I'd like to introduce our next speaker. Dr. Shreya Patel graduated from Dartmouth and went on to complete her MD at University of Arizona and an MPH at Hopkins. She completed residency in internal medicine with a focus on global health at Mass General before going on to her GI fellowship at UCSF where she stayed on faculty. She's currently an assistant professor at UCSF based at the Zuckerberg San Francisco General Hospital where she serves as director of quality improvement and innovation as well as the assistant program director for the GI fellowship program. Her focus is on cancer screening efforts in underserved populations utilizing EMR-based registries, automation, and low-cost technology outreach. Shreya's gonna speak to us about guidelines that are gonna change her practice this year. Thank you so much. So I wanna thank ASGE and obviously Dr. Law and Dr. Shergill for having me. The goal of this talk is to really bring us all up to date. So guidelines are changing so quickly across so many different fields within GI. As you can see from some of the things that I'm interested in, I really care about providing equitable care to all of our GI patients. So there's a lot of literature in cardiology where you're gonna get different care if you get seen in Texas versus in New York, and I never wanna see that in GI. So I wanna think that all of us across the country can provide the same level of evidence-based care and we can do that by following our society guidelines. So we're gonna take a really whirlwind tour today. I'm trying to really highlight guidelines that represent a pretty big change, so not gonna go through absolutely everything. Within general GI, we're gonna talk about the new lower GI bleak guidelines. We're gonna touch on the anticoagulation, antiplatelet management, touch on constipation. Gonna touch quickly on colon cancer screening age. We're gonna leave GI societies for a second and talk about diverticulitis management as well as C. diff management. Then we're gonna swing over to endoscopy-based guidelines. We're gonna talk about some perioperative management of the newer diabetes and weight loss agents that are gonna affect how you perform endoscopy. We're then gonna talk about ways to improve our ADR and some of the evidence behind it, and then go back to our polyp surveillance guidelines that are now a few years old. And then, as I like to tell my fellows, I am not a hepatologist, but in that light, we're actually gonna bring us all up to date on the new nomenclature, so we can all at least speak the same language. And then I'm gonna touch on a few guidelines around palliative care and the bovinos. So let's dive right in. So these are new guidelines that came out this year on the management of lower GI bleeding from the ACG. So to go through a few of the major points, so they do recommend now using a scoring system to risk stratify patients. And really, the goal here is not to get into the diciness of who needs to be on the floor versus tele versus the unit. It's actually more to identify the very low-risk patients who are gonna be completely safe to be followed as an outpatient or to be discharged from the hospital early. And then the other guidance that they recommend is that you really can consider deferring a colonoscopy completely if someone has had a high-quality exam within the past year. So the recurrent diverticular bleed that stops by itself and is self-limited can potentially avoid a second colonoscopy. They do list out some specific thresholds for resuscitation. I think these are all ones that we're pretty familiar with from the upper GI bleed literature. The one that I'll point out is that they do specifically comment that it is safe to do endoscopic therapy with an INR of 2.5 or lower. So that shouldn't really preclude us from going in. And as we'll touch on in future slides, there's no real role for reversal of anticoagulation unless someone's having kind of a very severe hemorrhage or life-threatening bleed. This third point is kind of the major change here. So we're really moving away from urgent colonoscopy. There's really good data. It mostly comes out of Japan from the Code Blue trial, but urgent colonoscopy does not improve re-bleeding rates or mortality. And because of this, we're moving more towards non-invasive diagnostics for lower GI bleeding. So CTA is gonna really be your initial test of choice, especially in the setting of significant or severe hemorrhage. If that's positive, if it is available to you, an IR approach would be the next recommended tool. If not, and if you do have expertise in treating lower GI bleeds and hemorrhage management, then certainly an endoscopic approach is appropriate as well. And then I really like this fourth point because I actually tell my fellows, this is probably where you're gonna have the most impact. So as cardiology has moved away from putting every single person we know on a baby aspirin, people haven't really caught up with that. And so we'll still see lots of patients coming in with recurrent diverticular bleeds over and over again. And the one thing we can do rather than clipping that single tick that's bleeding is to actually discontinue their aspirin, especially if they're on it for primary prophylaxis or to encourage limited NSAID use. So the table or the flowchart on the right is just gonna go through exactly what we just talked about, where if someone is having severe hematochezia, you're kind of following the left side of that diagram and going towards CTA as kind of your first step. So moving on to anticoagulation and antiplatelet management. So this came out last year. It was a joint guidance from ACG and the Canadian Society. So they broke it down into two main categories. So the first would be management of acute bleeding. And it gets really simple. We have all these fancy new agents, these reversal agents, but really they recommend against reversal unless there's life-threatening hemorrhage. If you are gonna reverse warfarin, the agent of choice is gonna be PCC. And then again, there's emphasis on stopping aspirin if someone is on it purely for primary prophylaxis. So then moving on to what most of us are doing in the outpatient setting on a day in and day out basis is the perioperative management. So the two kind of main points of guidance is choosing your procedural risk. And this table on the right breaks it down into low, moderate, bleeding risk would be less than 2%, and then high, bleeding risk. So basically any diagnostic exam as we're doing will obviously be a low risk. Anything including biopsy will be a low risk. And polyps less than a centimeter, again, as we just heard, very safe to cold snare and take out. The issue is that we don't know what we're gonna encounter in a colonoscopy. So the vast majority of us are going to treat any colonoscopy, especially if they're coming in for screening or a first exam as a potentially high-risk procedure because you might encounter a polyp that's larger. And then obviously any of your advanced procedures that are including like an FNA or EMR are gonna be in your high risk. So after you've assessed your procedural risk, you then talk about your thrombotic risk. So the thrombotic risk obviously is typically going to be determined by the PCP, but we're really moving away from holding anti-COAG and anti-platelet therapy unless we do a PCR test. Unless we truly know that we're gonna do an interventional procedure. So if someone remains at low bleeding risk, regardless of their thrombotic risk, if you're just gonna do a diagnostic AGD, we really should be continuing their anti-COAG and anti-platelet therapy. Now, for the patients that we're mostly encountering, say a diagnostic colonoscopy is coming and you don't know what you're going to find, we're gonna call them a high bleeding risk procedure and recommend holding a small interruption in their therapy. And it's gotten quite simple actually for how long we hold their agents. So you can see the newer agents, the direct oral anti-coagulants, apixaban, dabigatran, rivaroxaban, it's mostly a two-day hold for any potential polypectomy. Dabigatran is the most renally excreted and so that is the one that you're going to adjust for renal function. If they're on dual anti-platelet therapy, the recommendation is to hold the P2Y12 inhibitor, so your Plavix agent, but you should continue their aspirin. And then warfarin is a five-day hold. And the recommendation again is really moving away from bridging. And all of this data, you can see I changed, this is actually from the European and British Society Guidelines. They provide the most clarity around how long to hold these agents. And it all comes from the PAWS trial, which was actually in JAMA and then there was a recent subset analysis that came out in the Red Journal. And following this protocol, they had very low thromboembolic events and very few major post-procedural bleeding events. So this seems like it's a very safe plan. In terms of resuming, unfortunately, we still don't know. So the guidance really is that once you have hemostasis and you think that your risk of delayed bleeding is low, you kind of weigh that against your thrombosis risk and kind of come up with some guidance for the patient. So moving on, the AGA, ACG put out a joint guidance around constipation. We're all obviously very familiar with treatment of constipation. But a few things I wanna highlight here is they did break down our agents into those with strong recommendations and moderate evidence behind them and those with very low evidence and conditional recommendations. And so, for example, Linzess compared to Ametiza both kind of end up with chloride secretion in the colon and it's kind of a similar end pathway, but there is definitely much better data for Linzess as an agent over Ametiza. And then the other agent, which I think is not used as much and really should be used is prukalipride. So getting more familiar with this kind of pan-GI motility agent that does have strong evidence behind it. So we're all familiar with 45 being the new 50. And this table just goes through the fact that the U.S. Preventative Services Task Force, our U.S. Multisociety Task Force, the American Cancer Society, all recently updated their guidelines in 2021, 2023. We're very familiar with this new commentary. And unfortunately, the ACP put out guidance very recently, recommending actually that average risk patients start at age 50. And the response from our societies has been very clear that we still believe the data behind early onset colon cancer. The statistics are there below. These are the things I like to talk about when I'm talking about why we lowered down the age, somewhere between 10 and 15% of colon and rectal cancers are diagnosed in patients under the age of 50. And the estimate is that by 2030, colon cancer is gonna be the leading cause of death in patients under the age of 50, which is a really harrowing statistic, I think. But the idea behind the ACP guidance is just that all of the data is actually very low quality evidence, and it is all based on modeling. So at the end of the day, it is still a risk benefit discussion with your patients. But the idea here is that some patients may come in confused having heard this new language come out from the ACP. I think it's just important to know that there are still multiple societies, including the US Preventative Task Force that still does recommend starting at age 45. So speaking of the ACP, we're gonna talk about another set of guidelines that they put out last year that I do actually really like. So this is actually the management of left-sided acute colonic diverticulitis. So I think we're very familiar with the first statement that we should be using cross-sectional imaging to diagnose when there's diagnostic uncertainty, and that most patients should be managed in the outpatient setting for uncomplicated disease. But the last statement I think is really practice changing. And I actually haven't seen it come into play that much, and I think it should be really more emphasized. I think in GI, we often see the patients with recurrent diverticulitis who've been on courses and courses of antibiotics, and they have antibiotic-associated diarrhea and other side effects. And this is, I think, a really practice-changing guideline, that initial management for uncomplicated diverticulitis should be managed without antibiotics. So that's obviously excluding the patients who have complicated disease, SERS, they're immunocompromised. But when they looked at the data, there was absolutely no difference in complications, treatment failure, quality of life, surgery, and length of stay. Basically, everything they looked at was the same, which is what resulted in these guidelines. So moving to another society outside of GI, I'm going to talk about IDSA. So they're now a few years older, in 2021. But these are the IDSA guidelines around C. diff management. Again, we're typically not seeing patients for their first episode. It's oftentimes managed in primary care by general medicine. But the point here is that fidaxomycin is really the initial agent of choice. And I think that's probably different than the way most of us were trained. But the data is just much better for fidaxomycin, even over vancomycin. So when it is available to you, and it's not cost prohibitive, that would be the agent of choice. The other point I want to make is there's now an adjunctive agent. So bezlotoximab is a monoclonal antibody against the C. diff toxin B. And that can be an adjunctive therapy in their first recurrence. So that might be a time that we're getting involved. And then once we're hitting multiple recurrences, I think the question often comes to GI, when do we offer an FMT? And the guidelines recommending to offer it basically on their fourth episode. So they need to fail their first and two recurrences. And then on their fourth episode. And there's now two FDA-approved agents. So Rabiota is an enema. And then VAUST is the pill formulation. But these are both FDA-approved within the last year, I believe. And then at the bottom of the table, you can just see the schema to be used for fulminant disease. So moving on to more endoscopy-focused guidelines. So this is the American Society of Anesthesiology. So you can't go to a dinner party without somebody talking about ozempic these days. And I can't keep track of all of these different agents. There was a multi-society statement that was put out last month in August that basically says, these new diabetes and weight loss agents, we don't know how to manage them in the perioperative period. And so we really should exercise best practices and that more data is needed. So that's, I think, less than helpful, unfortunately. And the ASA feels very strongly about this. So I think we've all probably now had a patient whose procedure has been canceled because they did not appropriately hold these agents. And this is why. So the GLP-1s, their mechanism of action is that they actually lead to delayed gastric emptying. I think we're all seeing that in our clinic settings, by the way, as well. It's my favorite agent to go back to the PCPs and say, well, that's why your patient is having nausea and vomiting. But to go through these agents, because of the delayed gastric emptying, there's a higher risk for aspiration, especially during endoscopy. And so for the agents that are dosed weekly, the recommendation is to hold for a week. For the agents that are dosed daily, it's to hold the day of the procedure. So these are the GLP-1s. The SGLT-2s, more for diabetes, purer management, is actually, it ended up not even just as an ASA statement. This is on the FDA label now. This came out in March 2022, that these agents have higher risks of ketoacidosis in UTI and should be held in the periprocedural setting, as well. Most are just going to be held three days. There's a single agent that has a slightly longer mechanism, so it needs to be held for four days. But I think for us as GI to start being aware of these agents, to start seeing these on our patients' meds lists, and they should start ringing a bell to us as something that's important to be aware of. So the next one is, I think, actually a really nice paper that came out from the ASG Equality Committee a few years ago, or last year, actually, where they really talked about what are the interventions that truly matter when we're trying to increase their EDR. So all of us hear about things like use a cap, do a retroflexion, do this, do that. So what truly has evidence behind it? So I actually put these in mostly descending order of effectiveness. Seems like a lot of you also read this paper, so I was glad to see that people already know this. But the educational interventions are really the things that have been shown to impact EDR the most. So public reporting, focused educational interventions, physician report cards all have very good evidence. So if you are not receiving your EDR or tracking your EDR, that's something that's really important and that you should be doing to understand what kind of quality you're providing and how you can then improve. There's really great videos that are now available. So Kaiser Northern California has a free online video around lesion detection and how to improve EDR. There's a lot put out by the societies as well. But those are really the ones that you're going to get the most bang for your buck if you're trying to increase your EDR. So moving on, we are all familiar with these guidelines that came out in 2020. These were pretty practice-changing for us around polyp surveillance. But my point is, unfortunately, that adherence to these is still really low. And it's especially low for the areas where it's different than prior years, so low-risk adenomas. So we really know that low-risk adenomas are basically the same as a normal colonoscopy. So 1 to 2-subcentimeter adenomas do not really increase the patient's cancer risk over a normal exam when you trend that out over time. And seeing that data is what made me very comfortable with giving these longer recommendations for surveillance. The table is a little bit complicated. I'll just tell you what we do in our practice. So we simplified anybody with 1 to 2 polyps that are either serrated or adenomatous. We come back in seven years. So that is on the conservative side. But it captures both of those. You then don't have to think, was it a serrated lesion? Was it a tubular adenoma? It's just seven years. And then basically, everybody else that's higher risk than that, so multiple lesions, higher-risk pathology, is three years. And then obviously, the over 10 is one year. So it kind of is easier to follow that way. And then the other point is just around second surveillance. So again, this table is a little complicated. It's overwhelming to think I have to pull that out every time. But really, second surveillance mostly changes when your first exam had a high-risk lesion, so either a large lesion, advanced pathology, or more than five adenomas. So that's when you should just kind of keep in mind, if you do have those results, that you may need to bring back the patient earlier, and even if you had a normal or a low-risk exam. So we're going to quickly jump over to the liver. I never felt older than when I was talking to a resident once and I was like, oh, you know, the NOACs, the novel oral anticoagulants. And they're like, it's not called a novel anymore. They're the direct agents. So this is the way I feel in the liver, unfortunately, when I was presenting or talking to a fellow, and they're like, it's not called NAFL. It's called MASL. And I was like, I don't even know what that means. So the move is really to classify what has previously been known as fatty liver disease as steatotic liver disease. This was actually a very large 236 panelists from 56 countries came together and, under Delphi consensus, came up with this nomenclature. And the idea is that non-alcoholic and fatty were terms that were felt to be stigmatizing. And so the broad umbrella is steatotic liver disease. And the spectrum exists between metabolic-associated and alcohol-associated. And so for those with metabolic-associated steatotic liver disease, they should have at least one out of five of these risk factors for metabolic dysfunction. If they do, then you go down the pathway of calling it MASL or MASH. And if they don't, and there's no alternative etiologies like alcohol or drugs, then you call it cryptogenic. So just to, especially for those of us that don't practice a lot of liver, just to bring us all up to date so we don't look that embarrassing when we talk to our hepatology colleagues. And then I wanted to talk quickly about Boveno. So the Boveno guidelines came out with an updated approach to portal hypertension in April of 2022. And again, as a predominant endoscopist, where I think this really affects us is I think we're looking at the end of screening EGDs for portal hypertension. Really, the new paradigm is to take into account the severity of their portal hypertension through the liver stiffness and their platelet count. If both of those look OK, you can just avoid endoscopy completely. We've already been practicing that. But where they're really trying to drill down is instead of just trying to prevent variceal hemorrhage with banding or beta blockers in those who have higher risk varices, instead, basically, if a patient has clinically significant portal hypertension, either through their platelet count or through their liver stiffness, all of those patients are starting cartobatolol. And the goal is to prevent decompensation through any mechanism. And that's where the data comes in. So they've shown that cartobatolol specifically prevents clinical decompensation across ascites, hemorrhage, and encephalopathy. And so for those of us that are doing EGDs on these patients, I think we can start to move away from that. And why I say stay tuned is I've heard through my liver spies that apparently at the liver meeting next week, there's more that's going to be coming out around guidelines on this. So keep your eyes open. This guideline is from January of last year. And I mostly just want to tell you guys that this exists. I think this is a new field. So this is a practice guideline that came out around palliative care and symptom-based management in decompensated cirrhosis. And I think this is really a completely new field within hepatology. I think there's more and more recognition that patients with decompensated cirrhosis just have a lot of difficult symptoms to manage and unfortunately have very high non-transplant-free survival. And so linking them into palliative care early, I think, is going to be the next big thing. There's data in lung cancer that linkage to palliative care actually extends life. So people live longer. And I think we're going to see similar data eventually in cirrhosis as well. And then these tables actually are really nice for providers who do manage decompensated cirrhosis. I think these are really helpful for trying to choose agents to manage all of the complicated symptoms that patients might have. So that's my tour of some of the new guidelines. I just wanted to put some plugs in for ways that I personally keep up. And I would love to crowdsource here and hear what you guys like to use. We're all very busy. You can't sit there with your stacks of journals every day just reading as much as we would like to. I rely a lot on emails. So ASGE puts out a great journal scan that comes out weekly. And then the ACG does an evidence-based GI that comes out monthly. And I actually still subscribe to the New England Journal Journal Watch as well, because that's how I get these ACP guidelines or the ASA guidelines and things that we might not necessarily see. Podcasts are a great way. GI Pearls is a great lit review that comes out once a month. For those who are still connected to X or Twitter, those are also quick ways to be able to get this information. One account is John Damianos is actually a GI fellow, but does some really nice comprehensive reviews of some of these guidelines when they come out. And then Vumedi actually is another nice platform that people might not be aware of. It's basically YouTube, but you actually have to show your credentials as a physician. So it's kind of a protected space. And a lot of talks get posted on there. And so I find they have a nice app. It's a very quick way to just do a digestible 20-minute talk as you're moving around. And then I would just be remiss. We're here as women. And these photos are from when I was scoping. You can see Dr. Shergel in the background, actually. I was pregnant as a fellow with my first child. And then I actually developed De Quervain's during that pregnancy and postpartum. And a lot of the skills that she's taught me around ergonomics and even just mentorship about how to have a baby, how to manage life, are things that I applied for my second child, as you can see there. And so I think there's a lot of power to what we're doing here today. And I really wouldn't have been able to do it without the support I've had. So thank you, everyone. Please reach out if you have questions. And I hope this brought you a little bit more up-to-date on all of the new things that are coming out. Thank you.

gastroenterology

guidelines

equitable care

lower GI bleeding

colon cancer screening age

mentorship