PSG Rumblings Newsletter Fall 2021

PSG

Rumblings FALL 2021

PENNSYLVANIA SOCIETY OF GASTROENTEROLOGY / NEWSLETTER

President’s Message / David L. Diehl, MD, FACP, FASGE

www.pasg.org

Dear Colleagues, I feel extremely honored to take on the role of president of the PSG. Our outgoing president, Ravi Ghanta, has been very dedicated, and his high energy has been critical to keep the PSG moving forward. He will certainly be a hard act to follow! I am grateful for his efforts to ensure that the board officer transition will be a smooth one. I know that he will remain involved and that the PSG will be stronger because of that.

@DavidDiehlMD

We have been blessed over the years with amazing leadership, and very pro-active boards that have allowed the PSG to continue to grow and thrive. I aim to be a good steward of the society, keeping us on track regarding our society’s goals while at the same time building interest among the membership and continuing to increase our profile among GI trainees.

With the burdens of COVID-19 in the past almost 2 years, it has been a trying time for everyone, and for organizations such as ours. The centerpiece of the PSG year, the annual meeting, again could not be

held in person. This family-friendly event, that is such an important touchstone, will be pushed back another year. Hopefully things will have stabilized enough by next year to again allow in-person meetings.

We are planning the 2022 annual PSG meeting in Hershey for the weekend of September 9-11.

Please already make a note of it. and I hope to see everyone there!

However, the need for physician advocacy and engagement remains important. We continue to need to educate lawmakers, insurers, and hospitals about issues that impact how we deliver care, clinical outcomes and research. If we don’t provide the unique GI perspective, who will? And will they have our best interests in mind? Probably not. The PSG works closely with other professional societies, such as the Pennsylvania Medical Society and the American College of Gastroenterology. Together we can keep our fingers on the pulse of what is important to support practicing gastroenterologists in today’s challenging environment. continued on page 2

PSG/SOCIAL: @PAGastroSoc

INSIDE: 2 President’s Message

6 Clinical Pearls

10 CME Events

3 FIT Update

9 Meeting Overview

12 Board and Staff

President’s Message

continued from page 1

We are grateful for your membership in the PSG and that you find value in the organization and what it does. Just being a member reflects huge support for the PSG. If you are interested in deeper engagement in committee activities, or ad hoc task forces, please reach out to me. If you

identify an issue in your practice of gastroenterology with which the PSG can help, contact me or any of our board members or counselors. There is a ton of “institutional memory” at the PSG, it is very likely that we will be able to help.

Have a wonderful winter season, and please do not hesitate to reach out to me for any issue, big or small!

David L. Diehl, MD, FACP, FASGE President Pennsylvania Society of Gastroenterology

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FIT UPDATE: September 2021 Travis Magdaleno, DO started lasting longer. Having been pushed to my limits, I made another appointment. Frustratingly, my repeat EGD was normal. A week later, I was notified my esophageal biopsies demonstrated over 65 eosinophils/hpf – confirming the diagnosis of eosinophilic esophagitis (EoE).

I remember my first food impaction.

It was fall and I was raking leaves with my father when my grandmother arrived with a box of fresh Philly pretzels. She passed me one in the yard as I had worked up a hunger up from raking leaves. As I scarfed down the warm pretzel, I recall feeling this uncomfortable constant, dull pain in my chest. Shortly thereafter, I couldn’t swallow. Anything. I began spitting to avoid choking on my saliva. This “episode” lasted about 15 minutes before spontaneously resolving. I was in high school at the time and over the following decade, I would experience many more episodes. Often occurring at the worst possible times; during important meetings, on a date, while driving, etc. As they were and always self-resolved, I foolishly chose not to seek care.

It wasn’t until a med school GI rotation, when I encountered a young patient with the exact same symptoms. His EGD demonstrated a Schatzki’s ring which, once dilated, made him feel better. I immediately made an appointment. Sure enough, my EGD also demonstrated a ring which was dilated. However, I didn’t get better. In residency, my episodes only became more frequent and

EoE in an inflammatory process in which eosinophils infiltrate the esophageal tissue causing inflammation. All age ranges with varying symptoms can be affected.

In infants/toddlers, feeding difficulty and poor weight gain/growth may be the only sign. In children, abdominal pain, poor appetite, and solid food dysphagia are common. Adults present with GERD, dysphagia and food impactions. The condition is 3 times more common in males than females and tends to run in families indicating a possible genetic or hereditary predisposition. Asthma, eczema, and allergies (both food and seasonal/environmental) are known risk factors. Esophageal biopsies demonstrate > 15 eosinophils/hpf.

Endoscopic changes of EoE include esophageal longitudinal furrows, micro-abscesses, trachealization changes/rings and even significant edema and stricture. First line treatment is a trial of high dose proton pump inhibitor therapy with repeat endoscopy in 2 -3 months to evaluate for resolution of eosinophilia. In PPI refractory cases, topical therapy with inhaled or swallowed corticosteroids is recommended. Also, some or all of six food elimination diet (SFED: nuts, soy, wheat, dairy, eggs and/or shellfish) may be necessary.

As a GI fellow in the Lehigh Valley, we encounter EoE on a weekly basis, particularly in the setting of

an emergent on-call esophageal food impaction. I’ve gotten quite comfortable with dislodging the food bolus either with gentle advancing pressure or using tools to painstakingly remove it piece by piece. In fact, it is so common at our center, we have created a “food bolus bingo” board amongst the fellows to keep our spirits up during those late-night scopes. After speaking with several attendings who have trained and practiced outside of the Lehigh Valley, food impactions were reportedly a rare on-call occurrence.

I was curious to identify what is was about the Lehigh Valley which made this condition so prominent.

It appears however we are not alone.

Recently published data this year from the Netherlands indicate over a 300 fold increase in the incidence of EoE cases since 1995. Etiology for this dramatic increase has been thought to be multifactorial.

Modern extra hygienic conditions in childhood/infancy during immune maturation is thought to play a role – limiting the exposure of microbes during infancy can cause defects in immune tolerance and increased sensitivity to specific allergens. Additionally, the use of early antibiotics and cesarean births have been shown to change the gut microbiome – potentiating T-helper type 2 cell mediated responses in sensitive individuals. Environmental factors are also postulated to have contributed with the incorporation of the Western diet (low fiber, high saturated fats), and air quality/ allergens. Moreover, declining rates of H.pylori due to increased detection and treatment is thought to contribute to the rise of EoE as H.pylori has been shown to be a protective factor in the literature. continued on page 4

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FIT Update continued from page 3 Lastly, and surprisingly, the authors reported little evidence linking aeroallergen exposure to disease onset and flare as the number of cases during the year/seasons were equally distributed1. This was an interesting finding considering a retrospective study published in 2017 out of New York found a significant seasonal variation in onset of symptoms and diagnosis of EoE in pediatric population.

Notably, one report ranking the top 100 US cities with worst seasonal pollen allergies, Allentown, PA was ranked number 25. Over the past 3 years, it has moved up the ranks from the bottom half to the top quarter. Other Pennsylvania cities which have made the list were

Scranton (#1!), Pittsburgh (#5), Philadelphia (#28), Harrisburg (#78)2.

In my clinical opinion, I cannot help but suspect aeroallergens play a larger role than suspected in this disease, especially in cases refractory to dietary changes.

References 1. d e Rooij, Willemijn E et al. “Emerging incidence trends of eosinophilic esophagitis over 25 years: Results of a nationwide register-based pathology cohort.”

Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society vol. 33,7

As far as my experience goes, I was started on once daily proton pump inhibitor and within a few weeks, my symptoms completely resolved, and I have yet to have another impaction. My quality of life has significantly improved, and I will often voice my experiences and story to those unfortunate patients whom I meet during my on-call nights for a food bolus in hopes to improve compliance with their medical care.

(2021): e14072.

2. H irano I, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis.

Gastroenterology 2020;158:1776–1786.

3. F ahey L, Robinson G, Weinberger K, Giambrone AE, Solomon AB. Correlation Between Aeroallergen Levels and New Diagnosis of Eosinophilic Esophagitis in New York City. J Pediatr Gastroenterol Nutr.

2017;64(1):22-25.

4. 2 021 Allergy Capitals Annual Rankings report. The Asthma and Allergy Foundation of America (AAFA). https://www.aafa.

org/allergy-capitals/

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In Office Fibrosis Testing

By R. Fraser Stokes, MD PSG Practice Management Chairman Blood tests have been developed to assess liver fibrosis. The most studied tests are the APRI (AST to platelet ratio), the FibroTest / Fibrosure, Hepascore, and Fibrospect. The advantage of APRI is that it is easily calculated using routine labs. These serology panels are reasonably capable of distinguishing minimal (F0-1) fibrosis from more significant fibrosis (F2-4).

gastroenterologists when they take care of patients with liver disease is to assess the extent of fibrosis.

Ultrasound based Imaging techniques have been developed to measure liver stiffness (parallels fibrosis) by measuring propagation speed of ultrasound waves through liver tissue. These can be done in our offices in roughly 7-30 minutes.

Many Gi practices are now deciding whether to invest in these machines.

We are frequently consulted on patients who have decompensated cirrhosis who had no idea that they ever had a significant liver disease.

Sometimes they were told they had an ultrasound that showed fatty liver, but that their liver enzymes were normal, and that they had nothing to worry about.

FibroScan or transient elastography uses shear wave imaging by applying a vibrating source to tissue with the shear waves analyzed by a one dimensional ultrasound detector.

This technology is FDA approved and is helpful for distinguishing minimal to no fibrosis (F0-1) from advanced fibrosis (F2-4).

Thus, it is incumbent on GI providers in 2021 to do a periodic fibrosis assessment in those with chronic liver disease.

Two dimensional shear wave elastography (SWE) uses a linear array and allows for imaging of the target tissue. Many focal zones are reviewed, thus creating a cylindrical shear wave cone of tissue to measure stiffness. This technique also allows for good distinction between minimal fibrosis and advanced fibrosis. It can be integrated into standard in-office ultrasound scanners made by GE, Phillips, and others. The advantage of this technique is that a conventional

@fraserstokes

One of the necessities facing

One method for assessing liver fibrosis is liver biopsy. This is expensive, a bit risky (bleeding), and not entirely accurate, given frequent patchy involvement of fibrosis. Another method is via MR elastography. The primary issue with MRE is high cost.

ultrasound exam (like that of the RUQ) can be done at the same time, and this is needed to bill.

Three dimensional ultrasound has recently been FDA approved for liver fibrosis assessment. This device is called Velacur. One disadvantage here is the paucity of supporting data. Only a few abstracts are available that back this device, and they show that Velacur correlates well with MR elastography for fibrosis assessment.

Financial analysis needs to be done carefully when choosing whether to invest in ultrasound based fibrosis assessment. FibroScan is quite expensive, as I recently spoke to this company’s PA representative who indicated retail pricing is at $161,000 with discount pricing available substantially below that. CPT Coding used is 91200. Reimbursement is typically $37-42 per exam.

2D ultrasound (SWE) fibrosis assessment requires an ultrasound machine with a special wand attachment with total machine costs in the $50-65,000 range. Billing is with CPT code 76981. Medicare, Highmark, and UPMC insurance reimbursements range from $104 to $126 per exam.

3D ultrasound (Velacur) requires a special machine. According to the national rep, practices rent the machine with an up-front cost of between $3-30,000, with a monthly subscription of $1500, plus a negotiated per use fee.

They recommend using CPT code 76981. It is unclear what PA insurers continued on page 7

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continued from page 6

would pay or even whether they would accept Velacur for this code, as it does not do a conventional ultrasound exam. There are currently no Velacur machines in operation in our state.

The last major consideration for a practice is staffing needs . FibroScan and Velacur can be done by almost anyone and each takes about 7 minutes to do. 2D Ultrasound with SWE requires an ultrasound technician to perform and a physician to interpret the images.

Technician time is approximately 30 minutes.

In conclusion, it’s important to perform non-invasive cost-efficient fibrosis assessment in our liver disease patients. Blood based testing can provide valuable information and is covered by most insurers. For a practice that sees a large number of liver patients, the purchase of FibroScan, a 2D ultrasound machine, or Velacur might be a good option.

Hopefully, the future will bring a reduction in equipment cost, and reimbursement issues will be clarified and improved.

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PSG Social Media Corner

We have been working hard to generate meaningful content on our social channels for PSG members and other physician’s. This month we highlight Physician Suicide Awareness Day and PancreasFest 2021!

Keep your eye out for these great new content features and be sure to let us know what you want to see on our social pages by commenting, liking, retweeting or direct messaging us. Remember to follow @PAGastroSoc on Facebook, Twitter and Instagram to see what our Ambassador’s are up to! #PAGastro

Professional Milestones Dr. Austin Chiang has assumed an exciting position as Chief Medical Officer for Gastroenterology at Medtronic. He will lead projects on training & support needs in addition to clinical communications, provide insight on product development. Dr. Chiang is an assistant professor of medicine at Sidney Kimmel Medical College, Chief Medical Social Media Officer of Jefferson Health and Director of the Endoscopic Bariatric Program at Thomas Jefferson University Hospital. https://bit.ly/AustinChiang-Medtronic-CMO-GI

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PSG Meeting Overview Thank you to all attendees, corporate partners, and exhibitors for a successful 2021 Meeting!

FEATURED PODCASTS American Journal of Gastroenterology Podcast

Hear journal chiefs interview primary authors on the latest guideline updates and ground breaking articles at the Red Journal’s official podcast.

https://gi.org/journals-publications/podcasts/

GI Insights on ReachMD with Neilanjan Nandi, MD

Explore exciting and innovative research and learn clinical pearls to tackling issues in IBD, Hepatology, Functional bowel disease and more. The latest episodes review the DINE-CD trial, talking about sexual health in IBD and the latest Eosinophilic Esophagitis guidelines.

https://reachmd.com/clinical-practice/gastroenterology-and-hepatology/

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CME (GI) /EVENTS/2021-22 AIBD 2021 Orlando, FL December 9-11

https://acgmeetings.gi.org/ IN-PERSON

Crohn’s Colitis Congress 2022

DDW 2022 San Diego, CA May 21-24

Las Vegas January 20-22

https://acgmeetings.gi.org/ IN-PERSON

https://www.crohnscolitiscongress.org/ IN-PERSON

COVID-19 Update Looking for up to date information and resources for COVID-19? Please check out the PAMED COVID-19 Resource Center. https://www.pamedsoc.org/education-cme/public-health/covid/ corona-virus

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THANK YOU TO OUR SPONSORS

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PSG

PRSRT STD U.S. POSTAGE PAID HARRISBURG PA PERMIT NO. 922

BOARD&STAFF PRESIDENT

David L. Diehl, MD Geisinger Medical Center Gastroenterology/Nutrition 570-271-6856 dldiehl@geisinger.edu

@DavidDiehlMD

1st Vice-President

Karen Krok, MD Penn State Hershey Gastroenterology (717) 531-4950 kkrok@pennstatehealth.psu.edu

@klkrok

TREASURER

Neilanjan Nandi, MD, FACP University of Pennsylvania 215-662-8900 Neilanjan.Nandi@pennmedicine.upenn.edu

Rumblings EDITOR

Neilanjan Nandi, MD, FACP University of Pennsylvania 215-662-8900 Neilanjan.Nandi@pennmedicine.upenn.edu

@fitwitmd

ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE Ariel Jones (717) 909-2620 ext. 2620 info@pasg.org

STAFF Cindy Warren Operations Jessica Winger Meeting Manager Jill Bennish Member Service Specialist Tom Notarangelo Design Manager