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Paul Farkas @gastropaul.bsky.social · 13h

Beware of Fake foreign bodies...in the gut

🤔Case of ?FB at EGJ Was Lanthanum Carbonate

Radio-opaque meds: CHIPES (Chloral hydrate, heavy metals, iron, phenothiazides, slow release meds) Another take on CHIPES from Gu et al Korean J Spine 9/15 attached

History is 🔑

#IMsky #GIsky #medsky

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Paul Farkas @gastropaul.bsky.social · 4d

Unusual case in Gastro:

16yo: obstipation, 🔼 lfts, ileus, 🔼calcium

Athlete on Ayurvedic supplements (Bhasmas) from incineration of metals and minerals,and Shilajit resin from mountain rocks

All available on Amazon

Lead level 🔼

Resolved with chelation

#IMsky #Medsky #GIsky

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Paul Farkas @gastropaul.bsky.social · 6d

Delta Hep: 3 articles/one editorial CinGastro&Hep

🤔Only testing 4.9% meeting AASLD Criteria

🤔HDV associated with markedly 🔼 HCC

🤔Can use PAGE-8 score (or FIB-4) to predict HCC
(On Medscape Reach-B score)

Identifying D important with new meds coming out, and interferon

#IMsky #GISky #Medsky

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Paul Farkas @gastropaul.bsky.social · 8d

Acute Variceal Bleeding in cirrhosis...are we there yet?

😀No...not quite, but encouraging that in past two decades recurrent bleeding from 19.4% to 11.8%, Bleeding related mortality 23.6% to 18.3%.

🤔There is always room for improvement

#IMsky #GISKY #Medsky

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Paul Farkas @gastropaul.bsky.social · 8d

Scan shows Fatty Pancreas. What is that anyway?

🤔Often considered incedentaloma

🤔Marin-Serrano et al in Pancreas shows associated with cardiometabolic risk factors.

🤔Associated with hepatic steatosis.

Maybe we should consider this an Early Warning Sign, and delve in.

#GIsky #IMSky #Medsky

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Paul Farkas @gastropaul.bsky.social · 12d

If all else fails, re-examine the patient

🤔Tet Toe posted a case on Doximity

🤔Have seen it before as well

Pt with severe abdominal pain, negative workup
Re-examined ... Shingles

Can present with abdominal pain before rash.
One pt I saw was on her way to OR

#GIsky #IMsky #medsky

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Paul Farkas @gastropaul.bsky.social · 14d

Canadian GI Guidelines re non ulcer UGI Bleed (endorsed by ASGE)

🤔Bleed from NPL Rec Hemostatic spray over conventional endo therapy

🤔Mallory Weiss with non bleeding visible vessels or clots rec no hemostatic Rx

🤔GAVE: Preferred band ligation over APC, prefer APC to RFA.

#GIsky #imsky

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Paul Farkas @gastropaul.bsky.social · 16d

Hot Potato...Who treats Obesity?

PCP? GI? Endocrine??

Medscape Commentary: Dr. Muratore Opines that GI should treat
So many GI issues MASLD, MASH, GERD

Training pathways do exist, as well as specific courses

Often this responsibility ignored or passed off

Thoughts?

#GIsky #IMSky #Medsky

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Paul Farkas @gastropaul.bsky.social · 19d

Agree. Still a puzzle. Blood tests? Stool tests? Colon??? As someone said perhaps the best test is the one that gets done.

Paul Farkas @gastropaul.bsky.social · 19d

CRC Screening...remains a quandry

🤔Multitarget Stool DNA (Cologuard) at U.Pitt

😟Only 54.7% completed the test

Previous studies 87%-72% of positives undergo Colonoscopy
(Also disappointing)

Best approach to CRC screening remains a puzzle

#IMsky #GIsky #Medsky

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Paul Farkas @gastropaul.bsky.social · 20d

Refractory Ascites: The ALFA pump...

👍RA tough to treat. Paracenteses, TIPS, Txp options.

🤔Many not suitable for TIPS, Txp.

ALFA pumps ascites into bladder. Still issues including renal, and its place still uncertain

Recent study encouraging

Anyone with experience?

#Medsky #GIsky #IMSky

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Paul Farkas @gastropaul.bsky.social · 23d

I always get antibiotics for my colds

Survey: 54% unaware of C. Diff risk with ABs

Continue efforts to limit AB's.

Need to educate on risk of C. Diff, and warn that if they get diarrhea on antibiotics to let us know

Pt's may not call till critically ill

ICU's busy enough

#IMsky #Medsky

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Paul Farkas @gastropaul.bsky.social · 23d

First step would be diuretics/treating as ascites.
If fails can consider periodic pleural taps.
Ultimately (if the patient is a suitable candidate) usually will come down to a TIPS.
Transplant GREAT if pt qualifies and you can get it.

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Paul Farkas @gastropaul.bsky.social · 24d

Large R Pleural Effusion

Cirrhosis but no evid of Portal Hypertension
Hx CHF (stable)

Alb gradient 1.6 🔼
+Tc-99m peritoneal cavity scintigraphy

Hepatic Hydrothorax can occur in absence of ascites, but also in absence of other signs of portal hypertension.

Rx challenging

#GIsky #IMsky #Medsky

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Paul Farkas @gastropaul.bsky.social · 26d

Celiac: Beware of borderline negative TTG

311 pts with Nml IgA levels
39 borderline negative TTG
Of borderline negative TTG 36% Dx'd with CD (79% in those with borderline neg TTG and +EmA)

Low + and borderline - TTG frequently with dx of CD

Need to follow up on these patients.

#IMsky #Medsky

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Paul Farkas @gastropaul.bsky.social · 27d

Ideally primary docs will screen. FIB 4 simple and on med calculators. Most pts probably will not need meds. And primary generally more facile with GLP 1s. As to next level meds will be up to primary. If question of cirrhosis to specialist. Probably all depends on comfort level of primary

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Paul Farkas @gastropaul.bsky.social · Sep 25

Screen high risk pts for MASLD, and TREAT

👍Pts with T2DM, Obesity with 1 met risk factor, abnl LFT's..check FIB4 If abnl elastography

👍If F2-F3 consider treating.

👍All need review diet, exercise, weight loss, ETOH; consider bariatrics.

Reviewed before approval GLP-1

#Medsky #IMsky #GIsky

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Paul Farkas @gastropaul.bsky.social · Sep 23

Delta is ready when you are

🤔Guidelines exist for testing for D in chronic B hepatitis

🤔Delta associated with worse prognosis

In safety-net pop only 6.1% tested, and 15.7% positive

A reminder to think of Delta and test for it.

#medsky #IMsky #gisky

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Paul Farkas @gastropaul.bsky.social · Sep 21

2nd Victim Syndrome

🤔Distress we experience after being involved in medical error, adverse event or outcome. Can be severe

🤔Can effect all health workers

🤔Well defined stages

🤔We need wider recognition of SVS, and improved support for ourselves and our colleagues

#GIsky #IMsky #Medsky

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Paul Farkas @gastropaul.bsky.social · Sep 19

Nice guideline on Gastroporesis

🤔A tough subject, often frustrating for us and pts

👍Role of early small-particle, low-fat, low residue diet
👍Use of erythro with drug holidays
👍Low risk of TD with metaclopramide, but ?drug holidays.
👍Slowly escalating metaclopramide dose

#GIsky #Medsky #IMsky

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Paul Farkas @gastropaul.bsky.social · Sep 18

😮You are entering an evidence free zone (sort of)
Diet for IBD

Good review

🤔Some evidence for enteral feeds in peds CD

🤔Maybe better with combination of Enteral and CDED (CD
Exclusion Diet).

🤔Med Diet preferred over CHO Specific Diet. FODMAP may help with symptoms.

#Medsky #GISky #IMSky

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Paul Farkas @gastropaul.bsky.social · Sep 16

A gentle reminder: Check patients with Cryptogenic Cirrhosis for Celiac Disease

🤔Up to 1/20 pts with CC had Celiac

👍Liver status improved with Gluten Free Diet

Celiac Disease is everywhere.

#IMsky #GIsky #medsky

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Paul Farkas @gastropaul.bsky.social · Sep 15

THE DREADED Cannabis Hyperemesis Syndrome

😮CHS: Challenging, frustrating, endless

😟A consult you do not want to get

Nice review of CHS
Some meds to add to our list...

Topical Capsaicin cream
Droperidol
Olanzapine

Follow the yellow brick road:
emcrit.org/ibcc/cannabis/

#GIsky #IMsky #Medsky

Cannabis use & complications

CONTENTS clinical syndromes Basics Epidemiology of cannabis use Acute intoxication Acute cannabis intoxication Synthetic cannabinoid intoxication Subacute psychiatric syndromes Cannabis-induced anxiet...

emcrit.org

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Paul Farkas @gastropaul.bsky.social · Sep 14

Dr. House Warned Us

🤔Pts not always honest

🤔Phosphatidylethanol correlate with ETOH past 1-4 weeks

🤔Pts with MASLD, MetALD, ALD

39% pts in ALD groups underestimated consumption
11% in non ALD groups

Overall 39% MASLD also met ALD criteria

Should we be checking this?

#IMSky #Medsky #GIsky

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Paul Farkas @gastropaul.bsky.social · Sep 11

Say it Ain't So...Ocaliva for PBC withdrawn
(and another one bites the dust)

Just wanted to share this, as one who had placed patients with PBC (Primary Biliary Cholangitis) on Ocaliva (obeticholic acid)

Fortunately other options available/in pipeline.

#GIsky #Medsky #IMsky

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