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Paul Farkas @gastropaul.bsky.social · 1d

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 · 4d

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 · 4d

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 · 5d

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 · 8d

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 · 8d

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 · 8d

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 · 10d

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 · 12d

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 · 14d

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 · 16d

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 · 18d

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 · 20d

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 · 21d

😮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 · 23d

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 · 24d

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 · 25d

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 · 28d

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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Paul Farkas @gastropaul.bsky.social · 29d

Viral Infections with injection drug use (JAMA brief review)

🔼HIV, Hep B & C
👍Remember Delta and test in B
👍32%of Hep A pts with hx injection drug use

Reminders to test, frequently
To vaccinate A/B
Pre/Post proph for HIV

#medsky #IMsky #GIsky

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Paul Farkas @gastropaul.bsky.social · Sep 9

Review of MASLD/MASH from UK

🤔1/4 young adults with fatty liver Most not aware

🤔🔼 rates of advanced liver disease predicted

🤔Rx being developed/approved: GLP 1; Thyroid hormone B receptor agonists

👍Weight loss, no ETOH

Message: Look for it, evaluate it, and treat it

#Medsky #IMsky #GIsky

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Paul Farkas @gastropaul.bsky.social · Sep 8

988 A great resource (In US)

🤔In GI a substantial number of pts with depression.
Increased suicide rate (x11) in pts with chronic abdominal pain

But across all fields/specialties.

988 Sort of like 911, but for help with mental health crises
Available 24/7

#GIsky #IMsky #Medsky

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Reposted by Paul Farkas

josh farkas 💊 @pulmcrit.bsky.social · Sep 5

Percutaneous cholecystostomy drain for acute cholecystitis:

The evidence is VERY weak

If someone is deteriorating with refractory septic shock, then drain it

If the patient is responding to medical tx, then there is no need to place a tube.... 🧵 #1/3

pubmed.ncbi.nlm.nih.gov/40900585/ #EMIMCC

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Paul Farkas @gastropaul.bsky.social · Sep 7

😮HELP: Patient with Cirrhosis needs Surgery

👍Vocal Penn Score Calculator online

🙂ACG guidelines

If MELD 6-9 very low risk
pro and anti thrombotic paths changed, usual labs not accurate
Focus on nutrition, Rx liver, ?Pre op txp eval, viscoelastic test

Worth reviewing

#medsky #IMsky #gisky

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Paul Farkas @gastropaul.bsky.social · Sep 5

I'm Back...

🤔Pt with fatigue, sore throat, fever, rash and Bili 16, ALT 2850

🫢RPR 1:256

Syphilis Hepatitis

Incidence of Syph up 80% from '18-'22; We will be seeing more of this. (Though liver manifestations still rare)

To include in differential diagnosis

#IMsky #GISky #MedSky

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Paul Farkas @gastropaul.bsky.social · Sep 4

Captain Cook warned us

🤔pt with bruising, severe anemia, pulm hypertension

🤔Ultimately noted to have perifollicular macules, gingival changes

👍Scurvy, restrictive diet

quotes 5.9% in US with Vit C deficiency
Quick recovery with C

Reminds us to ask about pts diets

#IMsky #GIsky #medsky

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