Well, now we have some time here to address anything that we may have missed. If our, if our panel here wouldn't mind putting on their cameras and joining us if they can. We can talk about anything and if you guys want to put any questions any other burning questions or concerns you have. We'd love to talk about that. I don't have a question but I have a comment. Okay. I see there are still 138 participants on this late in the day on a Saturday when I know people have parties and dinners planned and things like that so I'm just so appreciative that so many of the attendees would still be with us. Thank you. Thank you. Absolutely. It's a long two days to take all this information in in front of a screen so it's, I too very appreciative you guys have managed to hang with us today. Interesting. I know it's late in the day I do see a lot of thank yous coming through in the chat there. I see a lot of questions coming up questions how many attendees yesterday versus today I think they were pretty similar. I think so too. You know, yeah we had on we had at the height of the day 162. Maybe, maybe the same amount, maybe a little more. Yeah. Okay. Thanks. Yeah. There are still some questions in the queue, it looks like yes there are some questions coming through so let's see. What has your experience been so far with res defra. I guess I, I don't have actually a lot of experience using res defra yet. We've had some more financial or access barriers to getting it approved for some of our patients I don't know if there are others who have a longer better experience than I do with res defra. I'm going to put my ignorance on display and ask you to me what is that. That's what I was going to get into this for those that don't understand or don't don't know about res defra. Medication that was just approved, maybe about a year ago now for treatment of fatty liver disease or metabolic dysfunction associated steatotic liver disease. Specifically for those patients with stage two or three fibrosis. So it's not indicated for stage one fibrosis and it's not indicated for cirrhosis patients. My understanding is it has been shown to reduce inflammatory changes and potentially reverse the fibrosis by one stage. So stage three may, you may be able to pull them back to stage two. But that's kind of been my experience. The side effects are what you hear about more at least in my experience from the patients. They pretty routinely counsel them that they're going to have GI side effects, nausea, vomiting, diarrhea, usually for the first three to four weeks on the medication. Usually it does subside beyond that. But in terms of long-term follow-up, I know I have a couple of patients on it. I haven't really reached the long-term follow-up where they're getting their repeat scans yet to see if there's been a significant change. But more to come on that I guess from my perspective. Somebody did put in a comment there that needing to check thyroid function before starting. The way that it works is it interferes, I believe, or it affects one of the thyroid TSH receptors in the liver, subsistence to the liver. I don't know the exact pathophysiology as to how that affects the fatty liver changes. But the mechanism is through one of the TSH receptors. So then the idea there is that if you check the TSH while on that agent, it may not be an accurate reflection of what's going on. I believe so. Yep. In the medication, there's also some interactions with other medications. You have to be mindful if there's a cytochrome P450 interaction about holding other medications and making sure we're communicating with the cardiologist as well. Yes, great points. Here's one. What is the standard of care for rectally inserted foreign objects if they don't appear sharp? That's a good question. I have fortunately in my years have not had to have that experience with retrieval of foreign objects rectally. In terms of urgent or emergent, I would probably try to avoid using enemas or any other stimulants to allow it to pass. Again, probably depends on the size, the shape, the location that you have on imaging, what the risk is with regards to that. I know several of my partners have had to go in for retrieval for rectal objects. It also depends on if they are rectally retrievable, if they are still in the rectum on imaging, or if there are cases where they've migrated proximally where we do have to have our surgical colleagues involved. I don't know that there's real differences between the type of objects. Yes, Amit. Sorry, just jumping into Joe. The group has had experience with rectal foreign bodies over the years and you hit all the key points. I think the best clinical point I can give is, within reason, do what you can to try to determine the size, the shape, and the location of the foreign object, what it is. In some ways, there's maybe a limitation of what we can do with devices that we have available for retrieval, and then the size or type of object, and perhaps needing some deeper level of sedation or anesthesia for relaxation of the anal sphincter. I think your points are spot on. Are we seeing a lot of GLPs for weight loss to help fatty liver, and who's ordering them, GI, endo, PCP? That's a great question as well. I do not have any experience prescribing GLP1s for fatty liver as the primary indication. I don't know if others have. I believe that if it's not yet approved, they're close to approval for fatty liver. Specifically for weight loss, again, I have not had that direct experience. I don't think our practice has yet started to tackle that ourselves. We're referring primarily to PCPs and endocrine for that prescription and management. Looks like there's another question there with regards to alcoholic and metabolic dysfunction associated. In terms of diagnosing or differentiating between alcoholic and metabolic dysfunction associated fatty liver, I think it really depends on are you confident in how much of that is alcohol versus the other, or a combination of both. Quite frequently, we're seeing a combination of both. But if they have significant comorbidities with regards to metabolic syndrome, obesity, diabetes, and such, then you have fair confidence that there is a component of metabolic dysfunction associated fatty liver. I would consider those patients to be candidates for resdifra. I don't know if there's any contraindication I should be aware of, but I don't think so. What about for patients on chronic PPIs, who should own the DEXA scans? Do we see the GIs owning those or PCPs? We don't have any societal guidelines to help us say what we need to monitor on chronic PPIs. From a PPI standpoint, I don't follow what DEXA scans. In that case, probably primary care, if there's an indication to do that. John, there's one that kind of pertained to our talk yesterday. Do you have any guides or how would you help determine when to order specific liver lab tests in response to elevated LFTs? They list a lot of the autoimmune type workup. Yeah, let me take a look at that question. Yeah. Guides you would recommend to help determine that. Yeah, you know, that's a very, that's a broad swath that that question covers. And the straight answer is no, because it's the differential is broad. And the thing that's going to help you cone it in, kind of like our case demonstration, in my opinion, yesterday, Caitlin, is the clinical scenario, which I think we tried to demonstrate that in the case that we went over. Like, for example, in our case, we had a clue at the very beginning, which was that the patient had pruritus and that they had a history of ulcerative colitis. So that already focuses us in terms of our differential diagnosis with respect to the order of what's most likely and what's less likely, so that we're not ordering a whole battery of unnecessary and very expensive tests. I think we can be fooled sometimes because, you know, we're not the pathologist into believing that they're just blood tests or they're cheap and they aren't necessarily. And, you know, depending on which pathology service you use, you might order a panel of 21, but all those get billed out separately. And each one generates a three-digit charge. I mean, a lot of those are several hundred bucks a piece. So, you know, a liver panel and a couple of autoimmune markers can cost more than endoscopy with anesthesia. And I think it's very easy for us to forget that reality. So stewardship towards clinical care and how our resources are used, I think, really requires us as citizens of patients' resources that are used to preserve and improve their health, you know, to make sure that we're cost-efficient and cost-effective about how we treat patients. And how we conduct our workup. So, you know, in a nutshell, I would say, look at the clinical situation first. I know that there's a habit at some institutions to just order the whole battery of autoimmune markers. Order the whole battery of viral hepatitis serologies. But, I mean, you know, you can tell whether it's acute hepatitis A or acute hepatitis B and rarely acute hepatitis C or not. That patient we presented definitely isn't presenting with any of those things. So I think it's still being a provider, being an APP or a physician that's going to help you start to cone some of those things down. There are excellent references from all the GI and hepatology organizations and also hundreds of excellent summaries as to how to interpret these tests. But that's not the hard part of it. The really hard part of it is being a good clinician and practicing effectively and efficiently. And if the patient isn't acutely ill, then you have a little time to look at these and look at those. But in general, you know, if the patient has other autoimmune things going on like ours did, I think I would consider other autoimmune manifestations of your immune system not acting normally. Our patient already had ulcerative colitis, and so that their liver enzymes might be elevated because of some autoimmune condition is probably a good way to, that's a good thought process. Great. This is a broad one. Constipation was not addressed. Differences in laxatives with ophthalmotics versus fertility agents. I personally don't have a lot of, I work in patients, so I don't prescribe a lot of different types of laxatives typically. I don't know if anybody has a good summary that we could quickly address that. And I'm happy to chime in since our mic's already on. I'm not an expert in lower GI motility, but I've certainly seen my share of hundreds of patients with this very, very common problem. Again, look at your patient's profile. Are they a younger person? Are they an older person? Has it been going on for 10 or 20 years or is it something that just started? And are there other symptoms going on? We always want to make sure that we don't think that it's a patient at high risk for an obstruction due to a malignancy, right? Those patients tend to be older or have a family history that would be suggestive of that. Maybe an older individual who's never been screened for colorectal cancer. These are sorts of things that might make you actually start with a colonoscopy, which isn't always the right answer. And in younger people, it usually isn't. But if it's an older patient and the other things in the clinical history that I described fit, then you may want to make sure there isn't an obstructive etiology first. Otherwise, if you think it's run-of-the-mill, more of a functional constipation, i.e. a dysmotility, when it comes to treatment, I usually try to do things that are least likely to have side effects and are not too expensive. And to me, that's starting out with an osmotic agent, something that's not going to cause fluid and electrolyte shifts and is convenient to take. So a polyethylene glycol product. I start at a lower dose because I don't want to overshoot and give them diarrhea and make them unhappy. and I usually teach them how to self-titrate their way up. Maybe start with a generic peg for constipation product that's usually sitting on the shelf at the drugstore or the supermarket next to the brand name of Miralax or something else and tell them to start at either one dose a day or split it and take it twice a day so that it's kind of spread out and if that doesn't cut it after a week to take the dose up to twice that amount and see if that helps more and then I'd usually like to touch base with them either through tele or in person that is patient dependent and then see if I want to change agents or up titrate from there. I think that'd be a reasonable way to do it. Don't start with stimulant laxatives, start with something osmotic and something that's isosmotic that doesn't cause fluid shifts and as the guy who talked about colon prep in this course it harkens back to exactly the same thing. No fluid and electrolyte shifts but a good effect whether that's for cleaning out before a colonoscopy or if it is for treatment of constipation. It looks like Jill has kindly offered a very nice reference which is from a good friend and colleague of Sorrel and mine here at our own home institution. Yeah this is a great reference for the Mayo Clinic proceedings. I think the way I absolutely support Dr. Martin, your approach is so reasonable and sound. I always provide education for patients is that I'd like to start off with the over-the-counter products and then implement prescription medication to see if that helps with their symptoms and a lot of times patients don't want to take anything which is really interesting and then once they start taking the medication then they get better and then they stop it so that's a whole other conversation to work with the patients. So that's how I approach it and then walk through those different prescription medications that are available either the Linoleic Acid or Fluconatide and some insurance companies will actually want you to try Ameteaser or I'm blanking on the name right now but a lot of it is going to be payer specific of what they recommend first that you try before you can advance to another class of patient medications. Fabulous, thank you. Oh it's because the article is on chronic constipation so that's what it's that's why I referenced it the title didn't come through. Looks like Michelle was able to share that. Okay thank you. I'll take this I kind of addressed this at one point yesterday can you diagnose ischemic colitis by symptoms only or should you do a colonoscopy with biopsy? My practice is generally with regards to following the patient clinically if you have good you have typical symptoms they've got left-sided abdominal pain, diarrhea, rectal bleeding and maybe typical features on a CT scan those are patients that I wouldn't necessarily put through a sigmoidoscopy or colonoscopy for diagnosis. I generally reserve that for if they're not improving or if there is a diagnostic dilemma where you're considering ischemic colitis but there may be other features that make you want to consider inflammatory bowel disease as an alternative. But usually these patients you can treat just with those clinical those clinical pieces of information as well you don't need to do a sigmoidoscopy or colonoscopy for those biopsies. That's that's I think that's variable though I do have partners in my group who are more more inclined to do the flexible sigmoidoscopy to visualize the area in biopsy so that's part of the art of practicing. There's no clear guideline that I'm aware of one way or the other. I'll take the PPI one sorry to interrupt you. Perfect yeah go ahead. Yeah it's certainly a hot topic right so I know I tell patients the studies that was out there is really that maybe there may be association but no true cause and effect. Most of my patients are high risk so it's a little bit of an easier sell to take these PPIs but I just focus on what are the the other side of the spectrum what options do we have to treat can we use h2 blockers can we use lifestyle but there are people that don't want to take PPI because of that. That's such an important point isn't it I think patients many times don't have the perspective of well how many different options are available. The options are really limited especially when you can't get payment for the potassium pump inhibitors then you've you know you've basically got PPIs h2 RAs some antacids and some invasive procedures of various sorts that's it. It's not an infinite list of options so couching what's available in the context of the patient's symptoms I think will end up driving it because if your GERD symptoms are bad and they're unaddressed then that may actually cause psychological problems of a different sort from dementia which might be worse. There's a couple questions on here both are pertinent basically when we for specifically for the APPs on the panel when we started in GI what resources conferences books did we find most helpful in learning and where else might we might new APPs be looking for more resources in the GI world. I'll start by saying that our committee is does have a dedicated page on the ASGE website and we aim to put out a course I'm sorry not a course a case study every month that's relevant that's quick that's digestible we're working on putting out some new videos as well that come out on a regular basis so that's a good place to start always professional committees typically will have good learning resources who else do we have on with us here Jill and and Sorrel. Yeah it was certainly a big big learning curve initially I can't think of anything specific other than having some sort of basic materials to kind of review for depending on where you going to work in but otherwise it's it's pretty much a steep learning curve and learn on the job as you go with good support and orientation period. I think in another excellent primary primary resource is is reviewing up to date and then doing your own literature search for updated guidelines because we're our practice we're judged on guidelines that are provided and us practicing to that standard of care so up to date if you have a clinical query of a question you know review the most recent guidelines and that's the time that you you approach that with your collaborating physician to ask them questions and say when's the last time came into this scenario what are your thoughts. I've also been loving open evidence I don't know if anybody out there's been using that but it's a new AI tool and it's it's geared specifically towards providers you actually have to give your NPI number to use it and it answers your questions like a chat GBT would but then it lists all the references really nicely so you can go and actually click on the papers that it's referring to and I've been a really big fan of using that and I think that's a great clinical tool that you can use every day whether you're experienced or brand new. I'm not an APP but I'm a physician educator and from my perspective I think many of the resources that our physician fellows go to are equally great for APPs and APP fellows. There are APP fellowships in GI just to make a pitch for our program even. How many do you take a year? They take two a year. Two a year so you know that's a one-year program and you know whether the fellows are APP fellows or physician fellows many of them seek out the syllabi from the various postgraduate courses like for example at DDW you can get the transcripts from those and also board review courses many of those are actually online and those syllabi can be shared amongst the group as well and many of those also have great multiple choice questions. If you're someone who learns well by reading a case and then answering a multiple choice question those oftentimes will have explanations for the right answers and the wrong answers and those can be great study aids and of course reading up on every patient condition that you see that's new that is definitely something that sticks better than just general reading is hey I just saw a patient with this condition I'm going to go read about that right away and like Jill said something that's online like UpToDate is an easy way to do that. Now if you don't work at a big institution where you have free access to UpToDate that's a pretty expensive app to access but that's not the only resource by any stretch of the imagination. Remember that Google searches are free and PubMed is free online and also the guidelines and reviews that are posted on the asge.org website those are all free for you to read and download and so forth so you know this is a wonderful age where all these options many of them which are free can be accessed on any PC or right on your phone. Thank you thanks. I think Jill added something as well to the chat. I did I added the reference for the Mayo Clinic board the gastroenterology board review so I was going to mention that as soon as Dr. Martin started to speak about that we've actually purchased that before with our new GI orientees and then we go through the different chapters together go through some of the different questions and and it allows for conversations because you don't always know the type of cases that that they've seen you know throughout the orientation so this is a way to stimulate that conversation and our orientations we don't tend to go to be as disease specific. I know the University of Rochester has their program set up so this allows us to have a more organic conversation to talk about the different cases that they see throughout the orientation. Thank you thanks for sharing that. It looks like we just have one one question left uh left over regarding uh different stool tests so when to specifically order different stool tests is it okay to just do a culture versus checking for c-diff, cyclospora, giardia, cryptosporidium, ova and parasite etc or do you or if you're doing a culture culture do you typically just check everything? Yeah I'll go ahead and answer that so if you're looking at a potential infectious process then you you want to look at a culture along with c-difficile so even have your index of suspicion be low because it is community acquired depending on if you're looking at acute versus chronic as I mentioned the guidelines say that when you're looking at patients with rolling out functional bowel disorder or IBS with diarrhea predominant recommendations are to check for giardia you know as well as celiac disease. So I've started to add we have a combination stool test that'll add giardia and cryptosporidium so I add the combination together so I I think at the minimum you want to look at culture c-diff and giardia you know when you once you get that patient's history you know did this acute diarrhea that turned into chronic did this start after they went out to a restaurant and they had sushi do you consider then adding on that ova and parasite whether you decide to do one or three as the patient had international travel you know it's amazing how how much our patients are traveling and you don't realize that they just got off you know from traveling last week from from Japan so as I mentioned getting that meticulous history will drive your medical decision making. Thanks Jo. So I don't see a ton of other questions that we haven't addressed. I'd like to thank everyone for attending from the bottom of my heart this has been really fun putting together. Definitely want to make sure we thank Michelle for helping that she's indispensable to this course our speakers and then Sam for the AV the AV help as well. Yes I'll echo those sentiments. Thank you to all of our speakers. Thank you to Sam. Thank you to Michelle for organizing and thank you Caitlin for all the hard work you put into organizing this this event these last two days have been excellent and thank you to all the speakers. Congratulations on a wonderful course Dr. Tawani and Caitlin. Our thanks to the faculty and to you our participants. As a reminder each of you will have ongoing access to the recordings from the course via G.I. Leap our learning management system when they're available in roughly two to three weeks. The course evaluation for today is now live in G.I. Leap and once you complete it you can download your certificate. If you need assistance logging into G.I. Leap please email practicemanagement at asge.org and someone can assist you. Also I want you to look out for information on ASG's upcoming virtual course for APPs it's on EOE and that'll be held virtually October 3rd. So be on the lookout for that. As many of the faculty stated we do have some resources ongoing resources we do an ASGE APP case of the month as well as we're going to be starting a question of the month video snippet. So I will send you information on that as well. I will send you information on that as well. This concludes the ASGE Annual G.I. Advanced Practice Provider course. We hope the knowledge gained here will be valuable to your practice. Thank you again for joining us and have a great rest of your weekend. Thanks everyone. Thank you. Great job everybody.

gastroenterology

Resmetirom

fatty liver

GLP1

chronic PPIs

constipation treatment

advanced practice providers