Nutrition, in full.

PEG remains the standard for durable enteral access in patients unable to swallow safely or meet nutritional needs orally, placed by the pull (Gauderer-Ponsky) technique, and ASGE 2024 now suggests PEG over IR-guided gastrostomy for initial placement in normal foregut anatomy. A single prophylactic IV dose of a beta-lactam antibiotic (e.g., cefazolin) is given before placement. Post-procedure bowel rest is no longer recommended: feeding may start within 3-4 hours of uncomplicated placement (ESGE 2021, strong/high-quality; ASGE 2024, strong/moderate), medications may be given immediately, and routine gastric residual volume checks are not indicated. Buried bumper prophylaxis is daily site care with DAILY inward tube mobilization and a loose external bumper kept 1-2 cm from the abdominal wall (ESGE 2021), not weekly rotation. Antiplatelet agents, including dual antiplatelet therapy, need not be routinely withheld for PEG; anticoagulant management is individualized by multidisciplinary discussion of bleeding versus thrombotic risk. In malignant dysphagia, either transoral pull PEG or direct (introducer) PEG is acceptable with counseling about implantation metastasis and periodic site examination. Device selection among PEG, PEG-J, DPEJ, surgical gastrostomy, and parenteral nutrition remains multidisciplinary, and a goals-of-care discussion before placement, including avoiding routine PEG in advanced dementia in favor of careful hand feeding (AGA 2020 / Choosing Wisely), is unchanged.

PRIMARY, AGA 2022 (pharmacotherapy, the GI-society spine): Manage obesity as a chronic disease with lifestyle intervention as the foundation. In adults with BMI ≥30 kg/m², OR BMI ≥27 kg/m² with a weight-related complication, who have an inadequate response to lifestyle intervention alone, the AGA STRONGLY recommends ADDING long-term pharmacotherapy to (not replacing) continued lifestyle intervention. Among agents the AGA suggests semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate ER, and naltrexone-bupropion ER (all moderate-certainty evidence), and, as lower-certainty options, e.g., where cost is a barrier, phentermine and diethylpropion (low-certainty evidence); when prioritizing for greatest weight loss the panel favored semaglutide 2.4 mg. The AGA suggests AGAINST orlistat and made no recommendation on Gelesis100 (identified as a knowledge gap). Agent choice should be individualized to comorbidities, contraindications, patient preference, and cost/access. COMORBIDITY BRANCHES (attributed separately, NOT part of the AGA document): For obesity-associated MASH, AASLD Practice Guidance supports selecting patients with stage F2-F3 fibrosis by non-invasive tests (VCTE ~8-15 kPa, MRE 3.1-4.4 kPa, or ELF 9.2-10.5) rather than mandatory biopsy, and endorses resmetirom (thyroid hormone receptor-β agonist; FDA-approved March 2024) as the only currently approved pharmacotherapy for MASH (not indicated for MASH cirrhosis). For metabolic/bariatric surgery, the 2022 ASMBS/IFSO indications recommend surgery at BMI ≥35 kg/m² regardless of comorbidity and consideration at BMI 30-34.9 kg/m² with metabolic disease (lower Asian-population thresholds: offer surgery at BMI >27.5, clinical obesity from >25), with multidisciplinary pre-operative evaluation. Concurrently screen for and manage the GI/hepatology comorbidities of obesity (MASLD/MASH, GERD, cholelithiasis).