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.

Manage short bowel syndrome / intestinal failure with a multidisciplinary IF team using a three-phase nutrition strategy: initiate TPN with IV hydration and electrolyte replacement in the acute hypersecretory phase, progressively advance enteral feeds and wean PN during the 1-2 year adaptation phase, then maintain an oral diet with selective PN as needed. In carefully selected PN-dependent patients, and only when prescribed by clinicians experienced in SBS/IF management (generally once the adaptation phase is complete), consider the GLP-2 analog teduglutide (0.05 mg/kg/day subcutaneously) to promote intestinal adaptation and reduce PN volume, but only after baseline screening to exclude neoplasia and contraindications (colonoscopy with removal of any polyps when colon and/or rectum is present, and assessment for active or recent [within 5 years] gastrointestinal, hepatobiliary, or pancreatic malignancy, which contraindicate its use) and with mandatory ongoing safety monitoring (surveillance colonoscopy after 1-2 years then every 5 years, plus vigilance for colorectal/GI polyps and neoplasia, intestinal obstruction, biliary/gallbladder and pancreatic disease, and fluid overload); add antimotility agents (loperamide, then codeine/opium tincture) for high-output stoma, and provide lifelong nutrient surveillance/supplementation (notably B12) plus monitoring for CRBSI, IFALD, oxalate stones, and refeeding syndrome.

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.