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

Confirm ulcerative colitis with endoscopy showing continuous colonic inflammation from the rectum plus histology, after excluding infection with two-step CDI testing. Treat mild-moderate disease with 5-ASA by route and extent (suppository for proctitis, enema for left-sided, oral plus rectal for extensive); if 5-ASA fails, treat as moderate-to-severe rather than stepping up gradually. Position advanced therapy by EFFICACY TIER, not by an anti-TNF-first rule. Advanced-therapy-naive, higher efficacy: infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab; intermediate: golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab; lower: adalimumab. PREVIOUSLY TNF-EXPOSED, higher efficacy: tofacitinib, upadacitinib, ustekinumab; lower: adalimumab, vedolizumab, ozanimod, etrasimod - S1P modulators are weakest in exactly this group. Do not cycle within the anti-TNF class after primary non-response; switch mechanism. Apply treat-to-target (STRIDE-II) to endoscopic improvement (MES 0-1). Screen for acute severe UC by Truelove-Witts and admit for IV steroids. Begin CRC surveillance 8-10 years after DIAGNOSIS for extensive or left-sided disease; isolated proctitis follows average-risk screening.

In patients with classic GERD symptoms (heartburn, regurgitation) and no alarm symptoms, give an 8-week trial of empiric PPI ONCE DAILY before a meal (strong, moderate evidence); administer PPI 30-60 minutes before a meal rather than at bedtime (strong, moderate). Endoscopy is the FIRST test in patients presenting with dysphagia or other alarm symptoms, the guideline names weight loss and GI bleeding, and also in patients with multiple risk factors for Barrett's esophagus (strong, low). If classic symptoms respond to the 8-week trial, attempt to discontinue the PPI (conditional, low); for patients without erosive esophagitis or Barrett's whose symptoms resolved, an attempt at discontinuation should be made; patients requiring maintenance should take the lowest effective dose. If symptoms do not respond adequately to the 8-week trial, or return on discontinuation, perform diagnostic endoscopy, ideally after PPIs are stopped for 2-4 weeks (strong, low). Where GERD is suspected but unclear and endoscopy shows no objective evidence, perform reflux monitoring OFF therapy to establish the diagnosis (strong, low); conversely, do NOT perform off-therapy reflux monitoring solely as a diagnostic test in patients already known to have LA grade C or D esophagitis or long-segment Barrett's, because the diagnosis is already established (strong, low). In refractory GERD, optimize PPI therapy first (strong, moderate); then pH monitoring OFF PPIs if GERD was not previously established by pH study, long-segment Barrett's, or LA grade C/D esophagitis, versus impedance-pH ON PPIs where GERD is already established but symptoms persist on twice-daily PPI (both conditional, low). Before antireflux surgery or endoscopic therapy, HRM is recommended to rule out achalasia and absent contractility, with provocative testing (e.g., multiple rapid swallows) to identify contractile reserve in ineffective esophageal motility; on-therapy reflux monitoring is suggested before intervention in patients with prior objective GERD findings who remain symptomatic. Antireflux surgery by an experienced surgeon is an option for patients with OBJECTIVE evidence of GERD, with severe esophagitis (LA C/D), large hiatal hernia, or persistent troublesome symptoms benefiting most; TIF is suggested only for troublesome regurgitation or heartburn in patients who do not wish to undergo antireflux surgery and who are WITHOUT severe esophagitis (LA C/D) or hiatal hernia >2 cm. For extraesophageal symptoms WITHOUT typical GERD symptoms, perform reflux testing BEFORE starting PPI therapy (strong, moderate); with concomitant typical symptoms, consider twice-daily PPI for 8-12 weeks before further testing (conditional, low). Lifestyle: weight loss in overweight/obese patients (strong, moderate); avoid meals within 2-3 hours of bedtime, avoid tobacco, avoid trigger foods, and elevate the head of the bed for nighttime symptoms (all conditional, low).

After polyp removal, assign the next colonoscopy surveillance interval using USMSTF 2020 based on polyp number, size, and histology (e.g., 1-2 tubular adenomas <10 mm 7-10 years; 3-4 tubular adenomas <10 mm 3-5 years; 5-10 tubular adenomas <10 mm, any adenoma ≥10 mm, or adenoma with tubulovillous/villous histology or high-grade dysplasia 3 years; >10 adenomas 1 year with polyposis evaluation; and for serrated polyps, 1-2 sessile serrated lesions <10 mm 5-10 years, 3-4 sessile serrated lesions <10 mm or a hyperplastic polyp ≥10 mm 3-5 years, and a sessile serrated lesion ≥10 mm or with dysplasia or a traditional serrated adenoma 3 years), and apply the shortest interval indicated when findings are mixed. 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.

Diagnosis: use a positive diagnostic strategy based on Rome IV criteria rather than a strategy of exclusion (strong for cost-effectiveness, high quality; consensus for time-to-therapy), and categorize by IBS subtype (consensus). In patients with IBS and diarrhea symptoms: check celiac serology (strong, moderate) and, in those WITHOUT alarm features, fecal calprotectin (or fecal lactoferrin) plus CRP to rule out IBD (strong; moderate quality for CRP/calprotectin, very low for lactoferrin). Recommend AGAINST routine stool testing for enteric pathogens (conditional, low) and AGAINST routine colonoscopy in patients younger than 45 without warning signs (conditional, low). Anorectal physiology testing only when symptoms suggest a pelvic floor disorder and/or for refractory constipation not responding to standard medical therapy (consensus). Treatment, all subtypes: soluble, not insoluble, fiber (strong, moderate); a LIMITED trial of a low-FODMAP diet (conditional, very low); gut-directed psychotherapies for global symptoms (conditional, very low); TCAs for global symptoms (strong, moderate); peppermint suggested (conditional, low); antispasmodics for abdominal pain (conditional, low); AGAINST probiotics (conditional, very low), AGAINST fecal transplant (strong, very low). IBS-C: chloride channel activators (strong, moderate) and guanylate cyclase activators (strong, high); AGAINST PEG products for global IBS-C symptoms (conditional, low); tegaserod reserved for women younger than 65 with ≤1 cardiovascular risk factor who have not adequately responded to secretagogues (strong/conditional, low). IBS-D: rifaximin (strong, moderate); alosetron only for women with severe IBS-D who have failed conventional therapy (conditional, low); mixed opioid agonists/antagonists, i.e. eluxadoline (conditional, moderate); AGAINST bile acid sequestrants (conditional, very low).