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.
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
Alpha-Gal Syndrome...nothing to do with Wonder Woman or T Swift😟
🤔Probably missing most of this, often IBS symptoms
🤔Allergy to alpha 1,3 galactose, brought on by lone star tic bite
🤔Symptoms 2-8 hr after ingesting animal products incl milk
🤔No treatment; IgE testing available
#IMsky #Medsky
🤔Probably missing most of this, often IBS symptoms
🤔Allergy to alpha 1,3 galactose, brought on by lone star tic bite
🤔Symptoms 2-8 hr after ingesting animal products incl milk
🤔No treatment; IgE testing available
#IMsky #Medsky
November 2, 2025 at 1:34 PM
Ascites...always a controversial issue
🤔AGA Clinical Practice update on Ascites, volume overload and hyponatremia
🤔Not to restrict water till Na <125
😟Still uncertain re-role of Vaptans???
🤔Pts with refractory ascites/hydrothorax consider liver txp referral
#IMsky #medsky #GIsky
🤔AGA Clinical Practice update on Ascites, volume overload and hyponatremia
🤔Not to restrict water till Na <125
😟Still uncertain re-role of Vaptans???
🤔Pts with refractory ascites/hydrothorax consider liver txp referral
#IMsky #medsky #GIsky
October 31, 2025 at 11:31 PM
Is Shorter better? Esophageal variceal bleed
due to portal hypertension
🤔Always wondered about value of 5 days of Octreotide after successfully banding varices
😀Study: 1 vs 5 days Rx: No difference in 5 day re-bleeding or 6 week re bleeding and all cause mortality
#GIsky #IMsky #medsky
due to portal hypertension
🤔Always wondered about value of 5 days of Octreotide after successfully banding varices
😀Study: 1 vs 5 days Rx: No difference in 5 day re-bleeding or 6 week re bleeding and all cause mortality
#GIsky #IMsky #medsky
October 28, 2025 at 11:08 AM
Gastroporesis thoughts, AmJGastro 10/25 Liu etal
🤔Yearly testing for nut deficiencies: ie D; B12, Folate, Iron
🤔?Daily MVI
🤔Dietary suggestions (below)
🤔Prucalopride ?1mg especially if constipated
🤔They support gastric electrical stimulation
🤔Some differential Dx thoughts
#GIsky #IMSky #MedSky
🤔Yearly testing for nut deficiencies: ie D; B12, Folate, Iron
🤔?Daily MVI
🤔Dietary suggestions (below)
🤔Prucalopride ?1mg especially if constipated
🤔They support gastric electrical stimulation
🤔Some differential Dx thoughts
#GIsky #IMSky #MedSky
October 27, 2025 at 11:08 AM
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
🤔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
October 24, 2025 at 9:57 PM
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
🤔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
October 18, 2025 at 1:00 PM
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
🤔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
October 16, 2025 at 4:49 PM
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
🤔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
October 13, 2025 at 11:07 AM