The week in GI, filtered to what is worth knowing.

Treat all subtypes with education, soluble fiber, a trial of low-FODMAP diet, and CBT/gut-directed hypnotherapy for refractory disease, then layer subtype-specific pharmacotherapy (secretagogues for IBS-C; loperamide, rifaximin, or bile acid sequestrant for IBS-D) and neuromodulators for pain.

pylori infection with urea breath test, monoclonal stool antigen, or endoscopic biopsy (never serology) before treating, and treat all patients with confirmed active infection who meet an indication (PUD, MALT lymphoma, atrophic gastritis/GIM, test-and-treat dyspepsia, unexplained IDA after bidirectional endoscopy, ITP). First-line is a 14-day regimen, bismuth quadruple preferred, or rifabutin triple (Talicia) or vonoprazan-based therapy, while empiric clarithromycin triple is no longer recommended in the US absent documented susceptibility. Mandatory test of cure by UBT or stool antigen confirms eradication after therapy.

Escalate to a second-line agent (obeticholic acid, seladelpar, elafibranor, or a fibrate) when response is inadequate, guided by a Child-Pugh/portal-hypertension hard gate, and manage pruritus with a stepwise ladder (cholestyramine → rifampin → sertraline → naltrexone). Refer for transplant evaluation for decompensation, refractory pruritus, or rising bilirubin.

A positive stool-based test requires diagnostic colonoscopy, and stool tests should not be ordered for patients who would decline follow-up colonoscopy. Generally stop at age 75 with individualized decisions for ages 76-85 and no screening beyond 85.

A positive stool-based test requires diagnostic colonoscopy, and stool tests should not be ordered for patients who would decline follow-up colonoscopy. Generally stop at age 75 with individualized decisions for ages 76-85 and no screening beyond 85.

Treat by disease extent and severity: mild-moderate proctitis/left-sided/extensive disease with topical and oral 5-ASA (escalating to budesonide-MMX), and moderate-severe disease with advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAK inhibitors, S1P modulators, or anti-IL-23p19). Apply treat-to-target (STRIDE-II) reassessment, screen for acute severe UC by Truelove-Witts criteria for inpatient IV-steroid management, and perform CRC surveillance colonoscopy starting 8 years from symptom onset.

Confirm complete resection and adequate prep before applying an interval, and use site-check/tumor-board pathways for piecemeal resection and malignant (T1) polyps. Refer for genetic evaluation when Lynch, FAP/AFAP/MAP, or serrated polyposis syndrome criteria are met.

Treat by disease extent and severity: mild-moderate proctitis/left-sided/extensive disease with topical and oral 5-ASA (escalating to budesonide-MMX), and moderate-severe disease with advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAK inhibitors, S1P modulators, or anti-IL-23p19). Apply treat-to-target (STRIDE-II) reassessment, screen for acute severe UC by Truelove-Witts criteria for inpatient IV-steroid management, and perform CRC surveillance colonoscopy starting 8 years from symptom onset.

Treat by disease extent and severity: mild-moderate proctitis/left-sided/extensive disease with topical and oral 5-ASA (escalating to budesonide-MMX), and moderate-severe disease with advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAK inhibitors, S1P modulators, or anti-IL-23p19). Apply treat-to-target (STRIDE-II) reassessment, screen for acute severe UC by Truelove-Witts criteria for inpatient IV-steroid management, and perform CRC surveillance colonoscopy starting 8 years from symptom onset.

For decompensated cirrhosis (Child B/C or any history of decompensation), use Epclusa ± weight-based ribavirin with concurrent transplant evaluation. Cure is defined by SVR12, with lifelong HCC surveillance continued in cirrhotics.

Surgical resection (enucleation, distal pancreatectomy, or Whipple) is preferred and curative for localized G1/G2 well-differentiated disease, with active surveillance an option for small low-grade non-functional lesions. For metastatic well-differentiated disease, first-line somatostatin analogs (octreotide LAR or lanreotide) are followed by targeted therapy (everolimus, sunitinib), PRRT (177Lu-DOTATATE), or CAPTEM chemotherapy.

A positive stool-based test requires diagnostic colonoscopy, and stool tests should not be ordered for patients who would decline follow-up colonoscopy. Generally stop at age 75 with individualized decisions for ages 76-85 and no screening beyond 85.

Offer subtype-matched definitive treatment, pneumatic dilation, laparoscopic Heller myotomy with partial fundoplication, or POEM, with POEM preferred for Type III; reserve botulinum toxin injection and pharmacologic agents for surgically unfit or bridge use. After treatment, monitor response with Eckardt score and timed barium, manage post-POEM reflux with lifelong PPI plus Barrett's surveillance, and consider esophageal SCC surveillance EGD after 10 years of disease.

Treat by disease extent and severity: mild-moderate proctitis/left-sided/extensive disease with topical and oral 5-ASA (escalating to budesonide-MMX), and moderate-severe disease with advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAK inhibitors, S1P modulators, or anti-IL-23p19). Apply treat-to-target (STRIDE-II) reassessment, screen for acute severe UC by Truelove-Witts criteria for inpatient IV-steroid management, and perform CRC surveillance colonoscopy starting 8 years from symptom onset.

Manage benign anastomotic and chronic-pancreatitis strictures with a fully-covered self-expanding metal stent for 6-12 months (multiple plastic stents when FCSEMS is contraindicated, hepaticojejunostomy if refractory), and treat cholangitis with an obstructed segment as a drainage emergency since every obstructed sector requires decompression. Direct etiology-specific care for Strasberg bile-duct injuries, post-transplant strictures, IgG4-sclerosing cholangitis, Mirizzi syndrome, and choledochal cysts.

Treat by disease extent and severity: mild-moderate proctitis/left-sided/extensive disease with topical and oral 5-ASA (escalating to budesonide-MMX), and moderate-severe disease with advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAK inhibitors, S1P modulators, or anti-IL-23p19). Apply treat-to-target (STRIDE-II) reassessment, screen for acute severe UC by Truelove-Witts criteria for inpatient IV-steroid management, and perform CRC surveillance colonoscopy starting 8 years from symptom onset.

Treat all patients with a lifelong strict gluten-free diet with registered dietitian referral, obtain baseline nutritional labs and DEXA, and complete the asplenia-equivalent vaccination schedule. Monitor response by symptoms and TTG-IgA trend, targeting normalization within 1-2 years, and work up non-response by frequency starting with ongoing gluten exposure.

Treat all subtypes with education, soluble fiber, a trial of low-FODMAP diet, and CBT/gut-directed hypnotherapy for refractory disease, then layer subtype-specific pharmacotherapy (secretagogues for IBS-C; loperamide, rifaximin, or bile acid sequestrant for IBS-D) and neuromodulators for pain.

Treat all subtypes with education, soluble fiber, a trial of low-FODMAP diet, and CBT/gut-directed hypnotherapy for refractory disease, then layer subtype-specific pharmacotherapy (secretagogues for IBS-C; loperamide, rifaximin, or bile acid sequestrant for IBS-D) and neuromodulators for pain.

Treat with a first-line agent as monotherapy, high-dose PPI, swallowed topical steroid, or dietary elimination × 8-12 weeks, then re-biopsy to confirm histologic remission (<15 eos/HPF), escalating to dupilumab for refractory disease and reserving dilation for persistent strictures after medical therapy. Continue effective therapy indefinitely given 50-90% relapse off treatment.

pylori test-of-cure, manage functional dyspepsia by eradicating H. pylori if positive and giving a PPI (4-8 weeks, dosed 30-60 min before meals); for persistent symptoms use gut neuromodulators, mirtazapine 15 mg QHS is first-line for PDS with weight loss, a TCA (amitriptyline 10-50 mg QHS, or nortriptyline in the elderly) for PPI-refractory EPS, buspirone 10 mg TID as a fundic relaxant, and prokinetics (prucalopride or short-course metoclopramide) for PDS. Initial evaluation follows ACG/CAG 2017: test-and-treat H. pylori in patients under 60 without alarm features, and EGD for age ≥60, alarm features, or high gastric-cancer-risk groups. Add psychological therapies (CBT, gut-directed hypnotherapy) and lifestyle measures.

Trial a low-FODMAP diet first-often more effective than gluten-free because wheat fructans are frequently the true culprit-reserving a strict gluten-free trial for partial responders, with dietitian supervision and nutritional adequacy planning. Confirm reproducibility on gluten reintroduction.

Without alarm features, treat typical symptoms with an 8-week empiric PPI trial dosed 30-60 minutes before the first meal plus lifestyle modification; confirm GERD objectively (Lyon Consensus 2.0 AET, or erosive esophagitis LA-B/C/D or Barrett's on EGD) in refractory or atypical cases, and require EGD, off-PPI pH-impedance, and high-resolution manometry before any anti-reflux surgery or endoscopic therapy.

Determine resectability at a multidisciplinary tumor board: resectable disease gets surgery (Whipple for head, distal pancreatectomy for body/tail) with adjuvant mFOLFIRINOX, borderline-resectable/locally advanced gets neoadjuvant chemotherapy ± chemoradiation, and metastatic disease gets first-line systemic therapy (mFOLFIRINOX, gemcitabine + nab-paclitaxel, or NALIRIFOX). Integrate supportive care including biliary drainage, PERT, pain control, VTE prophylaxis, and early palliative care.

A mandatory digital rectal exam is performed at the initial visit, and anorectal manometry with balloon expulsion testing should be done early when a defecation disorder is suspected, directing those patients to biofeedback rather than drug escalation.

Triage by risk: high-risk stigmata, main-duct/mixed IPMN go directly to surgical resection, worrisome features get EUS-FNA first for multidisciplinary decision, and low-risk BD-IPMN enters size-stratified surveillance; all presumed MCNs are resected regardless of size or features. Post-resection remnant pancreas requires lifelong surveillance, and family history/germline variants trigger the CAPS high-risk pathway.