GiT Updates and More

“test-and-treat” strategy is recommended to ensure eradication of the H.Pylori bacteria in ; Ø All patients with active PUD; Ø Patients with dyspepsia under the age of 60; Ø Patients initiating long-term, non-steroidal, anti-inflammatory drugs; Ø Patients with unexplained iron deficiency anemia Ø Adults with idiopathic thrombocytopenic purpura

New AGA clinical practice update on sclerosing mesenteritis—a rare, often silent condition affecting the bowel mesentery.

Cardiofundal gastric varices bleed🩸less commonly than esophageal varices or GOV1 gastric varices BUT the management can be challenging!

palliative care for cirrhosis 1. A strategy to support patients 2. Interventions proven to relieve symptoms 3. Tools proven to guide decisions 4. Complements the goals of transplant palliative care is not a referral. It is a strategy. A way of caring

Post-Polypectomy Recommendations (AGA, Gupta et al. 2020)

Antimitochondrial antibodies (AMA) are primarily associated with Primary Biliary Cholangitis (PBC), but they can also be present in other conditions. Here are some causes of positive AMA results outside of PBC 1. Drug-Induced Liver Injury: Certain medications, such as isoniazid, methyldopa, and chlorpromazine, may induce AMA production. 2. Autoimmune Hepatitis (AIH): While not as common, some patients with autoimmune hepatitis may also test positive for AMA alongside other autoantibodies such as antinuclear antibodies (ANA) or smooth muscle antibodies (SMA). 3. Cholestatic Liver Diseases: Conditions like primary sclerosing cholangitis (PSC) can sometimes show AMA positivity, although it is more characteristic of PBC. 4. Systemic Lupus Erythematosus (SLE): Some SLE patients may have positive AMA, particularly in cases with hepatic involvement. 5. Rheumatoid Arthritis (RA): Although not a classic association, certain RA patients may exhibit AMA. 6. Non-Alcoholic Fatty Liver Disease (NAFLD): There have been reports of non-alcoholic steatohepatitis (NASH) cases with positive AMA. 7. HCV Infection: Chronic hepatitis C virus infection may be associated with the presence of AMA in some patients. 8. Other Autoimmune Conditions: Various autoimmune disorders such as Sjögren’s syndrome can display AMA positivity. 9. Infectious Hepatitis: Some viral hepatitis infections, especially those showing significant liver damage, may have AMA in the serum. 10. Metabolic Syndrome: Certain metabolic diseases can manifest with AMA positivity in conjunction with liver involvement.

✴️For Endoscopist and Gastroenterologist Key Challenges in D1 Scope Stability: Anatomical constraints: The fixed retroperitoneal position and angulation of D1/D2 make maneuvering difficult. Bleeding obscures vision, making fine manipulation harder. Peristalsis and patient movement worsen instability. ✅ Techniques to Improve Scope Stability and Hemostasis in D1: 1. Positioning Adjustments: Patient position: Try left lateral, then switch to supine or right lateral if needed — this can improve gravity drainage and scope torque. Head-up tilt (reverse Trendelenburg) can reduce duodenal distention and help orient the lesion better. 2. Scope Handling & Maneuvers: Minimize torqueing from the esophagus/stomach: Once you're in the duodenum, use tip deflection more than body torque. Anchor the scope tip by hooking around the pylorus gently — this "pyloric hook" technique gives more control. Use short, controlled insufflation to avoid overdistension, which destabilizes your view. 3. Device Assistance: Cap-assisted endoscopy (transparent distal attachment) helps stabilize the view and can help compress the ulcer. Water immersion or water jet: Displaces blood, improves visualization, and stabilizes by reducing luminal collapse. Multibending or variable-stiffness scopes (if available) allow better control in difficult duodenal anatomy. 4. Choice of Hemostasis Tools: Clips: Pre-loading clips and practicing clip deployment in a forward-viewing position are crucial. Consider rotatable or repositionable clips (e.g., SureClip, Instinct). Injection + clip combo: Use diluted adrenaline to control active bleeding first — then apply a clip. Thermal methods (coaptive coagulation with hemostatic forceps) can be effective, but require even more stable positioning. Hemostatic powders (e.g., Hemospray) can be a rescue or temporizing measure when instability prevents mechanical therapy. 5. Simulation & Training: Practice scope stabilization techniques in models or simulators focused on the duodenum — helps develop muscle memory. Review videos of expert endoscopists managing D1 bleeds (e.g., from ASGE or ESGE teaching libraries). Attend live courses or hands-on workshops focused on hemostasis — many include difficult D1 cases. 🧠 Mental Model During Procedure: Stabilize first, even if it takes time. Visualize the bleeding point with irrigation or water-jet. Control with injection, then apply definitive therapy. Don’t hesitate to reposition the patient or scope multiple times — it’s normal. 🛠 Advanced Tools You Might Explore: Dual-channel endoscope: Enables one channel for irrigation or suction, and the other for clip or device. Overtubes: Rarely used, but in select cases can improve stability. Endoscopic suturing or over-the-scope clips (OTSC): For refractory cases or rebleeds.

Crohn’s Disease The Rutgeerts classification is a scoring system used to predict the likelihood of Crohn’s disease recurrence after ileocolic resection (surgical removal of the diseased segment of the ileum and part of the colon). It evaluates the presence and severity of endoscopic lesions at the neoterminal ileum (the part of the small intestine just above the anastomosis) during a postoperative ileocolonoscopy, typically performed 6–12 months after surgery. Rutgeerts Score: Score Description Recurrence Risk Treatment Implication i0 No lesions Very low Observation only i1 ≤5 aphthous lesions Low Observation or minimal treatment i2 >5 aphthous lesions with normal mucosa between them or lesions at the ileocolonic anastomosis Moderate Consider initiating or escalating therapy i3 Diffuse aphthous ileitis with diffusely inflamed mucosa High Initiate or escalate maintenance therapy (e.g., immunosuppressants or biologics) i4 Diffuse inflammation with large ulcers, nodules, or narrowing Very high Aggressive treatment (biologics ± immunomodulators) ⸻ Treatment Based on Rutgeerts Score i0 or i1 (Minimal to No Recurrence): • Treatment: No immediate need for maintenance therapy. • Monitoring: Regular follow-up with symptoms and biomarkers (CRP, fecal calprotectin). • Surveillance: Repeat colonoscopy in 1–2 years or as clinically indicated. i2 (Mild to Moderate Recurrence): • Treatment options: • Consider starting a thiopurine (azathioprine or 6-mercaptopurine). • Alternatively, low-dose biologics (e.g., anti-TNF agents) if higher risk. • Some may monitor closely without immediate treatment if asymptomatic. • Risk stratification: Important based on clinical factors (e.g., smoking, prior aggressive disease). i3 or i4 (Moderate to Severe Recurrence): • Treatment: • Initiate or switch to biologic therapy (anti-TNF like infliximab, adalimumab; or newer options like ustekinumab or vedolizumab). • Consider combination therapy (biologic + immunomodulator). • Close monitoring with CRP, fecal calprotectin, imaging, or repeat colonoscopy. ⸻ Additional Considerations: • Smoking cessation is strongly recommended, as smoking increases the risk of recurrence. • Therapeutic drug monitoring may be useful if biologics are used. • Individualization is key—treatment should be based on risk factors, symptoms, and patient preference in addition to endoscopic findings.

Updated Treatment of Chronic Hepatitis C (2025) Chronic hepatitis C (HCV) is now highly curable (>95% success rate) with direct-acting antivirals (DAAs). The choice of regimen depends on HCV genotype, liver disease severity, prior treatment, and comorbidities (e.g., CKD). Recommended DAA Regimens 1. First-Line Therapies (Pan-Genotypic – Preferred) - Glecaprevir/Pibrentasvir (GLE/PIB (Mavyret®) - Indications: All genotypes (1-6), treatment-naïve or experienced, compensated cirrhosis or non-cirrhotic. - Duration: - No cirrhosis: 8 weeks - Compensated cirrhosis: 12 weeks - Sofosbuvir/Velpatasvir (SOF/VEL – Epclusa®) - Indications: All genotypes (1-6), including decompensated cirrhosis (with ribavirin). - Duration: - No cirrhosis: 12 weeks - Compensated cirrhosis: 12 weeks - Decompensated cirrhosis (Child-Pugh B/C) : SOF/VEL + ribavirin × 12 weeks - Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX – Vosevi®) - Indications: Salvage therapy for prior DAA failure (all genotypes). - Duration : 12 weeks (with/without cirrhosis). 2. Alternative Genotype-Specific Options - Elbasvir/Grazoprevir (EBR/GZR – Zepatier®) - Indications: GT1, GT4 (check for NS5A resistance-associated substitutions (RASs) in GT1a). - Duration: 12-16 weeks (add ribavirin if RAS+). --- Special Populations - Decompensated Cirrhosis (Child-Pugh B/C): - SOF/VEL + ribavirin × 12 weeks (avoid protease inhibitors like GLE/PIB or VOX). - Chronic Kidney Disease (CKD): - GLE/PIB (safe in all CKD stages, including dialysis). - Avoid SOF-based regimens if eGFR <30 (risk of metabolite accumulation). - HIV/HCV Coinfection : Same regimens as HCV mono-infection (check drug interactions with ART). - Post-Liver Transplant: SOF/VEL ± ribavirin × 12 weeks (monitor for drug interactions). --- Key Considerations - Pretreatment Testing: - HCV RNA (quantitative), genotype (if using non-pan-genotypic regimens). - Fibrosis assessment (elastography/FibroScan®, APRI, FIB-4). - RAS testing for GT1a if using EBR/GZR. - Ribavirin Use : - Added in decompensated cirrhosis or prior DAA failure (dose: 1000–1200 mg/day, weight-based). - Contraindications: - Avoid protease inhibitors (GLE, VOX) in decompensated cirrhosis (risk of liver failure). --- Monitoring & Follow-Up - SVR12: Confirm cure (undetectable HCV RNA 12 weeks post-treatment). - Long-term : - Screen for HCC (if cirrhosis) with ultrasound q6 months. - Reinfection risk in high-risk groups (PWID, MSM). (Vosevi reserved for DAA-experienced patients.) --- References - AASLD/IDSA HCV Guidance (2024). - EASL Recommendations (2023).

✴️when night sweats are a red flag underlying medical issue 1. Serious infections, as endocarditis, Brucellosis, pyogenic abscess and tuberculosis 2. obstructive sleep apnea 3. Hyperthyroidism 4. Carcinoid tumors 5. Lymphoma 6. Hypoglycemia medications Cardiopulmonary causes 1. Nocturnal bronchial asthma 2. Acute LVF + pulmonary congestion 3. Acute MI in DM may be silent