Paul Farkas
@gastropaul.bsky.social
Retired after 44 years of clinical practice but still addicted to GI. Lecturer. Literature nerd. Lakes, canoeing, kayaking are also happy places.
G-POEM for Gastroparesis
😟Refractory GP hard to treat, miserable for pts
🤔Meta analysis of 23 studies, 871 pts s/p POEMs
Observational study
👍Long term benefit (5 years) in 81%. Predicting success was idiopathic, shorter duration, higher baseline severity
#GIsky #IMSky #Medsky
Poetry anyone?
😟Refractory GP hard to treat, miserable for pts
🤔Meta analysis of 23 studies, 871 pts s/p POEMs
Observational study
👍Long term benefit (5 years) in 81%. Predicting success was idiopathic, shorter duration, higher baseline severity
#GIsky #IMSky #Medsky
Poetry anyone?
December 15, 2025 at 2:15 PM
CDiff going to or coming from the dogs? (and cats)
🤔73yo recur Cdiff Rx'd with Van, Fidax, FMT, bezlotoxumab
👍Dogs + for Cdiff, dogs placed, no more Cdiff
🤔Studies have shown cats and dogs can harbor CDiff
🤔Consider in tough cases
(With apologies to dog/cat owners)
#GIsky #IMsky #Medsky
🤔73yo recur Cdiff Rx'd with Van, Fidax, FMT, bezlotoxumab
👍Dogs + for Cdiff, dogs placed, no more Cdiff
🤔Studies have shown cats and dogs can harbor CDiff
🤔Consider in tough cases
(With apologies to dog/cat owners)
#GIsky #IMsky #Medsky
December 14, 2025 at 2:06 PM
My name is Paul and I am a coffee addict
🤔Review suggesting regular consumption reduces progression of liver disease, slowing progression to cirrhosis and HCC. (also reviews mechanisms)
👍Of benefit in pts with ALD, Viral hep, MASLD, and Cirrhosis
😀Can I have another cup??
#GIsky #IMSky #medsky
🤔Review suggesting regular consumption reduces progression of liver disease, slowing progression to cirrhosis and HCC. (also reviews mechanisms)
👍Of benefit in pts with ALD, Viral hep, MASLD, and Cirrhosis
😀Can I have another cup??
#GIsky #IMSky #medsky
December 7, 2025 at 2:23 PM
The saga continues: Resmetirom for MASH
🤔1 yr extension Maestro-NAFLD ( Medscape, presented at ACG scientific meeting)
👍Child A MASH at 1 year res of clinically sig portal hypertension in 20%, year 2 28%
👍50% with 25% ⬇️ liver stiff
👍35% from F4 to F3
Not too shabby
#GISky #IMsky #MedSky
🤔1 yr extension Maestro-NAFLD ( Medscape, presented at ACG scientific meeting)
👍Child A MASH at 1 year res of clinically sig portal hypertension in 20%, year 2 28%
👍50% with 25% ⬇️ liver stiff
👍35% from F4 to F3
Not too shabby
#GISky #IMsky #MedSky
December 5, 2025 at 7:48 PM
ETOH Hepatitis...protocol for Steroids?
🤔Ed referring to article suggesting ⬇️90 day mortality with tapered steroid
🤔One concern, always, infections
👍Useful flow sheet, mostly suggesting tapering prednisolone (If Lille <.45) from 40 mg/day by 10 mg/week for 3 weeks.
#IMsky #Medsky #GIsky
🤔Ed referring to article suggesting ⬇️90 day mortality with tapered steroid
🤔One concern, always, infections
👍Useful flow sheet, mostly suggesting tapering prednisolone (If Lille <.45) from 40 mg/day by 10 mg/week for 3 weeks.
#IMsky #Medsky #GIsky
December 3, 2025 at 9:08 PM
You want me to do what with that coffee?
😟Coffee enemas, colon cleanses, irrigation, detox drinks?
🤔Review GI and Hep news...
No evid benefit.
NIH: can be unsafe and falsely advertised
🤔One detox product has tadalafil
Risks: change biome, perf, colitis, interact with meds
#imsky #medsky
😟Coffee enemas, colon cleanses, irrigation, detox drinks?
🤔Review GI and Hep news...
No evid benefit.
NIH: can be unsafe and falsely advertised
🤔One detox product has tadalafil
Risks: change biome, perf, colitis, interact with meds
#imsky #medsky
a man with a surprised look on his face has the word wow written above him
ALT: a man with a surprised look on his face has the word wow written above him
media.tenor.com
December 2, 2025 at 8:14 PM
Reposted by Paul Farkas
updated the acute liver failure chapter
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
November 28, 2025 at 1:51 PM
updated the acute liver failure chapter
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
biggest change is increasing support for early CRRT to remove NH3 (to reduce elevated intracranial pressure)
now rec'd for clinically overt encephalopathy (Grade 2-4)
if admitting to ICU for ALF & encephalopathy, just dialyze
emcrit.org/ibcc/alf/ #EMIMCC
The truth and nothing but the truth...PEth
🤔Phosphatidylethanol (PEth) detects ETOH exposure up to 12 days after a binge, up to 4 weeks with heavy use
🤔Reported ETOH consumption may not be accurate
🤔Useful to help sort out MASLD; MetALD, ALD
See flow sheets below
#IMsky #GIsky #Medsky
🤔Phosphatidylethanol (PEth) detects ETOH exposure up to 12 days after a binge, up to 4 weeks with heavy use
🤔Reported ETOH consumption may not be accurate
🤔Useful to help sort out MASLD; MetALD, ALD
See flow sheets below
#IMsky #GIsky #Medsky
November 28, 2025 at 7:21 PM
Reposted by Paul Farkas
Patient with cirrhosis and INR of 3 needs a procedure
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
November 27, 2025 at 1:06 PM
Patient with cirrhosis and INR of 3 needs a procedure
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
Please step away from the FFP
EVERY guideline & article agrees that FFP shouldn't be given for pre-procedure coag optimization (even high-risk procedures)
Plt & fibrinogen are more controversial
Discussion emcrit.org/ibcc/cirrhos... #EMIMCC
GLP-1's...GI safety better than we thought??
🤔🔼 risk of cholelithiasis by 2cases/1,000
🔼 risk of reflux by 4/1,000
😀No apparent increase in cholecystitis, cholangitis, pancreatitis, obstruction, ileus
There ain't no perfect drug, but this one has real benefits
#IMsky #Medsky #GIsky
🤔🔼 risk of cholelithiasis by 2cases/1,000
🔼 risk of reflux by 4/1,000
😀No apparent increase in cholecystitis, cholangitis, pancreatitis, obstruction, ileus
There ain't no perfect drug, but this one has real benefits
#IMsky #Medsky #GIsky
November 27, 2025 at 1:22 PM
A reminder: Early CCY after ERCP
🤔Although guidelines rec: Early CCY (same admission), only done about half the time
🤔Study: ACG Scientific Meeting
😒Biliary comps in 23% delayed, vs 0.8% early ccy
🔑: Risk NOT mitigated by sphincterotomy or stenting.
Carpe Diem:
#gisky #medsky #imsky
🤔Although guidelines rec: Early CCY (same admission), only done about half the time
🤔Study: ACG Scientific Meeting
😒Biliary comps in 23% delayed, vs 0.8% early ccy
🔑: Risk NOT mitigated by sphincterotomy or stenting.
Carpe Diem:
#gisky #medsky #imsky
November 25, 2025 at 11:29 PM
Save the kidneys! Outpt AKI in cirrhosis
🤔Defined AKI with labs up to 1 yr apart
🤔12% developed AKI in 3 year
🤔🔼 with ascites, HCC, ETOH,
👍Need to avoid/modify precpt causes: diuretics, GI losses ie with lactulose, nephrotoxins
Review of AKi emcrit.org/ibcc/aki/#top
#gisky #medsky #imsky
🤔Defined AKI with labs up to 1 yr apart
🤔12% developed AKI in 3 year
🤔🔼 with ascites, HCC, ETOH,
👍Need to avoid/modify precpt causes: diuretics, GI losses ie with lactulose, nephrotoxins
Review of AKi emcrit.org/ibcc/aki/#top
#gisky #medsky #imsky
November 23, 2025 at 1:19 PM
Save the kidneys! Outpt AKI in cirrhosis
🤔Defined AKI with labs up to 1 yr apart
🤔12% developed AKI in 3 year
🤔🔼 with ascites, HCC, ETOH,
👍Need to avoid/modify precpt causes: diuretics, GI losses ie with lactulose, nephrotoxins
Review of AKi emcrit.org/ibcc/aki/#top
#gisky #medsky #imsky
🤔Defined AKI with labs up to 1 yr apart
🤔12% developed AKI in 3 year
🤔🔼 with ascites, HCC, ETOH,
👍Need to avoid/modify precpt causes: diuretics, GI losses ie with lactulose, nephrotoxins
Review of AKi emcrit.org/ibcc/aki/#top
#gisky #medsky #imsky
Hepatic Encephalopathy with healthy liver?
🤔Pt with cognitive impairment, - neuro workup. Discharged with diagnosis of dementia, focal seizures.
👍CT lge intrahepatic portovenous shunt; Ammonia 🔼
😀Improved with PSE Rx, ultimately treated in IR
Sort of a congenital TIPS
#IMsky #GIsky #Medsky
🤔Pt with cognitive impairment, - neuro workup. Discharged with diagnosis of dementia, focal seizures.
👍CT lge intrahepatic portovenous shunt; Ammonia 🔼
😀Improved with PSE Rx, ultimately treated in IR
Sort of a congenital TIPS
#IMsky #GIsky #Medsky
November 20, 2025 at 10:38 PM
AUD Rx: Much room for improvement
🤔We Rx AUD in only <5% eligible patients!
👍Study (not ideal) showing meds tolerated in severe ALD (no adverse liver issues)
👍(Naltrexone, acamprosate) were major ones
Message: We should all be more aggressive in trying to treat AUD.
🤔We Rx AUD in only <5% eligible patients!
👍Study (not ideal) showing meds tolerated in severe ALD (no adverse liver issues)
👍(Naltrexone, acamprosate) were major ones
Message: We should all be more aggressive in trying to treat AUD.
November 17, 2025 at 1:11 PM
AUD Rx: Much room for improvement
🤔We Rx AUD in only <5% eligible patients!
👍Study (not ideal) showing meds tolerated in severe ALD (no adverse liver issues)
👍(Naltrexone, acamprosate) were major ones
Message: We should all be more aggressive in trying to treat AUD.
🤔We Rx AUD in only <5% eligible patients!
👍Study (not ideal) showing meds tolerated in severe ALD (no adverse liver issues)
👍(Naltrexone, acamprosate) were major ones
Message: We should all be more aggressive in trying to treat AUD.
Priming the Pump: Colon Prep
🤔Maeda et al AmJGastro: Linaclotide before low vol prep ➡️ better prep in "High-Risk" pts than senna
🤔Ed: suggests better tol than stimulant laxative
👍Personally found works great with large and small vol preps: especially with 🔼risk poor prep
#IMsky #GIsky #medsky
🤔Maeda et al AmJGastro: Linaclotide before low vol prep ➡️ better prep in "High-Risk" pts than senna
🤔Ed: suggests better tol than stimulant laxative
👍Personally found works great with large and small vol preps: especially with 🔼risk poor prep
#IMsky #GIsky #medsky
November 16, 2025 at 12:05 PM
Review of MASLD (Adults) in JAMA
👍Re-emphasizing value/use of the FIB-4 and follow up with elastography
👍Useful summary of therapeutic options: diet, exercise, no ETOH, considerations of Bariatric Surgery, semaglutide (GLP-1), and Resmetirom for moderate-advanced fibrosis
#IMSky #Medsky #GIsky
👍Re-emphasizing value/use of the FIB-4 and follow up with elastography
👍Useful summary of therapeutic options: diet, exercise, no ETOH, considerations of Bariatric Surgery, semaglutide (GLP-1), and Resmetirom for moderate-advanced fibrosis
#IMSky #Medsky #GIsky
November 15, 2025 at 5:58 PM
Reposted by Paul Farkas
my pressor strategy hepatorenal syndrome in the ICU:
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
Midodrine and octreotide should not be first line therapy for HRS-AKI #kidneywk
November 6, 2025 at 5:45 PM
my pressor strategy hepatorenal syndrome in the ICU:
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
#1) start with NE gtt for immediate BP target acquisition
#2) once pt is improving, use PO midodrine to accelerate weaning off NE
midodrine can be helpful to help liberate patients from ICU
but as initial therapy, midodrine is some weak sauce
Arguments with Neph. Rectal NSAIDS and AKI
🤔Rectal NSAIDS decrease ERCP Pancreatitis
🤔Study with stage 1-3b CKD >7,000 pts each group
👍NO difference in aki and group with NSAIDS less post-ERCP pancreatitis. (Abstract at ACG)
Once got trashed for doing this.😟
#GIsky #IMsky #MEDsky
🤔Rectal NSAIDS decrease ERCP Pancreatitis
🤔Study with stage 1-3b CKD >7,000 pts each group
👍NO difference in aki and group with NSAIDS less post-ERCP pancreatitis. (Abstract at ACG)
Once got trashed for doing this.😟
#GIsky #IMsky #MEDsky
November 8, 2025 at 11:33 PM
Fear is the path to the Dark Side.... Embrace the FIB-4
👍We need to be aggressive in r/o advanced fibrosis especially in fatty liver. FIB available from common labs, MD Calc etc to quick calculation.
👍If high risk (see below) or FIB 🔼 elastography.
Crucial with Rx available
#IMsky #MEDsky
👍We need to be aggressive in r/o advanced fibrosis especially in fatty liver. FIB available from common labs, MD Calc etc to quick calculation.
👍If high risk (see below) or FIB 🔼 elastography.
Crucial with Rx available
#IMsky #MEDsky
November 5, 2025 at 7:54 PM
