or someone who subspecializes in that topic and it will take off from there. Talk to your senior fellows about the ins and outs of research at your institution. They will be your best assets when trying to get your project up and running. 8. Challenge your skills. Later in your second year, when you are more proficient with screening colonoscopies and EGDs, start to focus on therapeutic endoscopy procedures. Seek out technically difficult and challenging cases such as GI bleeds, IBD, large polypectomies, dilations, etc. If you have an advance endoscopist at your institution, try to take advantage of their skillset. You will be amazed at how well they are able to get you through the most difficult cases. You will be a third-year fellow before you have a chance to blink. The firstand second-year fellows will look up to you as both, a leader and mentor. As the senior fellow, you have a
responsibility to educate. This will only help to solidify your own knowledge in anticipation of taking your boards. 9. Transition to attending. In your final year of training think through every case and develop plans as if you were the attending. This will help build confidence and make the transition to becoming an attending smoother. Use your last few months to fine tune your endoscopy skills. Often, new attendings wished they had completed more high-risk procedures during their training. Also, they wished they had pressured themselves to perform endoscopy faster without sacrificing technique or accuracy, as they are now required to do as an attending. Each year of fellowship seems to progress faster than the one prior. Before you know it, your training time will come to an end. Take this time to ask questions and do as much as you can. In the end, you are only as good as your training!
Richard E. Moses, DO, JD pharmacy chains, health insurers, and employers. In addition, younger professionals coming out of training are taking jobs with healthcare systems and private equity owned and controlled medical practices.
Collective bargaining is a
process of negotiation between an employer and a group of employees with the goal of regulating salaries, working conditions, benefits, and other rights for the workers. A trade union, to which the employee belongs, usually represents employees. The union negotiates with a single employer or entity to reach an agreement, encompassing the entire compensation package. Physician interest in collective bargaining is nothing new. It dates to the 1970s in response to changing physician reimbursement and large health organizations coming onto the healthcare scene. Organized medicine has historically frowned upon physician unions as antithetical to professional values. This trend may be softening as the U.S. health system continues to evolve, consolidating with hospital mergers and acquisitions resulting in mammoth health systems, large
Prior to discussing collective bargaining, we need to make note of the complex antitrust laws in the United States. Congress passed the first antitrust law, the Sherman Act, in 1890 as a “comprehensive charter of economic liberty aimed at preserving free and unfettered competition as the rule of trade.” In 1914, Congress passed two additional antitrust laws: The Federal Trade Commission Act, which created the FTC, and the Clayton Act. With some revisions, these are the three-core federal antitrust laws still in effect today. The antitrust laws proscribe unlawful mergers and business practices in general terms, leaving courts to decide which ones are illegal based on the facts of each case. Courts have applied the antitrust laws to changing markets for the past 130 years. Despite the passage of time, the antitrust laws still have the same basic objective: protect the process of competition for the benefit of consumers, making sure there are strong incentives for businesses to operate efficiently, keep prices down, and keep quality up. I have entertained many conversations over the years with physician colleagues eager to “unionize” for sundry reasons, usually in response to their frustrations. My response to their query has been standard, in that the basic
principles of both federal and state antitrust and labor laws affect the ability of physicians to collectively bargain. The National Labor Relations Act of 1935 (NLRA) was designed to protect employees from the power of their employer by providing a “labor exemption” from antitrust laws. “Employee” includes physicians but excludes independent contractors (self-employed) and persons exercising managerial or supervisory responsibilities. This is what has caused the problem and challenge with physician unionization, in that historically most medical practices were self-employed “ma and pa” practices. In addition, many employed physicians have supervisory or managerial roles, thereby excluding them from NLRA protections. Collective bargaining with private insurance companies has been unsuccessful for self-employed physicians. The Sherman Antitrust Act of 1890 regulates these attempts. The theory is that a competitive marketplace promotes competition and lowers costs, therefore benefitting consumers. The watermark case is U.S. v. Maricopa County Medical Society, 452 U.S. 223 (1982), where the U.S. Supreme Court held that when physicians negotiate collectively with insurers about fees and related matters and therefore do not compete with each other on price, this results in a horizontal agreement among competitors to price fix. (NB: “Horizontal restraints” between similar economic entities directly competing, physician groups in our case, at the same level is believed to limit competition).
One of the goals of the Patient Protection and Affordable Care Act or 2010, a/k/a the Affordable Care Act or Obamacare, was to decrease healthcare costs by moving away from the fee-forservice model of reimbursement to one of sharing substantial financial risk. Physician network joint ventures, physician-controlled ventures in which physicians, who otherwise might compete, agree on prices or other terms, have developed. They jointly market their services, usually to an insurer or other provider organization. A physician joint venture is one type of multi-provider network that might include a hospital and its physician employees as well as independent physicians in private practice. The Federal Trade Commission and Department of Justice issued several non-binding statements in the 1990s seeking to establish “safety zones” in which physician practices would not fall under antitrust enforcement. In order to have safety zone protection, physician networks need to share “substantial financial risk” and represent ≤20 - 30% of all physicians practicing a specialty in a geographic area. There are a number of “clinical integration” requirements beyond
the scope of our discussion. These requirements are extremely complex and require interpretation by a healthcare attorney well versed in clinical integration and the associated anti-trust laws. As of 2018, based on a six-year retrospective survey reported by the AMA, more physicians are employed by health networks than are in private practice. This has been an ongoing trend with employed physicians making up 47.4% of all patient care doctors in 2018. This is an increase of 6% since 2012. Self-employed physicians represented 45.9% of physicians in patient care, down 7% from 53.2%, since 2012. The physician employment trend may create the opportunity for physicians to organize and collectively bargain with their employer, i.e., health system, insurers or other entities as the recent consolidations, mergers and acquisitions in the health care industry has strengthened the power of health systems and payers. Physicians, as employees, are not in a position to manipulate price or competition when it comes to health care costs and delivery. The ability of private practice
physicians to collectively bargain and unionize has been limited due to the complexities of both federal and state antitrust laws. Attempts have historically met with failure. The changing health care environment and landscape with the move to physician employment may create a different scenario. Collective bargaining is a complicated area of law frequently requiring a multidisciplinary attorney to navigate the antitrust and employment law environments. Antitrust laws are complicated, and their application continues to evolve.
Practice Management Update Optimization and Collaboration
R. Fraser Stokes, MD. PSG Practice Management Task Force Chair. August 2020 dietary changes (e.g. six small meals per day, foods that are softer, more liquid, etc). Eosinophilic esophagitis is an increasingly recognized cause of dysphagia and meat impactions. Various elimination diets can be tremendously useful to reduce esophageal eosinophilia and improve swallowing function.
“ You don’t get paid for the hour. You get paid for the value you bring to the hour.” — Jim Rohn, American entrepreneur, @FraserStokes author, and motivational speaker
The PSG is committed to helping to
optimize GI practice management. Many gastroenterologists provide a wide variety of ancillary services at their practice, including on-site endoscopy, pathology, anesthesia services, infusions, etc. Increasingly, practices are also adding a nutritionist to their team to directly collaborate with GI providers to optimize treatment success for many digestive diseases. Examples of conditions that benefit from dietary therapy are many. Patients with celiac sprue and other gluten sensitivities are treated by going on a gluten free diet. Having a dedicated expert in this diet teach the patient and his / her family various healthy and tasty eating strategies while avoiding gluten – can be invaluable. We are seeing an increasing number of patients with various symptoms of gastroparesis, which often respond to specific
In addition, it has become apparent in the past three to five years that many patients with irritable bowel syndrome can benefit from a low fodmap diet. Other examples of GI diseases that can benefit from dietary therapy include gastroesophageal reflux disease, cirrhosis with ascites, and lactose / fructose intolerance. Perhaps the greatest longterm challenge facing medicine today is the obesity epidemic. Obesity often leads to the metabolic syndrome that includes the comorbidities of hypertension, diabetes, hypercholesterolemia, sleep apnea, and fatty liver disease. Fatty liver is the most common liver disorder in Western industrialized countries. We recently began doing in-office elastography to determine if NAFLD patients are developing significant fibrosis. The primary treatments for Nash are vitamin E, exercise, and weight loss. A GI based dietician can be a key resource for patients trying to lose weight. Our nutritionist offers a variety of diets to help patients lose weight, but has had great success with the Ideal Protein program. This is a
low carbohydrate diet that is highly structured whereby patients meet with our dietician weekly for dietary advice / coaching and the purchase of medical foods. The program is dedicated to both short term weight loss and long-term maintenance of the new healthy weight. We have noticed over time that our gastroenterologists and physician assistants have limited time to review specific diet instructions, answer nutrition questions, review patient meal diaries, and provide food related psychological counseling. A dedicated nutritionist in your practice can do a most thorough job handling these important issues. There are a few hurdles to consider when hiring a dietician. One is financial, as some insurers do not cover dietician consultation. For those patients, we require a patient to pay a modest fee for a medical nutrition consultation. Weight loss programs, such as Ideal Protein, can be somewhat profitable, helping to make the addition of a dietician more affordable. Smaller practices may want to consider hiring a GI dietician as a part-time employee to start.
FEATURED APPS ACG Mobile app https://gi.org/membership/acg-mobile-app/
Provides immediate access to the latest guidelines w/decision support tools, ACG Podcasts, useful GI diagrams and risk forecasting medical calculators to aid clinical decision making.
If you decide to add a GI dietician to your team, I would suggest that you consider asking him or her to attend a special conference geared toward GI nutrition. Dr. William Chey at the University of Michigan holds an annual course in Ann Arbor that is extensive, practical, and highly valuable for GI based nutritionists.
1. L ow FODMAP educational website, non-branded, educational grant funded; www.myGInutrition.com
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2. C ertified Dietitian website : www.eatrightpro.org 3. A CG endorsed & developed nutrition : www.gastrogirl.com 4. O ptifast www.optifast.com 5. N ew Direction and Numetra www.robard.com
The Ins and Outs of Academic Medicine in Gastroenterology: The Future Is At Stake… Shyam J. Thakkar, MD When the world of academia functions perfectly, both optimal patient care is delivered, and research and technological advancements are made in a collaborative environment.
A fter four years of undergraduate
school, four years of medical school, three years of residency, 3-4 years of fellowship, and quite possibly a mountain of debt, we as gastroenterologists are primed to start our careers. The very first decision we are faced with is whether to enter the academic realm or the private one. For me, until recently, this has never been a question. Academic medicine has held the greatest thrill, with the opportunity to teach and train, research and innovate, and apply my clinical skillset to the most challenging of cases. To that end, for the past 12 years, I have been able to live my dream. However, academic medicine has certain drawbacks, and if we are not careful to make adjustments, it will become increasingly difficult to entice the next generation of gastroenterologists into the academic community.
The majority of academic appointments are through universities or large hospital systems in which there is a mutual partnership and trust between the physician and the administration. These institutions often have missions and visions for universal principles and behaviors for staff to adhere to and work towards. For any individual success, there needs to be alignment of these goals with common interests. For example, early in my career, I held a Directorship of Developmental Endoscopy appointment in which the shared vision of the position was born out of the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES) and developing such procedures within the hospital system. Through administrative support, partnership, education, research, and collaboration, a miniaturized snake robot was developed that demonstrated feasibility for NOTES interventions, thereby overcoming many of the challenges of flexible endoscopes. Several iterations later, the snake robot is now commercially available as the first robotic platform in endoscopy. Through mutual dedication and commitment of the program, research and clinical work flourished. We learned to perform numerous NOTES procedures, including endoscopic necrosectomy, per-oral endoscopic myotomy, and
EUS directed gastrostomy ERCP (EDGE) procedures. This is the blueprint by which academia in its purest form can yield excellence in research, innovation, training, and most importantly, patient care. Yet, even under the most ideal conditions, there are pitfalls in academia that need addressed. The focus of medicine in general has been shifting more and more towards revenue generation. Even though quality metrics and valuebased care are being recognized, the emphasis often remains on bottom lines. To that end, most academic appointments are focused on productivity. At best, we are allotted 10% - 20% administration time in which we are expected to complete patient follow-up, review pathology, imaging, and laboratory results, while teaching trainees, performing cutting edge research, and/or providing leadership. Thus, most of us end up spending late evenings and weekend hours on such initiatives. This type of demand can lead to poor physician retention. Data shows that 67% of academic physicians are highly stressed and an average 38% say they are burned out. Couple this scenario with the inevitable politics that often trouble a professional setting, and it is a recipe for frustration that may ultimately jeopardize patient care. Academic leadership is not immune to the insecurities that come with technological and/or colleague advancement. Often it only takes the bitterness or divisiveness of a few individuals to bring the culture of an entire division or department down. Lack of physician happiness and wellbeing can be palpable among
peers and can be tracked—to a degree—by high turnover in faculty and/or leadership, which suggests disenfranchisement and instability of a practice. An environment in which there is a lack of trust will impede passion and create challenges that may outweigh the poise and perseverance needed to educate, conduct research, and provide high quality patient care. While these issues can be present in many professional settings, the perception among physicians plagued by the politics of academia is that private practice allows for more autonomy and stake in decision making while in certain academic settings, it is possible for your voice to get lost in the shuffle.
endoscopic bypass procedures. The technology in endoscopy is expanding exponentially while the world of medicine is becoming more and more minimally invasive. It is an exceptional time to be a gastroenterologist in an academic setting, making it even more imperative that we strive to remedy the shortfalls of academia in order to maintain the interest of our next generation gastroenterologists. Without this, advancement of the field will be sure to stall allowing for
We currently live in a golden age of endoscopy where essentially any procedure that is imagined can be performed. This is evident by the most recent advancements, including oncologic interventions, submucosal tunneling, large en-bloc endoscopic resections, bariatric gastric reductions, and
other specialties to take advantage of any gaps. The world of academia offers so many opportunities in one setting, including training young and gifted physicians, conducting groundbreaking research with plentiful resources not otherwise found in other settings, and most importantly, it provides the best opportunity to deliver high-level patient care by collaborating with other specialties under one roof. We must embrace these opportunities, address politics, and utilize good evidence, quality metrics, and innovation for the benefit of patient care. 1. L inzer M, Poplau S, Babbott S, Collins T, Guzman-Corrales L, Menk J, Murphy ML, Ovington K. Worklife and Wellness in Academic General Internal Medicine: Results from a National Survey. Journal of General Internal Medicine 31, 10041010(2016)
Crohn’s Disease Update:
EUS-guided Drainage of a Crohn’s Disease-associated Pelvic Abscess David L. Diehl, MD, FACP, FASGE, Director of Interventional Endoscopy, Geisinger Medical Center, Danville, PA Under EUS guidance, a 19G needle was inserted into the abscess and contrast injected under fluoroscopic guidance (FIG 3a).
This is a 22-year-old man with
a four-month history of Crohn’s disease who had been treated with azathioprine. He gave a two-week history of increasing abdominal pain, which led to hospital admission. CT imaging showed a flare of his Crohn’s with thickening of the terminal ileum with mesenteric stranding. Prednisone taper was begun. He was admitted for abdominal pain about two weeks later, and a CT showed a 4 x 6 cm pelvic abscess (FIG 1a, 1b).
FIG 1b In retrospect, review of the previous CT showed a 2 x 3 x 3cm abscess that was not appreciated. Interventional radiology was consulted regarding drainage of this abscess; however, it was felt to be inaccessible to a percutaneous approach. Therefore, it was decided to attempt EUS-guided transrectal drainage. At about 18cm from the anal verge, a 6 x 4 cm heterogenous and hypoechoic lesion suggestive of an abscess was found with the linear EUS scope (FIG 2).
FIG 1a FIG 2
FIG 3a This showed a collection consistent in size and location with the abscess seen on CT. A guidewire was coiled within the abscess (FIG 3b), and a wire-guided needle-knife device used to gain entry to the cavity.
A repeat CT scan done six weeks later showed resolution of the previous abscess collection, with the two pigtail stents in place from the collapsed cavity to the rectum (FIG 5a, 5b).
FIG 3b The puncture site was then dilated to 10.5mm with a wire-guided dilating balloon (FIG 3b). Finally, two 7-French double pigtail plastic biliary stents were placed into the cavity (FIG 3c, FIG 4).
The patient was feeling well without abdominal pain, fever, or other GI symptoms. He was begun on Humira therapy every two weeks. He reported spontaneously passing the stents rectally three months after placement. He remains well, without any GI symptoms, seven months after internal abscess drainage.
FIG 4 Post-procedure, the abdominal pain was much improved, and he could be discharged the next morning.
DISCUSSION: Therapeutic endoscopic ultrasound is an important area of growth in interventional GI. Initial use of EUSguided drainage was for pseudocysts and walled-off pancreatic necrosis. In the last several years, there has been expansion of this technique to drain other structures (gallbladder, bile duct, post-surgical leaks and collections).
Drainage of pelvic abscesses is often difficult with a percutaneous approach due to surrounding bowel, and the location being deep in the pelvis. When the collection is adjacent to the rectum or colon, an EUS-guided transmural approach is feasible. An advantage of the internal approach is that external drains, which often need to be in place for weeks, are not necessary. Hospitalization may even be shortened. There is extremely limited literature on EUS-guided internal drainage of abscesses related to inflammatory bowel disease. In all the reported cases in the published medical literature, I could find only two other examples of this technique used for Crohn’s abscesses. In the current case, the technique worked very well, and avoided the need for surgery. For non-Crohn’s related pelvic abscesses that are adjacent to the rectum or colon, EUS-guided transmural drainage should be considered as a first-line treatment. It was successful in this case of a Crohn’s abscess. More data is required on the outcomes of this technique in Crohn’s abscesses to see if this approach can avoid the need for surgery on a long-term basis. Giovannini M, Bories E, Moutardier V, Pesenti C, Guillemin A, Lelong B, Delpéro JR. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy. 2003 Jun;35(06):511-4. Varadarajulu S, Drelichman ER. Effectiveness of EUS in drainage of pelvic abscesses in 25 consecutive patients (with video). Gastrointestinal endoscopy. 2009 Dec 1;70(6):1121-7.
A Critical Case of Eosinophilic Esophagitis
Kristle Lee Lynch MD, Assistant Professor at the University of Pennsylvania, Director, Advanced Esophageal Fellowship Director, GI Physiology Laboratory daily and instructed to follow up in the clinic at our Esophageal and Swallowing Disorders Program at the University of Pennsylvania.
A 30-year-old woman with a history
of asthma, eczema, and eosinophilic esophagitis (EoE) presented to our emergency room with the sensation of food retained her throat after swallowing chicken. She had been diagnosed with EoE in her late 20s, advised to take swallowed fluticasone via inhaler for 3 months, and was told to follow up as needed. Upon presentation to the ER, she could not tolerate her secretions and underwent an emergent upper endoscopy which confirmed the presence of a food bolus in the mid esophagus. This endoscopy was complicated by a critical stricture proximal to the food bolus that did not allow for passage of the adult upper endoscope (Figure 1). Using a pediatric upper endoscope and pediatric biopsy forceps, the food bolus was dismantled over 2 hours and passed into the stomach. A second critical stricture was seen in the distal esophagus just proximal to the GE junction. The patient was discharged on omeprazole 40 mg
Figure 1. Proximal esophageal stricture 7 mm in diameter, requiring use of a pediatric upper endoscope Eosinophilic esophagitis is a chronic allergic condition of the esophagus characterized by eosinophilic infiltration of the esophageal mucosa. If untreated, this leads to longstanding esophageal dysfunction most commonly manifested by dysphagia. Ongoing inflammation results in fibrosis and stricturing, as noted in the patient above. Longterm therapy for this chronic disease is critical. The current mainstays of therapy for EoE include medications and dietary therapy, as well as dilations on an as-needed basis. The most common first-line medical therapy for EoE is proton pump inhibitors, which are thought to act via the eotaxin-3 pathway, as opposed to solely by direct acid suppression. Thus proton pump inhibitors are recommended in EoE patients with and without heartburn symptoms. The next line of medical therapy is topical steroids. The most commonly used topical agents are also asthma medications:
fluticasone (inhaler) and budesonide (respule). In EoE patients, these medications are altered to optimize esophageal distribution as outlined in Figure 2. A recent randomized trial of fluticasone 880 µg twice daily as compared to budesonide slurry 1 mg twice daily in EoE patients revealed no significant differences in response via histology, symptoms or endoscopic scores. An upper endoscopy with esophageal biopsies is recommended after the patient has been on any medical therapy for at least 8 weeks to ensure histologic remission (defined as less than 15 eosinophils per high powered field). Figure 2. Patient instructions for administration of topical steroids
Fluticasone inhaler Squirt inhaler into back of throat twice daily. Swallow medication; do not inhale. Rinse mouth with water afterwards and spit. Do not eat or drink for 30 minutes after taking this medication.
Of note, no medications are yet approved by the U.S. Food and Drug Administration for EoE. However, there are many emerging and innovative therapies for EoE including different steroid formulations as well as biologic agents (Figure 3). There are numerous ongoing active studies that are currently enrolling at our institution to evaluate the efficacy and safety of these novel medications.
Figure 3: Novel and Emerging Medical Therapies for EoE Drug Pharmacologic Category Budesonide oral suspension (PO)
Budesonide effervescent tablet (PO)
Fluticasone orally disintegrating tablet (PO)*
RPC4046 (IV) Anti-IL-13 receptor antibody Dupilumab (SC)*
Mepolizumab (SC) Anti-IL-5 antibody Reslizumab (IV) Benralizumab (SC)* Losartan (PO) Angiotension II receptor subtype 1 antagonist
Budesonide slurry Pour budesonide into a small medicine cup and add sucrose. Mix until the consistency is thick (like honey). Alternatives to sucrose include regular sugar, alternate sugar substitute, maple syrup, honey or cornstarchbased thickener. Brush teeth afterwards. Do not eat or drink for 30 minutes after taking this medication.
AK002(IV)* Anti-Siglec-8 antibody *actively enrolling patients at the University of Pennsylvania Various elimination diets are used to treat adults with eosinophilic esophagitis. Unfortunately, the allergy-guided diet has limited success and has fallen largely out of favor compared to the more rigorous six food elimination diet (SFED). This diet eliminates the six most common food allergen groups including wheat, dairy, eggs, nuts, soy, and shellfish/ seafood. If patients on SFED achieve histologic remission, food groups are added back in 1-2 at a time, followed by an endoscopy with esophageal biopsies to evaluate for histologic response. There are also many variations of SFED as well as other emerging elimination diets including the 4-food elimination diet, 2-food elimination diet, 2-4-6 step-up diet, 1-3 step-up diet, and 1-4-8 step-up diet.
Endoscopic dilations are performed when needed, with the intent that long-term suppressive therapy will avoid the formation of recurrent strictures. Long-term therapy for EoE is critical and must be emphasized in our patient population. In a Swiss study of EoE patients who had been in deep remission for over 6 months, steroid therapy was stopped. The majority of patients (82%) experienced clinical relapse at 22 weeks and almost all (98%) patients experienced clinical relapse continued on page 16
A Critical Case of Eosinophilic Esophagitis continued from page 15
by the end of the study at 35 weeks. Similarly, a recent double-blind trial assigned EoE patients in deep remission to either budesonide orodispersible tablet (BOT) or placebo for up to 48 weeks. At end of treatment, 75% of patients on BOT were in persistent remission and only 4.4% of placebo-assigned patients were in remission (p <.001). The median time to relapse was 87 days in the placebo group. Multiple studies have shown that withdrawal of therapy leads to symptomatic and histologic relapse. In clinical practice we see this manifested as recurrent food impaction requiring emergent endoscopic therapy. Maintenance therapy is of utmost importance in patients with this chronic inflammatory and fibrostenotic disease. References 1. D ellon ES, Woosley JT, Arrington A, McGee SJ, Covington J, Moist SE, Gebhart JH, Tylicki AE, Shoyoye SO, Martin CF, Galanko JA, Baron JA, Shaheen NJ. Efficacy of Budesonide vs Fluticasone for Initial Treatment of Eosinophilic Esophagitis in a Randomized Controlled Trial. Gastroenterology. 2019 Jul;157(1):65-73.e5. 2. G reuter T, Bussmann C, Safroneeva E, Schoepfer AM, Biedermann L, Vavricka SR, Straumann A. Long-Term Treatment of Eosinophilic Esophagitis With Swallowed Topical Corticosteroids: Development and Evaluation of a Therapeutic Concept. Am J Gastroenterol. 2017 Oct;112(10):1527-1535.
3. G reuter T, Hirano I, Dellon ES. Emerging therapies for eosinophilic esophagitis. J Allergy Clin Immunol. 2020 Jan;1 45(1):38-45. 4. S traumann A, Lucendo AJ, Miehlke S, Vieth M, Schlag C, Biedermann L, Vaquero CS, Ciriza de los Rios C, Schmoecker C, Madisch A, Hruz P, Hayat J, von Arnim U, Bredenoord AJ, Schubert S, Mueller R, Greinwald R, Schoepfer A, Attwood S, for the International EOS-2 Study Group, Budesonide Orodispersible Tablets Maintain Remission in a Randomized, Placebo-Controlled Trial of Patients With Eosinophilic Esophagitis, Gastroenterology (2020).
Dr. Lynch is the Program Director of the University of Pennsylvania’s Advanced Esophageal Fellowship. This one-year fellowship trains budding esophagologists for a career in academic medicine via immersion in advanced esophageal testing as well as endoscopic therapies. For more information click here: https://www.pennmedicine. org/departments-and-centers/ department-of-medicine/divisions/ gastroenterology/education-andtraining/fellowship-programs/ advanced-esophagology-andswallowing-fellowship
Harshit Khara, MD was appointed the Director of Endoscopy at Geisinger Medical Center and promoted as Clinical Associate Professor of Medicine at Geisinger Commonwealth School of Medicine.
Richard Moses, DO has transitioned from practice and joined Eli Lily as a Medical Fellow in Global Medical Affairs supporting the development of Bio-Medicines in gastroenterology.
Carlisle Digestive Disease Associates has joined the US Digestive Health Partners with the goal of expanding access to high quality, low cost gastroenterology
Austin Chiang, MD & Neilanjan Nandi, MD were nominees in the Healio Disruptive Innovators: Social Media Influencers category.
“I have always believed that a good laugh was good for both the mental and physical digestion.” —Abraham Lincoln
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CME (GI) /EVENTS/2020-21 ACG VIRTUAL MEETING October 23-28, 2020
12th Annual Penn IBD Symposium Saturday, March 13th, 2021
DDW VIRTUAL MEETING May 21-23, 2021
Symposium provides cutting edge insights in IBD on facets ranging from maximizing drug therapy, optimal use of endoscopy & imaging to the latest updates on advanced surgical management for Crohn’s & Ulcerative Colitis patients. Register Here: https://upenn.cloud-cme.com/IBD2021
Mechanicsburg Physician Elected Vice President of the Pennsylvania Medical Society F. Wilson Jackson, MD, a gastroenterologist from Mechanicsburg, was elected by a statewide group of physicians Saturday to serve as vice president of the Pennsylvania Medical Society (PAMED). After 1-year terms as vice president and president-elect, Dr. Jackson will become PAMED President in January 2023. He will be the first physician from Cumberland or Dauphin counties to serve as PAMED President in nearly 40 years. Saturday’s election took place during PAMED’s annual meeting, which was held virtually because of concerns about coronavirus. Dr. Jackson has served in several leadership roles with PAMED, most recently as vice chair of its board of trustees. He has also been chair of PAMED’s finance committee and a trustee representing specialty physicians. A central Pennsylvania native, Dr. Jackson followed his father into medicine. In 1999, Dr. Jackson joined and eventually took over his father’s solo gastroenterology practice. Under Dr. Jackson’s leadership, what is now known as Jackson Siegelbaum Gastroenterology has grown to eight physicians and five advanced providers. Despite competitive consolidation in the medical delivery systems in the Harrisburg area, the practice and its associated ambulatory endoscopy center remain independent, serving patients in the greater Harrisburg area now for two generations. “I am looking forward to advocating on behalf of the 41,000 physicians in our commonwealth and, by extension, the patients under their care” Dr. Jackson said.
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