The New Gastroenterologist

In this video, Peter Naas, MD, of Gastroenterology Associates in Greenville, South Carolina, shares insights on how young physicians can best position themselves for a successful career in private practice gastroenterology.

In this video, Peter Naas, MD, of Gastroenterology Associates in Greenville, South Carolina, shares insights on how young physicians can best position themselves for a successful career in private practice gastroenterology.

In this video, Peter Naas, MD, of Gastroenterology Associates in Greenville, South Carolina, shares insights on how young physicians can best position themselves for a successful career in private practice gastroenterology.

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has increased over the past several years and has become a cornerstone in both diabetes and weight loss management, particularly because of its unique combination of glucose control, weight reduction potential, and cardiac and metabolic benefits. However, increased use of these agents presents a dilemma in gastrointestinal endoscopy as it pertains to their safety and management during the periprocedural period.

This review explores management of GLP-1 RAs in the periprocedural setting for endoscopic procedures based on current evidence and guidelines, highlighting gaps and future directions.

 

Pharmacology and Mechanisms of Action

GLP-1 RAs have several mechanisms of action that make them relevant in gastrointestinal endoscopy. These medications modulate glucose control via enhancement of glucose-dependent insulin secretion and reduction of postprandial glucagon, which promotes satiety and delays gastric emptying. This delay in gastric emptying mediated by vagal pathways has been postulated to increase gastric residuals, posing a risk for aspiration during anesthesia.¹

It is important to also consider the pharmacokinetics of GLP-1 RAs, as some have shorter half-lives on the order of several hours, like exenatide, while others, like semaglutide, are dosed weekly. Additionally, common side effects of GLP-1 RAs include nausea, vomiting, bloating, and early satiety, which pose challenges for patients undergoing endoscopic procedures. 

 

Current Guidelines

Various societies have published guidelines on the periprocedural use of GLP-1 RAs. The American Society of Anesthesiologist (ASA) in 2023 presented early recommendations to hold GLP-1 RAs either day of procedure or week prior depending on pharmacokinetics, because of the risk of delayed gastric emptying and increased potential for aspiration.² Soon thereafter, a multi-gastroenterology society guideline was released stating more data is needed to decide if GLP-1 RAs need to be held prior to endoscopic procedures.³

In early 2024, the American Gastroenterological Association (AGA) published a rapid clinical update that advocated for a more individualized approach, particularly in light of limited overall data for GLP-1 RAs and endoscopic procedures.⁴ In asymptomatic patients who follow typical fasting protocols for procedures, it is generally safe to proceed with endoscopy without holding GLP-1 RAs. In symptomatic patients (nausea, abdominal distension, etc), the AGA advises additional precautions, including performing transabdominal ultrasound if feasible to assess retained gastric contents. The AGA also suggests placing a patient on a clear liquid diet the day prior to the procedure — rather than holding GLP-1 RAs — as another reasonable strategy.

The guidelines continue to evolve with newer multi-society guidelines establishing best practices. While initially in 2023 the ASA did recommend holding these medications prior to endoscopy, the initial guidance was based on expert opinion with limited evidence. Newer multi-society guidance published jointly by the ASA along with various gastroenterology societies, including the AGA in December 2024, takes a more nuanced approach.⁵

The newer guidelines include two main recommendations:

1. Periprocedural management of GLP-1 RAs should be a joint decision among the procedural, anesthesia, and prescribing team balancing metabolic needs vs patient risks.

• In a low-risk patient, one that is asymptomatic and on standard dosing, among other factors, the guidance states that GLP-1 RAs can be continued.
• In higher-risk patients, the original guidance of holding a day or a week prior to endoscopic procedures should be followed.

2. Periprocedural management of GLP-1 RAs should attempt to minimize the aspiration risks loosely associated with delayed gastric emptying.

• Consider a 24-hour clear liquid diet a day prior to the procedure and transabdominal ultrasound to check gastric contents.
• It is acknowledged that this guidance is based on limited evidence and will be evolving as new medications and data are released.

Recent Clinical Studies

Although there is very little data to guide clinicians, several recent studies have been published that can direct clinical decision-making as guidelines continue to be refined and updated.

A multicenter trial of approximately 800 patients undergoing upper endoscopy found a significant difference in rates of retained gastric contents between those that underwent endoscopy who did and did not follow the ASA guidance on periprocedural management of GLP-1 RAs (12.7% vs 4.4%; P < .0001). However, there were no significant differences in rates of aborted procedures or unplanned intubations.

Furthermore, a multivariable analysis was performed controlling for GLP-1 RA type and other factors, which found the likelihood of gastric retention increased by 36% for every 1% increase in hemoglobin A1c. This study suggests that a more individualized approach to holding GLP-1 RA would be applicable rather than a universal periprocedural hold.⁶

More recently, a single-center study of nearly 600 patients undergoing upper endoscopy showed that while there were slightly increased rates of retained gastric contents (OR 3.80; P = .003) and aborted procedures (1.3% vs 0%; P = .02), the rates of adverse anesthesia events (hypoxia, etc) were similar between the groups and no cases of pulmonary aspiration were noted.7

One single-center study of 57 patients evaluated the safety of GLP-1 RAs in those undergoing endoscopic sleeve gastrectomy. GLP-1 RAs were continued on all patients, but all adhered to a liquid only diet for at least 24 hours prior to the procedure. There were no instances of retained gastric solids, aspiration, or hypoxia. This study suggests that with a 24-hour clear liquid diet and routine NPO recommendations prior to endoscopy, it would be safe to continue GLP-1 RAs. This study provides rationale for the AGA recommendation for a clear liquid diet 24 hours prior to endoscopic procedures for those on GLP-1 RAs.⁸

A study looking at those who underwent emergency surgery and endoscopy with claims data of use of GLP-1 RAs found an overall incidence of postoperative respiratory complications of 3.5% for those with GLP-1 RAs fill history vs 4.0% for those without (P = .12). Approximately 800 of the 24,000 patients identified had undergone endoscopic procedures for GI bleeding or food impaction. The study overall showed that preoperative use of GLP-1 RAs in patients undergoing surgery or endoscopy, evaluated as a combined group, was not associated with an increased risk of pulmonary complications.⁹

Lastly, a systematic review and meta-analysis that included 15 studies that quantified gastric emptying using various methods, including gastric emptying scintigraphy and acetaminophen absorption test, found that there was a quantifiable delay in gastric emptying of about 36 minutes, compared to placebo (P < .01), in patients using GLP-1 RAs. However, compared to standard periprocedural fasting, this delay is clinically insignificant and standard fasting protocols would still be appropriate for patients on GLP-1 RAs.¹⁰

These studies taken together suggest that while GLP-1 RAs can mildly increase the likelihood of retained gastric contents, there is no statistically significant increase in the risk of aspiration or other anesthesia complications. Furthermore, while decreased gastric emptying is a known effect of GLP-1 RAs, this effect may not be clinically significant in the context of standard periprocedural fasting protocols particularly when combined with a 24-hour clear liquid diet. These findings support at a minimum a more patient-specific strategy for periprocedural management of GLP-1 RAs.

 

Clinical Implications

These most recent studies, as well as prior studies and guidelines by various societies lead to a dilemma among endoscopists on proper patient counseling on GLP-1 RAs use before endoscopic procedures. Clinicians must balance the metabolic benefits of GLP-1 RAs with potential endoscopic complications and risks.

Holding therapy theoretically decreases aspiration risk and pulmonary complications, though evidence remains low to support this. Holding medication, however, affects glycemic control leading to potential rebound hyperglycemia which may impact and delay plans for endoscopy. With growing indications for the use of GLP-1 RAs, a more tailored patient-centered treatment plan may be required, especially with consideration of procedure indication and comorbidities.

Currently, practice patterns at different institutions vary widely, making standardization much more difficult. Some centers have opted to follow ASA guidelines of holding these medications up to 1 week prior to procedures, while others have continued therapy with no pre-procedural adjustments. This leaves endoscopists to deal with the downstream effects of inconvenience to patients, care delays, and financial considerations if procedures are postponed related to GLP-1 RAs use.

 

Future Directions

Future studies are needed to make further evidence-based recommendations. Studies should focus on stratifying risks and recommendations based on procedure type (EGD, colonoscopy, etc). More widespread implementation of gastric ultrasound can assist in real-time decision-making, albeit this would require expertise and dedicated time within the pre-procedural workflow. Randomized controlled trials comparing outcomes of patients who continue GLP-1 RAs vs those who discontinue stratified by baseline risk will be instrumental for making concrete guidelines that provide clarity on periprocedural management of GLP-1 RAs.

Conclusion

The periprocedural management of GLP-1 RAs remains a controversial topic that presents unique challenges in endoscopy. Several guidelines have been released by various stakeholders including anesthesiologists, gastroenterologists, and other prescribing providers. Clinical data remains limited with no robust evidence available to suggest that gastric emptying delays caused by GLP-1 RAs prior to endoscopic procedures significantly increases risk of aspiration, pulmonary complications, or other comorbidities. Evolving multi-society guidelines will be important to establish more consistent practices with reassessment of the data as new studies emerge. A multidisciplinary, individualized patient approach may be the best strategy for managing GLP-1 RAs for patients undergoing endoscopic procedures.

Dr. Sekar and Dr. Asamoah are based in the department of gastroenterology at MedStar Georgetown University Hospital, Washington, D.C. Dr. Sekar reports no conflicts of interest in regard to this article. Dr. Asamoah serves on the Johnson & Johnson advisory board for inflammatory bowel disease–related therapies.

References

1. Halim MA et al. Glucagon-Like Peptide-1 Inhibits Prandial Gastrointestinal Motility Through Myenteric Neuronal Mechanisms in Humans. J Clin Endocrinol Metab. 2018 Feb. doi: 10.1210/jc.2017-02006.

2. American Society of Anesthesiologists. American Society of Anesthesiologists releases consensus-based guidance on preoperative use of GLP-1 receptor agonists. 2023 Jun 20. www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

3. American Gastroenterological Association. GI multi-society statement regarding GLP-1 agonists and endoscopy. 2023 Jul 25. gastro.org/news/gi-multi-society-statement-regarding-glp-1-agonists-and-endoscopy/.

4. Hashash JG et al. AGA Rapid Clinical Practice Update on the Management of Patients Taking GLP-1 Receptor Agonists Prior to Endoscopy: Communication. Clin Gastroenterol Hepatol. 2024 Apr. doi: 10.1016/j.cgh.2023.11.002.

5. Kindel TL et al; American Gastroenterological Association; American Society for Metabolic and Bariatric Surgery; American Society of Anesthesiologists; International Society of Perioperative Care of Patients with Obesity; Society of American Gastrointestinal and Endoscopic Surgeons. Multi-society Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 Oct. doi: 10.1016/j.cgh.2024.10.003.

6. Phan J et al. Glucagon-Like Peptide Receptor Agonists Use Before Endoscopy Is Associated With Low Retained Gastric Contents: A Multicenter Cross-Sectional Analysis. Am J Gastroenterol. 2025 Mar. doi: 10.14309/ajg.0000000000002969.

7. Panchal S et al. Endoscopy and Anesthesia Outcomes Associated With Glucagon-like Peptide-1 Receptor Agonist use in Patients Undergoing Outpatient Upper Endoscopy. Gastrointest Endosc. 2025 Aug. doi:10.1016/j.gie.2025.01.004.

8. Maselli DB et al. Safe Continuation of glucagon-like Peptide 1 Receptor Agonists at Endoscopy: A Case Series of 57 Adults Undergoing Endoscopic Sleeve Gastroplasty. Obes Surg. 2024 Jul. doi: 10.1007/s11695-024-07278-2.

9. Dixit AA et al. Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications. JAMA. 2024 Apr. doi: 10.1001/jama.2024.5003.

10. Hiramoto B et al. Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol. 2024 Jun. doi: 10.14309/ajg.0000000000002820.

Exocrine pancreatic insufficiency (EPI) is a recognized condition in patients with underlying pancreatic disease. However, it is a disease state that requires a meticulous approach to diagnose, as misdiagnosis can lead to inappropriate testing and unnecessary treatment.

EPI has been defined as “a near total decline in the quantity and/or activity of endogenous pancreatic enzymes to a level that is inadequate to maintain normal digestive capacity leading to steatorrhea.”¹ It can lead to complications including malnutrition, micronutrient deficiencies, metabolic bone disease and have significant impact on quality of life. In this article, we will review the approach to diagnosis of EPI, differential diagnosis considerations, the approach to treatment of EPI, and screening for complications.
 

EPI Diagnosis

EPI results from ineffective or insufficient pancreatic digestive enzyme secretion. In 2021, a group of experts from the American Gastroenterological Association (AGA) and PancreasFest met and proposed a new mechanistic definition of EPI. This suggests that EPI is the failure of sufficient pancreatic enzymes to effectively reach the intestine in order to allow for optimal digestion of ingested nutrients, leading to downstream macronutrient and micronutrient deficiencies with symptoms of maldigestion including post-prandial abdominal pain, bloating, steatorrhea, loose stools, or weight loss.²

A more pragmatic definition by Khan, et al in 2022 utilized a staging system to distinguish exocrine pancreatic dysfunction (EDP) from EPI. As such EPD occurs when there is a decline in pancreatic function without impaired digestive capacity, while EPI requires digestive capacity impairment leading to objective steatorrhea (coefficient of fat absorption <93 %).³Differential Diagnosis: There are many factors that can impact normal digestion. In approaching EPI, symptoms are often the most common reason to test for disease state in the appropriate clinical context. There can be pancreatic causes of EPI and non-pancreatic (secondary) causes of EPI (see Figure 1), though the latter can be challenging to detect.

The most common parenchymal etiologies for EPI include chronic pancreatitis, recurrent acute pancreatitis, cystic fibrosis, pancreatic cancer or prior pancreatic resections. Non-pancreatic conditions that impact synchronous mixing of endogenous pancreatic enzymes with meals (i.e., Roux-en-Y gastric bypass, short bowel syndrome, delayed gastric emptying), mucosal barriers causing decrease endogenous pancreatic stimulation despite intact parenchyma, such as celiac disease, foregut Crohn’s disease, intraluminal inactivation of pancreatic enzymes (Zollinger-Ellison syndrome), and bile salts de-conjugation with small intestinal bacterial overgrowth (SIBO) can predispose to EPI.^4-6 The true prevalence of EPI is difficult to ascertain due to a variety of factors including challenges in diagnosis and misdiagnosis.

Some of the major challenges in the diagnosis and treatment of EPI is that the symptoms of EPI overlap with many other GI conditions including celiac disease, diabetes mellitus, SIBO, irritable bowel syndrome (IBS), bile acid diarrhea, and other functional GI syndromes. These non-pancreatic conditions can also be associated with falsely low FE-1. Hence, ordering FE-1 should be employed with caution when the pretest probability is low. Patients with EPI will generally have a significant response to pancreatic enzyme replacement therapy (PERT) if it is adequately dosed and a lack of response should prompt consideration of an alternative diagnosis. A framework to factors which contribute to EPI is outlined in Figure 2.

Symptoms Screening and Signs: Pancreatic enzymes output estimation is the most reliable indicator for pancreatic digestive capacity. However, EPI diagnosis requires a combination of symptoms screening, stool-based (indirect pancreatic function) testing or direct pancreatic function testing (PFT).

Although symptoms might not correlate with objective disease state, in screening for symptoms of steatorrhea or maldigestion, it is important to ask specific questions regarding bloating, abdominal pain, stool frequency, consistency, and quality. Screening questions should be specific and include question such as, “Is there oil in the toilet bowl or is the stool greasy/shiny?”, “Is the stool sticky and difficult to flush or wipe?”, “Is there malodorous flatus?” If patients screen positive for EPI symptoms and there is a high pre-test probability of EPI such as the presence of severe chronic pancreatitis or significant pancreatic resection (> 90% loss of pancreatic parenchyma), then cautious trial of PERT and assessment for treatment response can be considered without additional stool-based testing. However, this practice end points are unclear and mainly based on subjective response.

Patients with EPI are at increased risk for malnutrition and micronutrient deficiencies. While not required for the diagnosis, low levels of fat-soluble vitamins (vitamin AEDK) or other minerals (zinc, selenium, magnesium, phosphorus) can suggest issues with malabsorption. Once the diagnosis of EPI is made, micronutrient screening should occur annually.

Stool Based Testing: The gold standard clinical test for steatorrhea is measuring coefficient of fat absorption (CFA). With a normal range of 93% fat absorption, the test is performed on a 72-hours fecal fat collection kit. To ensure accurate results, a patient must adhere to a diet with a minimum of 100 grams of fat per day in the three days leading up to the test and during the duration of the test. Patients must also abstain from taking PERT during the duration of the test. This can be incredibly challenging for someone with underlying steatorrhea but can reliably distinguish between EPD and EPI.

A more commonly used stool test is fecal elastase (FE-1). While easier to perform, the test often results in many false positives and false negatives. FE-1 is an ELISA based test, which measures the concentration of the specific isoform CELA3 (chymotrypsin-like elastase family) in the stool sample. The test must be run on a solid stool sample as soft or liquid stool will dilute down elastase concentration falsely. One test advantage is that a patient can continue PERT if needed. FE-1 test measures the concentration of patients’ elastase and PERT is porcine derived. As such, there is no interaction between porcine lipase and human elastase in stool. FE-1 sensitivity and specificity are high for severe disease (<100 mcg/g) if the test is performed properly on patients with a high pretest probability. However, the sensitivity and specificity are poor in mild to moderate pancreatic disease and in the absence of known pancreatic disease.⁷

Our suggested approach to utilizing FE-1 test is to reserve it for patients with known severe chronic pancreatitis or prior pancreatic surgery in patients with symptoms. In patients without pancreatic disease who are at low risk of EPI, a positive FE-1 can lead to misdiagnosis, further diagnostic testing, and unnecessary treatment. Currently, there is no stool-based test that is accurate, reproducible, and reliable.

Direct Pancreatic Function testing: Secretin stimulated PFT is highly reliable in measuring ductal function with bicarbonate concentration. However, it cannot reliably estimate acinar function as both do not decline at the same rate, unless in severe pancreatic disease. A much more robust test should include cholecystokinin analog to measure pancreatic enzymes concentration. This test involves endoscopy, administration of secretin, and/or a cholecystokinin analog, and subsequent measurement of bicarbonate and digestive enzymes in the pancreatic juice. This test is not routinely offered as it is invasive, cumbersome, and difficult to repeat for reassessment of pancreatic function over time.⁸

Treatment

The primary goal of treatment is to improve symptoms and nutritional status of the patient. EPI treatment consists of PERT and nutritional counseling. In the United States, there are multiple FDA approved PERT preparations, which include Creon, Zenpep, Pancreaze, Pertzye, Viokase, and Relizorb. While dosing is dependent on lipase concentration, all PERT (aside from Relizorb) preparations have a combination of lipase, proteases, and amylase. All but Viokace and Relizorb are enteric-coated formulations.⁹

In patients with an inadequate response to enteric coated PERT, non-enteric coated PERT can be added as it may provide a more immediate effect than enteric coated formulations, specially if concern about rapid gut transit with inadequate mixing is raised. If a non-enteric formations is used, acid suppression should be added to prevent inactivation of the PERT. Relizorb is a cartridge system which delivers lipase directly to tube feeds. This cartridge is only utilized in patients receiving enteral nutrition and allows for treatment of EPI even when patients are unable to tolerate oral feeding.

PERT dosing is intended to at least compensate for 10% of the physiologically secreted amount of endogenous lipase after a normal meal (approximately 30,000 IU). Hence, dosing is primarily weight-based. In symptomatic adults, PERT dose of 500-1000 units/kg/meal and half of the amount with snacks is appropriate. Although higher doses of 1500-2000 units/kg/meal may be needed when there is significant steatorrhea, weight loss, or micronutrient deficiencies, PERT doses exceeding 2500 units/kg/meal are not recommended and warrant further investigation.¹⁰

Proper counseling is important to ensure compliance with pancreatin preparations. PERT will generally be effective in improving steatorrhea, weight loss, bowel movement frequency, and reversal of nutritional deficiencies, but it does not reliably help symptoms of bloating or abdominal pain. If a patient’s steatorrhea does not respond to PERT, then alternative diagnoses such as SIBO, or diarrhea-predominant IBS should be considered.

PERT must be taken with meals. There are studies that support split dosing as a more effective way of absorbing fat.¹¹ If PERT is ineffective or minimally effective, review of appropriate dosing and timing of PERT to a meal is recommended. Addition of acid suppression may be required to improve treatment efficacy, especially in patients with abnormal intestinal motility or prior pancreatic surgery as PERT is effective at a pH of 4.5. Cost, pill burden, and persistence of certain symptoms may impact adherence to PERT and thus pre-treatment counseling and close follow-up after initiation is important. This aids in assessment of patients’ response to therapy, ensure appropriate PERT administration, and identifying any barriers to therapy adherence.

Nutritional management of EPI consists of an assessment of nutritional status, diet, and lifestyle. An important component of nutritional management is the assessment of micronutrient deficiencies. Patients with a confirmed diagnosis of EPI should be screened for the following micronutrients annually: Vitamins (A, E, D, K, B12), folate, zinc, selenium, magnesium, and iron. Patients with chronic pancreatitis and EPI should also be screened for metabolic bone disease once every two years and for diabetes mellitus annually.^{4, 12}

Conclusion

EPI is a challenging diagnosis as many symptoms overlap with other GI conditions. Pancreas exocrine function is rich with significant reserve to allow for proper digestive capacity, yet EPI occurs when an individual’s pancreatic digestive enzymes are insufficient to meet their nutritional needs. In patients with high likelihood of having EPI, such as those with pre-existing pancreatic disease, diagnosing EPI combines clinical evidence based on subjective symptoms and stool-based testing to support a disease state.

Appropriate dosing and timing of PERT is critical to improve nutritional outcomes and improve certain symptoms of EPI. Failure of PERT requires evaluating for proper dosing/timing, and consideration of additional or alternative diagnosis. EPI morbidity can lead to significant impact on patients’ quality of life, but with counseling, proper PERT use, nutritional consequences can be mediated, and quality of life can improve.

Dr. Hernandez-Barco is based in the Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts. Dr. Ashkar is based in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Dr. Hernandez-Barco disclosed consulting for AMGEN and served as a scientific advisor for Nestle Health Science. She had project-related funding support or conflicts of interest to disclose. Dr. Ashkar disclosed consulting for AMGEN. He had no project-related funding support or conflicts of interest to disclose.

References

1. Othman MO, et al. Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician. Int J Clin Pract. 2018 Feb. doi: 10.1111/ijcp.13066.

2. Whitcomb DC, et al. AGA-PancreasFest Joint Symposium on Exocrine Pancreatitic Insufficiency. Gastro Hep Adv. 2022 Nov. doi: 10.1016/j.gastha.2022.11.008.

3. Khan A, et al. Staging Exocrine Pancreatic Dysfunction. Pancreatology. 2022 Jan. doi: 10.1016/j.pan.2021.11.005.

4. Whitcomb DC, et al. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatitis insufficiency: Expert Review. Gastroenterology. 2023 Nov. doi: 10.1053/j.gastro.2023.07.007.

5. Kunovský L, et al. Causes of Exocrine Pancreatic Insufficiency Other than Chronic Pancreatitis. J Clin Med. 2021 Dec. doi: 10.3390/jcm10245779.

6. Singh VK, et al. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017 Oct. doi: 10.3748/wjg.v23.i39.7059.

7. Lankisch PG, et al. Faecal elastase 1: not helpful in diagnosing chronic pancreatitis associated with mid to moderate exocrine pancreatic insufficiency. Gut. 1998 Apr. doi: 10.1136/gut.42.4.551.

8. Gardner TB, et al. ACG Clinical Guideline: Chronic Pancreatitis. Am J Gastroenterol. 2020 Mar. doi: 10.14309/ajg.0000000000000535.

9. Lewis DM, et al. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci. 2024 Feb. doi: 10.1007/s10620-023-08184-w.

10. Borowitz DS, et al. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. Consensus Committee. J Pediatr. 1995 Nov. doi: 10.1016/s0022-3476(95)70153-2.

11. Domínguez-Muñoz JE, et al. Effect of the Administration Schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: a randomized, three-way crossover study. Aliment Pharmacol Ther. 2005 Apr. doi: 10.1111/j.1365-2036.2005.02390.x.

12. Hart PA and Conwell DL. Chronic Pancreatitis: Managing a Difficult Disease. Am J Gastroenterol. 2020 Jan. doi: 10.14309/ajg.0000000000000421.

Exocrine pancreatic insufficiency (EPI) is a recognized condition in patients with underlying pancreatic disease. However, it is a disease state that requires a meticulous approach to diagnose, as misdiagnosis can lead to inappropriate testing and unnecessary treatment.

EPI has been defined as “a near total decline in the quantity and/or activity of endogenous pancreatic enzymes to a level that is inadequate to maintain normal digestive capacity leading to steatorrhea.”¹ It can lead to complications including malnutrition, micronutrient deficiencies, metabolic bone disease and have significant impact on quality of life. In this article, we will review the approach to diagnosis of EPI, differential diagnosis considerations, the approach to treatment of EPI, and screening for complications.
 

EPI Diagnosis

EPI results from ineffective or insufficient pancreatic digestive enzyme secretion. In 2021, a group of experts from the American Gastroenterological Association (AGA) and PancreasFest met and proposed a new mechanistic definition of EPI. This suggests that EPI is the failure of sufficient pancreatic enzymes to effectively reach the intestine in order to allow for optimal digestion of ingested nutrients, leading to downstream macronutrient and micronutrient deficiencies with symptoms of maldigestion including post-prandial abdominal pain, bloating, steatorrhea, loose stools, or weight loss.²

A more pragmatic definition by Khan, et al in 2022 utilized a staging system to distinguish exocrine pancreatic dysfunction (EDP) from EPI. As such EPD occurs when there is a decline in pancreatic function without impaired digestive capacity, while EPI requires digestive capacity impairment leading to objective steatorrhea (coefficient of fat absorption <93 %).³Differential Diagnosis: There are many factors that can impact normal digestion. In approaching EPI, symptoms are often the most common reason to test for disease state in the appropriate clinical context. There can be pancreatic causes of EPI and non-pancreatic (secondary) causes of EPI (see Figure 1), though the latter can be challenging to detect.

The most common parenchymal etiologies for EPI include chronic pancreatitis, recurrent acute pancreatitis, cystic fibrosis, pancreatic cancer or prior pancreatic resections. Non-pancreatic conditions that impact synchronous mixing of endogenous pancreatic enzymes with meals (i.e., Roux-en-Y gastric bypass, short bowel syndrome, delayed gastric emptying), mucosal barriers causing decrease endogenous pancreatic stimulation despite intact parenchyma, such as celiac disease, foregut Crohn’s disease, intraluminal inactivation of pancreatic enzymes (Zollinger-Ellison syndrome), and bile salts de-conjugation with small intestinal bacterial overgrowth (SIBO) can predispose to EPI.^4-6 The true prevalence of EPI is difficult to ascertain due to a variety of factors including challenges in diagnosis and misdiagnosis.

Some of the major challenges in the diagnosis and treatment of EPI is that the symptoms of EPI overlap with many other GI conditions including celiac disease, diabetes mellitus, SIBO, irritable bowel syndrome (IBS), bile acid diarrhea, and other functional GI syndromes. These non-pancreatic conditions can also be associated with falsely low FE-1. Hence, ordering FE-1 should be employed with caution when the pretest probability is low. Patients with EPI will generally have a significant response to pancreatic enzyme replacement therapy (PERT) if it is adequately dosed and a lack of response should prompt consideration of an alternative diagnosis. A framework to factors which contribute to EPI is outlined in Figure 2.

Symptoms Screening and Signs: Pancreatic enzymes output estimation is the most reliable indicator for pancreatic digestive capacity. However, EPI diagnosis requires a combination of symptoms screening, stool-based (indirect pancreatic function) testing or direct pancreatic function testing (PFT).

Although symptoms might not correlate with objective disease state, in screening for symptoms of steatorrhea or maldigestion, it is important to ask specific questions regarding bloating, abdominal pain, stool frequency, consistency, and quality. Screening questions should be specific and include question such as, “Is there oil in the toilet bowl or is the stool greasy/shiny?”, “Is the stool sticky and difficult to flush or wipe?”, “Is there malodorous flatus?” If patients screen positive for EPI symptoms and there is a high pre-test probability of EPI such as the presence of severe chronic pancreatitis or significant pancreatic resection (> 90% loss of pancreatic parenchyma), then cautious trial of PERT and assessment for treatment response can be considered without additional stool-based testing. However, this practice end points are unclear and mainly based on subjective response.

Patients with EPI are at increased risk for malnutrition and micronutrient deficiencies. While not required for the diagnosis, low levels of fat-soluble vitamins (vitamin AEDK) or other minerals (zinc, selenium, magnesium, phosphorus) can suggest issues with malabsorption. Once the diagnosis of EPI is made, micronutrient screening should occur annually.

Stool Based Testing: The gold standard clinical test for steatorrhea is measuring coefficient of fat absorption (CFA). With a normal range of 93% fat absorption, the test is performed on a 72-hours fecal fat collection kit. To ensure accurate results, a patient must adhere to a diet with a minimum of 100 grams of fat per day in the three days leading up to the test and during the duration of the test. Patients must also abstain from taking PERT during the duration of the test. This can be incredibly challenging for someone with underlying steatorrhea but can reliably distinguish between EPD and EPI.

A more commonly used stool test is fecal elastase (FE-1). While easier to perform, the test often results in many false positives and false negatives. FE-1 is an ELISA based test, which measures the concentration of the specific isoform CELA3 (chymotrypsin-like elastase family) in the stool sample. The test must be run on a solid stool sample as soft or liquid stool will dilute down elastase concentration falsely. One test advantage is that a patient can continue PERT if needed. FE-1 test measures the concentration of patients’ elastase and PERT is porcine derived. As such, there is no interaction between porcine lipase and human elastase in stool. FE-1 sensitivity and specificity are high for severe disease (<100 mcg/g) if the test is performed properly on patients with a high pretest probability. However, the sensitivity and specificity are poor in mild to moderate pancreatic disease and in the absence of known pancreatic disease.⁷

Our suggested approach to utilizing FE-1 test is to reserve it for patients with known severe chronic pancreatitis or prior pancreatic surgery in patients with symptoms. In patients without pancreatic disease who are at low risk of EPI, a positive FE-1 can lead to misdiagnosis, further diagnostic testing, and unnecessary treatment. Currently, there is no stool-based test that is accurate, reproducible, and reliable.

Direct Pancreatic Function testing: Secretin stimulated PFT is highly reliable in measuring ductal function with bicarbonate concentration. However, it cannot reliably estimate acinar function as both do not decline at the same rate, unless in severe pancreatic disease. A much more robust test should include cholecystokinin analog to measure pancreatic enzymes concentration. This test involves endoscopy, administration of secretin, and/or a cholecystokinin analog, and subsequent measurement of bicarbonate and digestive enzymes in the pancreatic juice. This test is not routinely offered as it is invasive, cumbersome, and difficult to repeat for reassessment of pancreatic function over time.⁸

Treatment

The primary goal of treatment is to improve symptoms and nutritional status of the patient. EPI treatment consists of PERT and nutritional counseling. In the United States, there are multiple FDA approved PERT preparations, which include Creon, Zenpep, Pancreaze, Pertzye, Viokase, and Relizorb. While dosing is dependent on lipase concentration, all PERT (aside from Relizorb) preparations have a combination of lipase, proteases, and amylase. All but Viokace and Relizorb are enteric-coated formulations.⁹

In patients with an inadequate response to enteric coated PERT, non-enteric coated PERT can be added as it may provide a more immediate effect than enteric coated formulations, specially if concern about rapid gut transit with inadequate mixing is raised. If a non-enteric formations is used, acid suppression should be added to prevent inactivation of the PERT. Relizorb is a cartridge system which delivers lipase directly to tube feeds. This cartridge is only utilized in patients receiving enteral nutrition and allows for treatment of EPI even when patients are unable to tolerate oral feeding.

PERT dosing is intended to at least compensate for 10% of the physiologically secreted amount of endogenous lipase after a normal meal (approximately 30,000 IU). Hence, dosing is primarily weight-based. In symptomatic adults, PERT dose of 500-1000 units/kg/meal and half of the amount with snacks is appropriate. Although higher doses of 1500-2000 units/kg/meal may be needed when there is significant steatorrhea, weight loss, or micronutrient deficiencies, PERT doses exceeding 2500 units/kg/meal are not recommended and warrant further investigation.¹⁰

Proper counseling is important to ensure compliance with pancreatin preparations. PERT will generally be effective in improving steatorrhea, weight loss, bowel movement frequency, and reversal of nutritional deficiencies, but it does not reliably help symptoms of bloating or abdominal pain. If a patient’s steatorrhea does not respond to PERT, then alternative diagnoses such as SIBO, or diarrhea-predominant IBS should be considered.

PERT must be taken with meals. There are studies that support split dosing as a more effective way of absorbing fat.¹¹ If PERT is ineffective or minimally effective, review of appropriate dosing and timing of PERT to a meal is recommended. Addition of acid suppression may be required to improve treatment efficacy, especially in patients with abnormal intestinal motility or prior pancreatic surgery as PERT is effective at a pH of 4.5. Cost, pill burden, and persistence of certain symptoms may impact adherence to PERT and thus pre-treatment counseling and close follow-up after initiation is important. This aids in assessment of patients’ response to therapy, ensure appropriate PERT administration, and identifying any barriers to therapy adherence.

Nutritional management of EPI consists of an assessment of nutritional status, diet, and lifestyle. An important component of nutritional management is the assessment of micronutrient deficiencies. Patients with a confirmed diagnosis of EPI should be screened for the following micronutrients annually: Vitamins (A, E, D, K, B12), folate, zinc, selenium, magnesium, and iron. Patients with chronic pancreatitis and EPI should also be screened for metabolic bone disease once every two years and for diabetes mellitus annually.^{4, 12}

Conclusion

EPI is a challenging diagnosis as many symptoms overlap with other GI conditions. Pancreas exocrine function is rich with significant reserve to allow for proper digestive capacity, yet EPI occurs when an individual’s pancreatic digestive enzymes are insufficient to meet their nutritional needs. In patients with high likelihood of having EPI, such as those with pre-existing pancreatic disease, diagnosing EPI combines clinical evidence based on subjective symptoms and stool-based testing to support a disease state.

Appropriate dosing and timing of PERT is critical to improve nutritional outcomes and improve certain symptoms of EPI. Failure of PERT requires evaluating for proper dosing/timing, and consideration of additional or alternative diagnosis. EPI morbidity can lead to significant impact on patients’ quality of life, but with counseling, proper PERT use, nutritional consequences can be mediated, and quality of life can improve.

Dr. Hernandez-Barco is based in the Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts. Dr. Ashkar is based in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Dr. Hernandez-Barco disclosed consulting for AMGEN and served as a scientific advisor for Nestle Health Science. She had project-related funding support or conflicts of interest to disclose. Dr. Ashkar disclosed consulting for AMGEN. He had no project-related funding support or conflicts of interest to disclose.

References

1. Othman MO, et al. Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician. Int J Clin Pract. 2018 Feb. doi: 10.1111/ijcp.13066.

2. Whitcomb DC, et al. AGA-PancreasFest Joint Symposium on Exocrine Pancreatitic Insufficiency. Gastro Hep Adv. 2022 Nov. doi: 10.1016/j.gastha.2022.11.008.

3. Khan A, et al. Staging Exocrine Pancreatic Dysfunction. Pancreatology. 2022 Jan. doi: 10.1016/j.pan.2021.11.005.

4. Whitcomb DC, et al. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatitis insufficiency: Expert Review. Gastroenterology. 2023 Nov. doi: 10.1053/j.gastro.2023.07.007.

5. Kunovský L, et al. Causes of Exocrine Pancreatic Insufficiency Other than Chronic Pancreatitis. J Clin Med. 2021 Dec. doi: 10.3390/jcm10245779.

6. Singh VK, et al. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017 Oct. doi: 10.3748/wjg.v23.i39.7059.

7. Lankisch PG, et al. Faecal elastase 1: not helpful in diagnosing chronic pancreatitis associated with mid to moderate exocrine pancreatic insufficiency. Gut. 1998 Apr. doi: 10.1136/gut.42.4.551.

8. Gardner TB, et al. ACG Clinical Guideline: Chronic Pancreatitis. Am J Gastroenterol. 2020 Mar. doi: 10.14309/ajg.0000000000000535.

9. Lewis DM, et al. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci. 2024 Feb. doi: 10.1007/s10620-023-08184-w.

10. Borowitz DS, et al. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. Consensus Committee. J Pediatr. 1995 Nov. doi: 10.1016/s0022-3476(95)70153-2.

11. Domínguez-Muñoz JE, et al. Effect of the Administration Schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: a randomized, three-way crossover study. Aliment Pharmacol Ther. 2005 Apr. doi: 10.1111/j.1365-2036.2005.02390.x.

12. Hart PA and Conwell DL. Chronic Pancreatitis: Managing a Difficult Disease. Am J Gastroenterol. 2020 Jan. doi: 10.14309/ajg.0000000000000421.

Exocrine pancreatic insufficiency (EPI) is a recognized condition in patients with underlying pancreatic disease. However, it is a disease state that requires a meticulous approach to diagnose, as misdiagnosis can lead to inappropriate testing and unnecessary treatment.

EPI has been defined as “a near total decline in the quantity and/or activity of endogenous pancreatic enzymes to a level that is inadequate to maintain normal digestive capacity leading to steatorrhea.”¹ It can lead to complications including malnutrition, micronutrient deficiencies, metabolic bone disease and have significant impact on quality of life. In this article, we will review the approach to diagnosis of EPI, differential diagnosis considerations, the approach to treatment of EPI, and screening for complications.
 

EPI Diagnosis

EPI results from ineffective or insufficient pancreatic digestive enzyme secretion. In 2021, a group of experts from the American Gastroenterological Association (AGA) and PancreasFest met and proposed a new mechanistic definition of EPI. This suggests that EPI is the failure of sufficient pancreatic enzymes to effectively reach the intestine in order to allow for optimal digestion of ingested nutrients, leading to downstream macronutrient and micronutrient deficiencies with symptoms of maldigestion including post-prandial abdominal pain, bloating, steatorrhea, loose stools, or weight loss.²

A more pragmatic definition by Khan, et al in 2022 utilized a staging system to distinguish exocrine pancreatic dysfunction (EDP) from EPI. As such EPD occurs when there is a decline in pancreatic function without impaired digestive capacity, while EPI requires digestive capacity impairment leading to objective steatorrhea (coefficient of fat absorption <93 %).³Differential Diagnosis: There are many factors that can impact normal digestion. In approaching EPI, symptoms are often the most common reason to test for disease state in the appropriate clinical context. There can be pancreatic causes of EPI and non-pancreatic (secondary) causes of EPI (see Figure 1), though the latter can be challenging to detect.

The most common parenchymal etiologies for EPI include chronic pancreatitis, recurrent acute pancreatitis, cystic fibrosis, pancreatic cancer or prior pancreatic resections. Non-pancreatic conditions that impact synchronous mixing of endogenous pancreatic enzymes with meals (i.e., Roux-en-Y gastric bypass, short bowel syndrome, delayed gastric emptying), mucosal barriers causing decrease endogenous pancreatic stimulation despite intact parenchyma, such as celiac disease, foregut Crohn’s disease, intraluminal inactivation of pancreatic enzymes (Zollinger-Ellison syndrome), and bile salts de-conjugation with small intestinal bacterial overgrowth (SIBO) can predispose to EPI.^4-6 The true prevalence of EPI is difficult to ascertain due to a variety of factors including challenges in diagnosis and misdiagnosis.

Some of the major challenges in the diagnosis and treatment of EPI is that the symptoms of EPI overlap with many other GI conditions including celiac disease, diabetes mellitus, SIBO, irritable bowel syndrome (IBS), bile acid diarrhea, and other functional GI syndromes. These non-pancreatic conditions can also be associated with falsely low FE-1. Hence, ordering FE-1 should be employed with caution when the pretest probability is low. Patients with EPI will generally have a significant response to pancreatic enzyme replacement therapy (PERT) if it is adequately dosed and a lack of response should prompt consideration of an alternative diagnosis. A framework to factors which contribute to EPI is outlined in Figure 2.

Symptoms Screening and Signs: Pancreatic enzymes output estimation is the most reliable indicator for pancreatic digestive capacity. However, EPI diagnosis requires a combination of symptoms screening, stool-based (indirect pancreatic function) testing or direct pancreatic function testing (PFT).

Although symptoms might not correlate with objective disease state, in screening for symptoms of steatorrhea or maldigestion, it is important to ask specific questions regarding bloating, abdominal pain, stool frequency, consistency, and quality. Screening questions should be specific and include question such as, “Is there oil in the toilet bowl or is the stool greasy/shiny?”, “Is the stool sticky and difficult to flush or wipe?”, “Is there malodorous flatus?” If patients screen positive for EPI symptoms and there is a high pre-test probability of EPI such as the presence of severe chronic pancreatitis or significant pancreatic resection (> 90% loss of pancreatic parenchyma), then cautious trial of PERT and assessment for treatment response can be considered without additional stool-based testing. However, this practice end points are unclear and mainly based on subjective response.

Patients with EPI are at increased risk for malnutrition and micronutrient deficiencies. While not required for the diagnosis, low levels of fat-soluble vitamins (vitamin AEDK) or other minerals (zinc, selenium, magnesium, phosphorus) can suggest issues with malabsorption. Once the diagnosis of EPI is made, micronutrient screening should occur annually.

Stool Based Testing: The gold standard clinical test for steatorrhea is measuring coefficient of fat absorption (CFA). With a normal range of 93% fat absorption, the test is performed on a 72-hours fecal fat collection kit. To ensure accurate results, a patient must adhere to a diet with a minimum of 100 grams of fat per day in the three days leading up to the test and during the duration of the test. Patients must also abstain from taking PERT during the duration of the test. This can be incredibly challenging for someone with underlying steatorrhea but can reliably distinguish between EPD and EPI.

A more commonly used stool test is fecal elastase (FE-1). While easier to perform, the test often results in many false positives and false negatives. FE-1 is an ELISA based test, which measures the concentration of the specific isoform CELA3 (chymotrypsin-like elastase family) in the stool sample. The test must be run on a solid stool sample as soft or liquid stool will dilute down elastase concentration falsely. One test advantage is that a patient can continue PERT if needed. FE-1 test measures the concentration of patients’ elastase and PERT is porcine derived. As such, there is no interaction between porcine lipase and human elastase in stool. FE-1 sensitivity and specificity are high for severe disease (<100 mcg/g) if the test is performed properly on patients with a high pretest probability. However, the sensitivity and specificity are poor in mild to moderate pancreatic disease and in the absence of known pancreatic disease.⁷

Our suggested approach to utilizing FE-1 test is to reserve it for patients with known severe chronic pancreatitis or prior pancreatic surgery in patients with symptoms. In patients without pancreatic disease who are at low risk of EPI, a positive FE-1 can lead to misdiagnosis, further diagnostic testing, and unnecessary treatment. Currently, there is no stool-based test that is accurate, reproducible, and reliable.

Direct Pancreatic Function testing: Secretin stimulated PFT is highly reliable in measuring ductal function with bicarbonate concentration. However, it cannot reliably estimate acinar function as both do not decline at the same rate, unless in severe pancreatic disease. A much more robust test should include cholecystokinin analog to measure pancreatic enzymes concentration. This test involves endoscopy, administration of secretin, and/or a cholecystokinin analog, and subsequent measurement of bicarbonate and digestive enzymes in the pancreatic juice. This test is not routinely offered as it is invasive, cumbersome, and difficult to repeat for reassessment of pancreatic function over time.⁸

Treatment

The primary goal of treatment is to improve symptoms and nutritional status of the patient. EPI treatment consists of PERT and nutritional counseling. In the United States, there are multiple FDA approved PERT preparations, which include Creon, Zenpep, Pancreaze, Pertzye, Viokase, and Relizorb. While dosing is dependent on lipase concentration, all PERT (aside from Relizorb) preparations have a combination of lipase, proteases, and amylase. All but Viokace and Relizorb are enteric-coated formulations.⁹

In patients with an inadequate response to enteric coated PERT, non-enteric coated PERT can be added as it may provide a more immediate effect than enteric coated formulations, specially if concern about rapid gut transit with inadequate mixing is raised. If a non-enteric formations is used, acid suppression should be added to prevent inactivation of the PERT. Relizorb is a cartridge system which delivers lipase directly to tube feeds. This cartridge is only utilized in patients receiving enteral nutrition and allows for treatment of EPI even when patients are unable to tolerate oral feeding.

PERT dosing is intended to at least compensate for 10% of the physiologically secreted amount of endogenous lipase after a normal meal (approximately 30,000 IU). Hence, dosing is primarily weight-based. In symptomatic adults, PERT dose of 500-1000 units/kg/meal and half of the amount with snacks is appropriate. Although higher doses of 1500-2000 units/kg/meal may be needed when there is significant steatorrhea, weight loss, or micronutrient deficiencies, PERT doses exceeding 2500 units/kg/meal are not recommended and warrant further investigation.¹⁰

Proper counseling is important to ensure compliance with pancreatin preparations. PERT will generally be effective in improving steatorrhea, weight loss, bowel movement frequency, and reversal of nutritional deficiencies, but it does not reliably help symptoms of bloating or abdominal pain. If a patient’s steatorrhea does not respond to PERT, then alternative diagnoses such as SIBO, or diarrhea-predominant IBS should be considered.

PERT must be taken with meals. There are studies that support split dosing as a more effective way of absorbing fat.¹¹ If PERT is ineffective or minimally effective, review of appropriate dosing and timing of PERT to a meal is recommended. Addition of acid suppression may be required to improve treatment efficacy, especially in patients with abnormal intestinal motility or prior pancreatic surgery as PERT is effective at a pH of 4.5. Cost, pill burden, and persistence of certain symptoms may impact adherence to PERT and thus pre-treatment counseling and close follow-up after initiation is important. This aids in assessment of patients’ response to therapy, ensure appropriate PERT administration, and identifying any barriers to therapy adherence.

Nutritional management of EPI consists of an assessment of nutritional status, diet, and lifestyle. An important component of nutritional management is the assessment of micronutrient deficiencies. Patients with a confirmed diagnosis of EPI should be screened for the following micronutrients annually: Vitamins (A, E, D, K, B12), folate, zinc, selenium, magnesium, and iron. Patients with chronic pancreatitis and EPI should also be screened for metabolic bone disease once every two years and for diabetes mellitus annually.^{4, 12}

Conclusion

EPI is a challenging diagnosis as many symptoms overlap with other GI conditions. Pancreas exocrine function is rich with significant reserve to allow for proper digestive capacity, yet EPI occurs when an individual’s pancreatic digestive enzymes are insufficient to meet their nutritional needs. In patients with high likelihood of having EPI, such as those with pre-existing pancreatic disease, diagnosing EPI combines clinical evidence based on subjective symptoms and stool-based testing to support a disease state.

Appropriate dosing and timing of PERT is critical to improve nutritional outcomes and improve certain symptoms of EPI. Failure of PERT requires evaluating for proper dosing/timing, and consideration of additional or alternative diagnosis. EPI morbidity can lead to significant impact on patients’ quality of life, but with counseling, proper PERT use, nutritional consequences can be mediated, and quality of life can improve.

Dr. Hernandez-Barco is based in the Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts. Dr. Ashkar is based in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Dr. Hernandez-Barco disclosed consulting for AMGEN and served as a scientific advisor for Nestle Health Science. She had project-related funding support or conflicts of interest to disclose. Dr. Ashkar disclosed consulting for AMGEN. He had no project-related funding support or conflicts of interest to disclose.

References

1. Othman MO, et al. Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician. Int J Clin Pract. 2018 Feb. doi: 10.1111/ijcp.13066.

2. Whitcomb DC, et al. AGA-PancreasFest Joint Symposium on Exocrine Pancreatitic Insufficiency. Gastro Hep Adv. 2022 Nov. doi: 10.1016/j.gastha.2022.11.008.

3. Khan A, et al. Staging Exocrine Pancreatic Dysfunction. Pancreatology. 2022 Jan. doi: 10.1016/j.pan.2021.11.005.

4. Whitcomb DC, et al. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatitis insufficiency: Expert Review. Gastroenterology. 2023 Nov. doi: 10.1053/j.gastro.2023.07.007.

5. Kunovský L, et al. Causes of Exocrine Pancreatic Insufficiency Other than Chronic Pancreatitis. J Clin Med. 2021 Dec. doi: 10.3390/jcm10245779.

6. Singh VK, et al. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017 Oct. doi: 10.3748/wjg.v23.i39.7059.

7. Lankisch PG, et al. Faecal elastase 1: not helpful in diagnosing chronic pancreatitis associated with mid to moderate exocrine pancreatic insufficiency. Gut. 1998 Apr. doi: 10.1136/gut.42.4.551.

8. Gardner TB, et al. ACG Clinical Guideline: Chronic Pancreatitis. Am J Gastroenterol. 2020 Mar. doi: 10.14309/ajg.0000000000000535.

9. Lewis DM, et al. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci. 2024 Feb. doi: 10.1007/s10620-023-08184-w.

10. Borowitz DS, et al. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. Consensus Committee. J Pediatr. 1995 Nov. doi: 10.1016/s0022-3476(95)70153-2.

11. Domínguez-Muñoz JE, et al. Effect of the Administration Schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: a randomized, three-way crossover study. Aliment Pharmacol Ther. 2005 Apr. doi: 10.1111/j.1365-2036.2005.02390.x.

12. Hart PA and Conwell DL. Chronic Pancreatitis: Managing a Difficult Disease. Am J Gastroenterol. 2020 Jan. doi: 10.14309/ajg.0000000000000421.

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Danielle Kiefer ([email protected]), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Danielle Kiefer ([email protected]), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Dear Friends,

Like many readers, I just returned from Digestive Disease Week® (DDW) in San Diego, California. For the first time in my early career, my experience was not just overwhelming and exhausting. Before, I wanted to do everything – lectures, posters, meetings with friends, prospective research collaborators, and more! This year, I acknowledged that instead of spreading myself thin and not fully engaging, I made a focused daily schedule mixed with productivity and social events, selecting only what was most important to me at this time in my career. This time, after DDW, instead of giving in to my inner introvert and holing myself in my house for a week to recover, I am invigorated by what I learned and the people I met. I can’t wait to see what’s to come next year!

In this issue’s “In Focus”, Dr. Evan Dellon describes his diagnostic approach, including a clear history, endoscopic evaluation with biopsy, and ruling out other causes of esophageal eosinophilia. He emphasizes that treatment should target both inflammation and fibrostenosis and reviews the guidelines and evidence behind first-line treatments, surveillance, and long-term maintenance.

In the second of a two-part series in the “Short Clinical Review” section, Dr. Christopher Vélez, Dr. Rosa L. Yu, and Dr. Jennifer Dimino discuss care for patients with disorders of brain-gut interaction from historically marginalized communities. They highlight ways to improve care for these patients in day-to-day clinical practice.

The transition from trainee to a practicing gastroenterologist may bring with it responsibilities of giving feedback to trainees and/or colleagues to improve. In the “Early Career” section, Dr. Michelle Baliss and Dr. Christine Hachem give practical tips on how best to deliver feedback, with a focus on creating time, building rapport, bidirectional communication, and more.

Lastly, in the “Finance/Legal” section, John S. Gardner, a financial advisor, guides trainees and early career gastroenterologists through estate planning – why it’s important, how to do it effectively, and long-term benefits to starting early.

If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Danielle Kiefer ([email protected]), Communications/Managing Editor of TNG.

Until next time, I leave you with a historical fun fact because we would not be where we are now without appreciating where we were: the first case of eosinophilic esophagitis was only first described in 1978 and became a distinct entity in the early 1990s.

Yours truly, 

Judy A. Trieu, MD, MPH

Editor-in-Chief

Assistant Professor of Medicine

Interventional Endoscopy, Division of Gastroenterology

Washington University School of Medicine in St. Louis

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

Feedback is the purposeful practice of offering constructive, goal-directed input rooted in the power of observation and behavioral assessment. Healthcare inherently fosters a broad range of interactions among people with unique insights, and feedback can naturally emerge from this milieu. In medical training, feedback is an indispensable element that personalizes the learning process and drives the professional development of physicians through all career stages.

If delivered effectively, feedback can strengthen the relationship between the evaluator and recipient, promote self-reflection, and enhance motivation. As such, it has the potential to impact us and those we serve for a lifetime. Feedback has been invaluable to our growth as clinicians and has been embedded into our roles as educators. However, delivering effective feedback requires preparation and consideration of potential challenges. Here, we provide some “tried and true” practical tips on delivering feedback to trainees and co-workers and on navigating potential barriers based on lessons learned.

 

Barriers to Effective Feedback

• Time: Feedback is predicated on observation over time and consideration of repetitive processes rather than isolated events. Perhaps the most challenging factor faced by both parties is that of time constraints, leading to limited ability to engage and build rapport.
• Fear: Hesitancy by evaluators to provide feedback in fear of negative impacts on the recipient’s morale or rapport can lead them to shy away from personalized corrective feedback strategies and choose to rely on written evaluations or generic advice.
• Varying approaches: Feedback strategies have evolved from unidirectional, critique-based, hierarchical practices that emphasize the evaluator’s skills to models that prioritize the recipient’s goals and participation (see Table 1). Traditionally employed feedback models such as the “Feedback Sandwich” or the “Pendleton Rules” are criticized because of a lack of proven benefit on performance, recipient goal prioritization, and open communication.^1,2 Studies showing incongruent perceptions of feedback adequacy between trainees and faculty further support the need for recipient-focused strategies.³ Recognition of the foundational role of the reciprocal learner-teacher alliance in feedback integration inspired newer feedback models, such as the “R2C2” and the “Self-Assessment, Feedback, Encouragement, Direction.”^4,5

But which way is best? With increasing abundance and complexity of feedback frameworks, selecting an approach can feel overwhelming and impractical. A generic “one-size-fits-all” strategy or avoidance of feedback altogether can be detrimental. Structured feedback models can also lead to rigid, inauthentic interactions. Below, we suggest a more practical approach through our tips that unifies the common themes of various feedback models and embeds them into daily practice habits while leaving room for personalization.

 

Our Practical Feedback Tips

Tip 1: Set the scene: Create a positive feedback culture

Proactively creating a culture in which feedback is embedded and encouraged is perhaps the most important step. Priming both parties for feedback clarifies intent, increases receptiveness, and paves the way for growth and open communication. It also prevents the misinterpretation of unexpected feedback as an expression of disapproval. To do this, start by regularly stating your intentions at the start of every experience. Explicitly expressing your vision for mutual learning, bidirectional feedback, and growth in your respective roles attaches a positive intention to feedback. Providing a reminder that we are all works in progress and acknowledging this on a regular basis sets the stage for structured growth opportunities.

Scheduling future feedback encounters from the start maintains accountability and prevents feedback from being perceived as the consequence of a particular behavior. The number and timing of feedback sessions can be customized to the duration of the working relationship, generally allowing enough time for a second interaction (at the end of each week, halfway point, etc.).

 

Tip 2: Build rapport

Increasing clinical workloads and pressure to teach in time-constrained settings often results in insufficient time to engage in conversation and trust building. However, a foundational relationship is an essential precursor to meaningful feedback. Ramani et al. state that “relationships, not recipes, are more likely to promote feedback that has an impact on learner performance and ultimately patient care.”⁶ Building this rapport can begin by dedicating a few minutes (before/during rounds, between cases) to exchange information about career interests, hobbies, favorite restaurants, etc. This “small talk” is the beginning of a two-way exchange that ultimately develops into more meaningful exchanges.

In our experience, this simple step is impactful and fulfilling to both parties. This is also a good time for shared vulnerability by talking about what you are currently working on or have worked on at their stage to affirm that feedback is a continuous part of professional development and not a reflection of how far they are from competence at a given point in time. 

 

Tip 3: Consider Timing, assess readiness, and preschedule sessions

Lack of attention to timing can hinder feedback acceptance. We suggest adhering to delivering positive feedback publicly and corrective feedback privately (“Praise in public, perfect in private”). This reinforces positive behaviors, increases motivation, and minimizes demoralization. Prolonged delays between the observed behavior and feedback can decrease its relevance. Conversely, delivering feedback too soon after an emotionally charged experience can be perceived as blame. Pre-designated times for feedback can minimize the guesswork and maintain your accountability for giving feedback without inadvertently linking it to one particular behavior. If the recipient does not appear to be in a state to receive feedback at the predesignated time, you can pivot to a “check-in” session to show support and strengthen rapport.

Tip 4: Customize to the learner and set shared goals

Diversity in backgrounds, perspectives, and personalities can impact how people perceive their own performances and experience feedback. Given the profound impact of sociocultural factors on feedback assimilation, maintaining the recipient and their goals at the core of performance evaluations is key to feedback acceptance. 

A. Trainees

We suggest starting by introducing the idea of feedback as a partnership and something you feel privileged to do to help them achieve mutual goals. It helps to ask them to use the first day to get oriented with the experience, general expectations, challenges they expect to encounter, and their feedback goals. Tailoring your feedback to their goals creates a sense of shared purpose which increases motivation. Encouraging them to develop their own strategies allows them to play an active role in their growth. Giving them the opportunity to share their perceived strengths and deficiencies provides you with valuable information regarding their insight and ability to self-evaluate. This can help you predict their readiness for your feedback and to tailor your approach when there is a mismatch. 

Examples:

• Medical student: Start with “What do you think you are doing well?” and “What do you think you need to work on?” Build on their response with encouragement and empathy. This helps make them more deliberate with what they work on because being a medical student can be overwhelming and can feel as though they have everything to work on.
• Resident/Fellow: By this point, trainees usually have an increased awareness of their strengths and deficiencies. Your questions can then be more specific, giving them autonomy over their learning, such as “What are some of the things you are working on that you want me to give you feedback on this week?” This makes them more aware, intentional, and receptive to your feedback because it is framed as something that they sought out.

B. Colleagues/Staff

Unlike the training environment in which feedback is built-in, giving feedback to co-workers requires you to establish a feedback-conducive environment and to develop a more in-depth understanding of coworkers’ personalities. Similar strategies can be applied, such as proactively setting the scene for open communication, scheduling check-ins, demonstrating receptiveness to feedback, and investing in trust-building. 

Longer working relationships allow for strong foundational connections that make feedback less threatening. Personality assessment testing like Myers-Briggs Type Indicator or DiSC Assessment can aid in tailoring feedback to different individuals.^7,8 An analytical thinker may appreciate direct, data-driven feedback. Relationship-oriented individuals might respond better to softer, encouragement-based approaches. Always maintain shared goals at the center of your interactions and consider collaborative opportunities such as quality improvement projects. This can improve your working relationship in a constructive way without casting blame.

 

Tip 5: Work on delivery: Bidirectional communication and body language

Non-verbal cues can have a profound impact on how your feedback is interpreted and on the recipient’s comfort to engage in conversation. Sitting down, making eye contact, nodding, and avoiding closed-off body posture can project support and feel less judgmental. Creating a safe and non-distracted environment with privacy can make them feel valued. Use motivating, respectful language focused on directly observed behaviors rather than personal attributes or second-hand reports.

Remember that focusing on repetitive patterns is likely more helpful than isolated incidents. Validate their hard work and give them a global idea of where they stand before diving into individual behaviors. Encourage their participation and empower them to suggest changes they plan to implement. Conclude by having them summarize their action plan to give them ownership and to verify that your feedback was interpreted as you intended. Thank them for being a part of the process, as it does take a partnership for feedback to be effective. 

 

Tip 6: Be open to feedback 

Demonstrating your willingness to accept and act on feedback reinforces a positive culture where feedback is normalized and valued. After an unintended outcome, initiate a two-way conversation and ask their input on anything they wish you would have done differently. This reaffirms your commitment to maintaining culture that does not revolve around one-sided critiques. Frequently soliciting feedback about your feedback skills can also guide you to adapt your approach and to recognize any ineffective feedback practices.

Tip 7: When things don’t go as planned

Receiving feedback, no matter how thoughtfully it is delivered, can be an emotionally-charged experience ending in hurt feelings. This happens because of misinterpretation of feedback as an indicator of inadequacy, heightened awareness of underlying insecurities, sociocultural or personal circumstances, frustration with oneself, needing additional guidance, or being caught off-guard by the assessment.

The evaluator should always acknowledge the recipient’s feelings, show compassion, and allow time for processing. When they are ready to talk, it is important to help reframe the recipients’ mindsets to recognize that feedback is not personal or defining and is not a “one and done” reflection of whether they have “made it.” Instead, it is a continual process that we benefit from through all career stages. Again, shared vulnerability can help to normalize feedback and maintain open dialogue. Setting an opportunity for a future check-in can reinforce support and lead to a more productive conversation after they have had time to process. 

 

Conclusion

Effective feedback delivery is an invaluable skill that can result in meaningful goal-directed changes while strengthening professional relationships. Given the complexity of feedback interactions and the many factors that influence its acceptance, no single approach is suitable for all recipients and frequent adaptation of the approach is essential.

In our experience, adhering to these general overarching feedback principles (see Figure 1) has allowed us to have more successful interactions with trainees and colleagues.

Dr. Baliss is based in the Division of Gastroenterology, Washington University in St. Louis, Missouri. Dr. Hachem is director of the Division of Gastroenterology and Digestive Health at Intermountain Medical, Sandy, Utah. Both authors declare no conflicts of interest.

References

1. Parkes J, et al. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013 Aug. doi:10.1007/s10459-012-9377-9.

2. van de Ridder JMM and Wijnen-Meijer M. Pendleton’s Rules: A Mini Review of a Feedback Method. Am J Biomed Sci & Res. 2023 May. doi: 10.34297/AJBSR.2023.19.002542.

3. Sender Liberman A, et al. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005 Aug. doi: 10.1080/0142590500129183.

4. Sargeant J, et al. R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency. J Grad Med Educ. 2017 Apr. doi: 10.4300/JGME-D-16-00398.1.

5. Liakos W, et al. Frameworks for Effective Feedback in Health Professions Education. Acad Med. 2023 May. doi: 10.1097/ACM.0000000000004884.

6. Ramani S, et al. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019 May. doi: 10.1007/s11606-019-04874-2.

7. Woods RA and Hill PB. Myers-Briggs Type Indicator. StatPearls. StatPearls Publishing. 2022 Sept. https://www.ncbi.nlm.nih.gov/books/NBK554596/

8. Slowikowski MK. Using the DISC behavioral instrument to guide leadership and communication. AORN J. 2005 Nov. doi: 10.1016/s0001-2092(06)60276-7.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or [email protected].

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or [email protected].

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

As a physician, you’ve spent years building a career that not only provides financial security for your family but also allows you to make a meaningful impact in your community. However, without a comprehensive estate plan in place, much of what you’ve worked so hard to build may not be preserved according to your wishes.

Many physicians delay estate planning, assuming it’s something to consider later in life. However, the most successful estate plans are those that are established early and evolve over time. Proper planning ensures that your assets are protected, your loved ones are provided for, and your legacy is preserved in the most tax-efficient and legally-sound manner possible.¹

This article explores why estate planning is particularly crucial for physicians, the key elements of a strong estate plan, and how beginning early can create long-term financial advantages.

 

Why Estate Planning Matters for Physicians

Physicians are in a unique financial position compared to many other professionals. With high earning potential, specialized assets, and significant liability exposure, their estate planning needs differ from those of the average individual. A well-structured estate plan not only facilitates the smooth transfer of wealth but also protects assets from excessive taxation, legal complications, and potential risks such as malpractice claims.

1. High Net-Worth Considerations

Physicians often accumulate substantial wealth over time. Without a clear estate plan, your estate could face excessive taxation, with a large portion of your assets potentially going to the government rather than your heirs. Estate taxes, probate costs, and legal fees can significantly erode your legacy if not properly planned for.

2. Asset Protection from Liability Risks

Unlike most professionals, physicians are at a higher risk of litigation. A comprehensive estate plan can incorporate asset protection strategies, such as irrevocable trusts, family limited partnerships, or liability insurance, to shield your wealth from lawsuits or creditor claims.

3. Family and Generational Wealth Planning

Many physicians prioritize ensuring their family’s financial stability. Whether you want to provide for your spouse, children, or even charitable causes, estate planning allows you to dictate how your wealth is distributed. Establishing trusts for your children or grandchildren can help manage how and when they receive their inheritance, preventing mismanagement and ensuring financial responsibility.

4. Business and Practice Continuity

If you own a medical practice, succession planning should be part of your estate plan. Without clear directives, the future of your practice may be uncertain in the event of your passing or incapacitation. A well-drafted estate plan provides a roadmap for ownership transition, ensuring continuity for patients, employees, and business partners.

Key Elements of an Effective Estate Plan

Every estate plan should be customized based on your financial situation, goals, and family dynamics. However, certain fundamental components apply to nearly all high-net-worth individuals, including physicians.

1. Revocable Living Trusts

A revocable living trust allows you to manage your assets during your lifetime while providing a clear path for distribution after your passing. Unlike a will, a trust helps your estate avoid probate, ensuring a smoother and more private transition of wealth. You maintain control over your assets while also establishing clear rules for distribution, particularly useful if you have minor children or complex family structures.²

2. Irrevocable Trusts for Asset Protection

For physicians concerned about lawsuits or estate tax exposure, irrevocable trusts can offer robust asset protection. Since assets placed in these trusts are no longer legally owned by you, they are shielded from creditors and legal claims while also reducing your taxable estate.²

3. Powers of Attorney and Healthcare Directives

Estate planning isn’t just about what happens after your passing—it’s also about protecting you and your family if you become incapacitated. A durable power of attorney allows a trusted individual to manage your financial affairs, while a healthcare directive ensures your medical decisions align with your wishes.³

4. Life Insurance Planning

Life insurance is an essential estate planning tool for physicians, providing liquidity to cover estate taxes, debts, or income replacement for your family. A properly structured life insurance trust can help ensure that policy proceeds remain outside of your taxable estate while being efficiently distributed according to your wishes.⁴

5. Business Succession Planning

If you own a medical practice, a well-designed succession plan can ensure that your business continues to operate smoothly in your absence. This may involve buy-sell agreements, key-person insurance, or identifying a successor to take over your role.⁵

The Long-Term Benefits of Early Estate Planning

Estate planning is not a one-time event—it’s a process that should evolve with your career, financial growth, and family dynamics. The earlier you begin, the more control you have over your financial future. Here’s why starting early is a strategic advantage:

1. Maximizing Tax Efficiency

Many estate planning strategies, such as gifting assets or establishing irrevocable trusts, are most effective when implemented over time. By spreading out wealth transfers and taking advantage of annual gift exclusions, you can significantly reduce estate tax liability while maintaining financial security.

2. Adjusting for Life Changes

Your financial situation and family needs will change over the years. Marriages, births, career advancements, and new investments all impact your estate planning needs. By starting early, you can make gradual adjustments rather than facing an overwhelming restructuring later in life.¹

3. Ensuring Asset Protection Strategies Are in Place

Many asset protection strategies require time to be effective. For instance, certain types of trusts must be in place for a number of years before they fully shield assets from legal claims. Delaying planning could leave your wealth unnecessarily exposed.

4. Creating a Legacy Beyond Wealth

Estate planning is not just about finances—it’s about legacy. Whether you want to support a charitable cause, endow a scholarship, or establish a foundation, early planning gives you the ability to shape your long-term impact.

5. Adapt to Ever Changing Legislation

Estate planning needs to be adaptable. The federal government can change the estate tax exemption at any time; this was even a topic of the last election cycle. Early planning allows you to implement necessary changes throughout your life to minimize estate taxes. At present, unless new policy is enacted, the exemption per individual will reduce by half in 2026 (see Figure 1).

Final Thoughts: Taking Action Today

Estate planning is a powerful tool for physicians looking to protect their wealth, provide for their families, and leave a lasting legacy. The complexity of physician finances—ranging from high income and significant assets to legal risks—makes individualized estate planning an absolute necessity.

By taking proactive steps today, you can maximize tax efficiency, safeguard your assets, and ensure your wishes are carried out without unnecessary delays or legal battles. Working with a financial advisor and estate planning attorney who understands the unique needs of physicians can help you craft a plan that aligns with your goals and evolves as your career progresses.

Mr. Gardner is a financial advisor at Lifetime Financial Growth, LLC, in Columbus, Ohio, one of the largest privately held wealth management firms in the country. John has had a passion for finance since his early years in college when his tennis coach introduced him. He also has a passion for helping physicians, as his wife is a gastroenterologist at Ohio State University. He reports no relevant disclosures relevant to this article. If you have additional questions, please contact John at 740-403-4891 or [email protected].

References

1. The Law Offices of Diron Rutty, LLC. https://www.dironruttyllc.com/reasons-to-start-estate-planning-early/. 

2. Physician Side Gigs. https://www.physiciansidegigs.com/estateplanning.

3. Afshar, A & MacBeth, S. https://www.schwabe.com/publication/estate-planning-for-physicians-why-its-important-and-how-to-get-started/. December 2024. 

4. Skeeles, JC. https://ohioline.osu.edu/factsheet/ep-1. July 2012.

5. Rosenfeld, J. Physician estate planning guide. Medical Economics. 2022 Nov. https://www.medicaleconomics.com/view/physician-estate-planning-guide.

Introduction: Cases

Patient 1: A 57-year-old man with post-prandial distress variant functional dyspepsia (FD) was recommended to start nortriptyline. He previously established primary care with a physician he met at a barbershop health fair in Harlem, who referred him for specialty evaluation. Today, he presents for follow-up and reports he did not take this medication because he heard it is an antidepressant. How would you counsel him? 

Patient 2: A 61-year-old woman was previously diagnosed with mixed variant irritable bowel syndrome (IBS-M). Her symptoms have not significantly changed. Her prior workup has been reassuring and consistent with IBS-M. Despite this, the patient pushes to repeat a colonoscopy, fearful that something is being missed or that she is not being offered care because of her undocumented status. How do you respond? 

Patient 3: A 36-year-old man is followed for the management of generalized anxiety disorder and functional heartburn. He was started on low-dose amitriptyline with some benefit, but follow-up has been sporadic. On further discussion, he reports financial stressors, time barriers, and difficulty scheduling a meeting with his union representative for work accommodations as he lives in a more rural community. How do you reply?

Patient 4: A 74-year-old man with Parkinson’s disease who uses a wheelchair has functional constipation that is well controlled on his current regimen. He has never undergone colon cancer screening. He occasionally notices blood in his stool, so a colonoscopy was recommended to confirm that his hematochezia reflects functional constipation complicated by hemorrhoids. He is concerned about the bowel preparation required for a colonoscopy given his limited mobility, as his insurance does not cover assistance at home. He does not have family members to help him. How can you assist him?

Social determinants of health, health disparities, and DGBIs

Social determinants of health affect all aspects of patient care, with an increasing body of published work looking at potential disparities in organ-based and structural diseases.^1,2,3,4 However, little has been done to explore their influence on disorders of gut-brain interaction or DGBIs.

From a pathophysiologic perspective, the impact of biopsychosocial stressors is particularly relevant in patients with DGBIs. As DGBIs cannot be diagnosed with a single laboratory or endoscopic test, the patient history is of the utmost importance and physician-patient rapport is paramount in their treatment. Such rapport may be more difficult to establish in patients coming from historically marginalized and minoritized communities who may be distrustful of healthcare as an institution of (discriminatory) power. 

 

Potential DGBI management pitfalls in historically marginalized or minoritized communities

For racial and ethnic minorities in the United States, disparities in healthcare take on many forms. People from racial and ethnic minority communities are less likely to receive a gastroenterology consultation and those with IBS are more likely to undergo procedures as compared to White patients with IBS.⁶ Implicit bias may lead to fewer specialist referrals, and specialty care may be limited or unavailable in some areas. Patients may prefer seeing providers in their own community, with whom they share racial or ethnic identities, which could lead to fewer referrals to specialists outside of the community.

Historical discrimination contributes to a lack of trust in healthcare professionals, which may lead patients to favor more objective diagnostics such as endoscopy or view being counseled against invasive procedures as having necessary care denied. Due to a broader cultural stigma surrounding mental illness, patients may be more hesitant to utilize neuromodulators, which have historically been used for psychiatric diagnoses, as it may lead them to conflate their GI illness with mental illness.^7,8

Since DGBIs cannot be diagnosed with a single test or managed with a single treatment modality, providing excellent care for patients with DGBIs requires clear communication. For patients with limited English proficiency (LEP), access to high-quality language assistance is the foundation of comprehensive care. Interpreter use (or lack thereof) may limit the ability to obtain a complete and accurate clinical history, which can lead to fewer referrals to specialists and increased reliance on endoscopic evaluations that may not be clinically indicated.

These language barriers affect patients on many levels – in their ability to understand instructions for medication administration, preparation for procedures, and return precautions – which may ultimately lead to poorer responses to therapy or delays in care. LEP alone is broadly associated with fewer referrals for outpatient follow-up, adverse health outcomes and complications, and longer hospital stays.⁹ These disparities can be mitigated by investing in high-quality interpreter services, providing instructions and forms in multiple languages, and engaging the patient’s family and social supports according to their preferences.

People experiencing poverty (urban and rural) face challenges across multiple domains including access to healthcare, health insurance, stable housing and employment, and more. Many patients seek care at federally qualified health centers, which may face greater difficulties coordinating care with external gastroenterologists.¹⁰

 

Insurance barriers limit access to essential medications, tests, and procedures, and create delays in establishing care with specialists. Significant psychological stress and higher rates of comorbid anxiety and depression contribute to increased IBS severity.¹¹ Financial limitations may limit dietary choices, which can further exacerbate DGBI symptoms. Long work hours with limited flexibility may prohibit them from presenting for regular follow-ups and establishing advanced DGBI care such as with a dietitian or psychologist.

Patients with disabilities face many of the health inequities previously discussed, as well as additional challenges with physical accessibility, transportation, exclusion from education and employment, discrimination, and stigma. Higher prevalence of comorbid mental illness and higher rates of intimate partner violence and interpersonal violence all contribute to DGBI severity and challenges with access to care.^12,13 Patients with disabilities may struggle to arrive at appointments, maneuver through the building or exam room, and ultimately follow recommended care plans.

 

How to approach DGBIs in historically marginalized and minoritized communities

Returning to the patients from the introduction, how would you counsel each of them?

Patient 1: We can discuss with the patient how nortriptyline and other typical antidepressants can and often are used for indications other than depression. These medications modify centrally-mediated pain signaling and many patients with functional dyspepsia experience a significant benefit. It is critical to build on the rapport that was established at the community health outreach event and to explore the patient’s concerns thoroughly.

Patient 2: We would begin by inquiring about her underlying fears associated with her symptoms and seek to understand her goals for repeat intervention. We can review the risks of endoscopy and shift the focus to improving her symptoms. If we can improve her bowel habits or her pain, her desire for further interventions may lessen. 

Patient 3: It will be important to work within the realistic time and monetary constraints in this patient’s life. We can validate him and the challenges he is facing, provide positive reinforcement for the progress he has made so far, and avoid disparaging him for the aspects of the treatment plan he has been unable to follow through with. As he reported a benefit from amitriptyline, we can consider increasing his dose as a feasible next step. 

Patient 4: We can encourage the patient to discuss with his primary care physician how they may be able to coordinate an inpatient admission for colonoscopy preparation. Given his co-morbidities, this avenue will provide him dedicated support to help him adequately prep to ensure a higher quality examination and limit the need for repeat procedures.

DGBI care in historically marginalized and minoritized communities: A call to action

Understanding cultural differences and existing disparities in care is essential to improving care for patients from historically minoritized communities with DGBIs. Motivational interviewing and shared decision-making, with acknowledgment of social and cultural differences, allow us to work together with patients and their support systems to set and achieve feasible goals.¹⁴

 

To address known health disparities, offices can take steps to ensure the accessibility of language, forms, physical space, providers, and care teams. Providing culturally sensitive care and lowering barriers to care are the first steps to effecting meaningful change for patients with DGBIs from historically minoritized communities.

Dr. Yu is based at Division of Gastroenterology and Hepatology, Boston Medical Center and Boston University, both in Boston, Massachusetts. Dr. Dimino and Dr. Vélez are based at the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, both in Boston, Massachusetts. Dr. Yu, Dr. Dimino, and Dr. Vélez do not have any conflicts of interest for this article.

Additional Online Resources

Form Accessibility 

• Intake Form Guidance for Providers
• Making Your Clinic Welcoming to LGBTQ Patients
• Transgender data collection in the electronic health record: Current concepts and issues

Language Accessibility 

• Overcoming the challenges of providing care to limited English proficient patients

Physical Accessibility 

• Access to Medical Care for Individuals with Mobility Disabilities
• Making your medical office accessible

References

1. Zavala VA, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021 Jan. doi: 10.1038/s41416-020-01038-6.

2. Kardashian A, et al. Health disparities in chronic liver disease. Hepatology. 2023 Apr. doi: 10.1002/hep.32743.

3. Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl. 2021 Jun. doi: 10.1002/lt.25996.

4. Anyane-Yeboa A, et al. The Impact of the Social Determinants of Health on Disparities in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol. 2022 Nov. doi: 10.1016/j.cgh.2022.03.011.

5. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.032.

6. Silvernale C, et al. Racial disparity in healthcare utilization among patients with Irritable Bowel Syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2021 May. doi: 10.1111/nmo.14039.

7. Hearn M, et al. Stigma and irritable bowel syndrome: a taboo subject? Lancet Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/S2468-1253(19)30348-6.

8. Yan XJ, et al. The impact of stigma on medication adherence in patients with functional dyspepsia. Neurogastroenterol Motil. 2021 Feb. doi: 10.1111/nmo.13956.

9. Twersky SE, et al. The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review. Healthcare (Basel). 2024 Jan. doi: 10.3390/healthcare12030364.

10. Bayly JE, et al. Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021. Prev Med Rep. 2024 Feb. doi: 10.1016/j.pmedr.2024.102638.

11. Cheng K, et al. Epidemiology of Irritable Bowel Syndrome in a Large Academic Safety-Net Hospital. J Clin Med. 2024 Feb. doi: 10.3390/jcm13051314.

12. Breiding MJ, Armour BS. The association between disability and intimate partner violence in the United States. Ann Epidemiol. 2015 Jun. doi: 10.1016/j.annepidem.2015.03.017.

13. Mitra M, et al. Prevalence and characteristics of sexual violence against men with disabilities. Am J Prev Med. 2016 Mar. doi: 10.1016/j.amepre.2015.07.030.

14. Bahafzallah L, et al. Motivational Interviewing in Ethnic Populations. J Immigr Minor Health. 2020 Aug. doi: 10.1007/s10903-019-00940-3.

Introduction: Cases

Patient 1: A 57-year-old man with post-prandial distress variant functional dyspepsia (FD) was recommended to start nortriptyline. He previously established primary care with a physician he met at a barbershop health fair in Harlem, who referred him for specialty evaluation. Today, he presents for follow-up and reports he did not take this medication because he heard it is an antidepressant. How would you counsel him? 

Patient 2: A 61-year-old woman was previously diagnosed with mixed variant irritable bowel syndrome (IBS-M). Her symptoms have not significantly changed. Her prior workup has been reassuring and consistent with IBS-M. Despite this, the patient pushes to repeat a colonoscopy, fearful that something is being missed or that she is not being offered care because of her undocumented status. How do you respond? 

Patient 3: A 36-year-old man is followed for the management of generalized anxiety disorder and functional heartburn. He was started on low-dose amitriptyline with some benefit, but follow-up has been sporadic. On further discussion, he reports financial stressors, time barriers, and difficulty scheduling a meeting with his union representative for work accommodations as he lives in a more rural community. How do you reply?

Patient 4: A 74-year-old man with Parkinson’s disease who uses a wheelchair has functional constipation that is well controlled on his current regimen. He has never undergone colon cancer screening. He occasionally notices blood in his stool, so a colonoscopy was recommended to confirm that his hematochezia reflects functional constipation complicated by hemorrhoids. He is concerned about the bowel preparation required for a colonoscopy given his limited mobility, as his insurance does not cover assistance at home. He does not have family members to help him. How can you assist him?

Social determinants of health, health disparities, and DGBIs

Social determinants of health affect all aspects of patient care, with an increasing body of published work looking at potential disparities in organ-based and structural diseases.^1,2,3,4 However, little has been done to explore their influence on disorders of gut-brain interaction or DGBIs.

From a pathophysiologic perspective, the impact of biopsychosocial stressors is particularly relevant in patients with DGBIs. As DGBIs cannot be diagnosed with a single laboratory or endoscopic test, the patient history is of the utmost importance and physician-patient rapport is paramount in their treatment. Such rapport may be more difficult to establish in patients coming from historically marginalized and minoritized communities who may be distrustful of healthcare as an institution of (discriminatory) power. 

 

Potential DGBI management pitfalls in historically marginalized or minoritized communities

For racial and ethnic minorities in the United States, disparities in healthcare take on many forms. People from racial and ethnic minority communities are less likely to receive a gastroenterology consultation and those with IBS are more likely to undergo procedures as compared to White patients with IBS.⁶ Implicit bias may lead to fewer specialist referrals, and specialty care may be limited or unavailable in some areas. Patients may prefer seeing providers in their own community, with whom they share racial or ethnic identities, which could lead to fewer referrals to specialists outside of the community.

Historical discrimination contributes to a lack of trust in healthcare professionals, which may lead patients to favor more objective diagnostics such as endoscopy or view being counseled against invasive procedures as having necessary care denied. Due to a broader cultural stigma surrounding mental illness, patients may be more hesitant to utilize neuromodulators, which have historically been used for psychiatric diagnoses, as it may lead them to conflate their GI illness with mental illness.^7,8

Since DGBIs cannot be diagnosed with a single test or managed with a single treatment modality, providing excellent care for patients with DGBIs requires clear communication. For patients with limited English proficiency (LEP), access to high-quality language assistance is the foundation of comprehensive care. Interpreter use (or lack thereof) may limit the ability to obtain a complete and accurate clinical history, which can lead to fewer referrals to specialists and increased reliance on endoscopic evaluations that may not be clinically indicated.

These language barriers affect patients on many levels – in their ability to understand instructions for medication administration, preparation for procedures, and return precautions – which may ultimately lead to poorer responses to therapy or delays in care. LEP alone is broadly associated with fewer referrals for outpatient follow-up, adverse health outcomes and complications, and longer hospital stays.⁹ These disparities can be mitigated by investing in high-quality interpreter services, providing instructions and forms in multiple languages, and engaging the patient’s family and social supports according to their preferences.

People experiencing poverty (urban and rural) face challenges across multiple domains including access to healthcare, health insurance, stable housing and employment, and more. Many patients seek care at federally qualified health centers, which may face greater difficulties coordinating care with external gastroenterologists.¹⁰

 

Insurance barriers limit access to essential medications, tests, and procedures, and create delays in establishing care with specialists. Significant psychological stress and higher rates of comorbid anxiety and depression contribute to increased IBS severity.¹¹ Financial limitations may limit dietary choices, which can further exacerbate DGBI symptoms. Long work hours with limited flexibility may prohibit them from presenting for regular follow-ups and establishing advanced DGBI care such as with a dietitian or psychologist.

Patients with disabilities face many of the health inequities previously discussed, as well as additional challenges with physical accessibility, transportation, exclusion from education and employment, discrimination, and stigma. Higher prevalence of comorbid mental illness and higher rates of intimate partner violence and interpersonal violence all contribute to DGBI severity and challenges with access to care.^12,13 Patients with disabilities may struggle to arrive at appointments, maneuver through the building or exam room, and ultimately follow recommended care plans.

 

How to approach DGBIs in historically marginalized and minoritized communities

Returning to the patients from the introduction, how would you counsel each of them?

Patient 1: We can discuss with the patient how nortriptyline and other typical antidepressants can and often are used for indications other than depression. These medications modify centrally-mediated pain signaling and many patients with functional dyspepsia experience a significant benefit. It is critical to build on the rapport that was established at the community health outreach event and to explore the patient’s concerns thoroughly.

Patient 2: We would begin by inquiring about her underlying fears associated with her symptoms and seek to understand her goals for repeat intervention. We can review the risks of endoscopy and shift the focus to improving her symptoms. If we can improve her bowel habits or her pain, her desire for further interventions may lessen. 

Patient 3: It will be important to work within the realistic time and monetary constraints in this patient’s life. We can validate him and the challenges he is facing, provide positive reinforcement for the progress he has made so far, and avoid disparaging him for the aspects of the treatment plan he has been unable to follow through with. As he reported a benefit from amitriptyline, we can consider increasing his dose as a feasible next step. 

Patient 4: We can encourage the patient to discuss with his primary care physician how they may be able to coordinate an inpatient admission for colonoscopy preparation. Given his co-morbidities, this avenue will provide him dedicated support to help him adequately prep to ensure a higher quality examination and limit the need for repeat procedures.

DGBI care in historically marginalized and minoritized communities: A call to action

Understanding cultural differences and existing disparities in care is essential to improving care for patients from historically minoritized communities with DGBIs. Motivational interviewing and shared decision-making, with acknowledgment of social and cultural differences, allow us to work together with patients and their support systems to set and achieve feasible goals.¹⁴

 

To address known health disparities, offices can take steps to ensure the accessibility of language, forms, physical space, providers, and care teams. Providing culturally sensitive care and lowering barriers to care are the first steps to effecting meaningful change for patients with DGBIs from historically minoritized communities.

Dr. Yu is based at Division of Gastroenterology and Hepatology, Boston Medical Center and Boston University, both in Boston, Massachusetts. Dr. Dimino and Dr. Vélez are based at the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, both in Boston, Massachusetts. Dr. Yu, Dr. Dimino, and Dr. Vélez do not have any conflicts of interest for this article.

Additional Online Resources

Form Accessibility 

• Intake Form Guidance for Providers
• Making Your Clinic Welcoming to LGBTQ Patients
• Transgender data collection in the electronic health record: Current concepts and issues

Language Accessibility 

• Overcoming the challenges of providing care to limited English proficient patients

Physical Accessibility 

• Access to Medical Care for Individuals with Mobility Disabilities
• Making your medical office accessible

References

1. Zavala VA, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021 Jan. doi: 10.1038/s41416-020-01038-6.

2. Kardashian A, et al. Health disparities in chronic liver disease. Hepatology. 2023 Apr. doi: 10.1002/hep.32743.

3. Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl. 2021 Jun. doi: 10.1002/lt.25996.

4. Anyane-Yeboa A, et al. The Impact of the Social Determinants of Health on Disparities in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol. 2022 Nov. doi: 10.1016/j.cgh.2022.03.011.

5. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.032.

6. Silvernale C, et al. Racial disparity in healthcare utilization among patients with Irritable Bowel Syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2021 May. doi: 10.1111/nmo.14039.

7. Hearn M, et al. Stigma and irritable bowel syndrome: a taboo subject? Lancet Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/S2468-1253(19)30348-6.

8. Yan XJ, et al. The impact of stigma on medication adherence in patients with functional dyspepsia. Neurogastroenterol Motil. 2021 Feb. doi: 10.1111/nmo.13956.

9. Twersky SE, et al. The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review. Healthcare (Basel). 2024 Jan. doi: 10.3390/healthcare12030364.

10. Bayly JE, et al. Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021. Prev Med Rep. 2024 Feb. doi: 10.1016/j.pmedr.2024.102638.

11. Cheng K, et al. Epidemiology of Irritable Bowel Syndrome in a Large Academic Safety-Net Hospital. J Clin Med. 2024 Feb. doi: 10.3390/jcm13051314.

12. Breiding MJ, Armour BS. The association between disability and intimate partner violence in the United States. Ann Epidemiol. 2015 Jun. doi: 10.1016/j.annepidem.2015.03.017.

13. Mitra M, et al. Prevalence and characteristics of sexual violence against men with disabilities. Am J Prev Med. 2016 Mar. doi: 10.1016/j.amepre.2015.07.030.

14. Bahafzallah L, et al. Motivational Interviewing in Ethnic Populations. J Immigr Minor Health. 2020 Aug. doi: 10.1007/s10903-019-00940-3.

Introduction: Cases

Patient 1: A 57-year-old man with post-prandial distress variant functional dyspepsia (FD) was recommended to start nortriptyline. He previously established primary care with a physician he met at a barbershop health fair in Harlem, who referred him for specialty evaluation. Today, he presents for follow-up and reports he did not take this medication because he heard it is an antidepressant. How would you counsel him? 

Patient 2: A 61-year-old woman was previously diagnosed with mixed variant irritable bowel syndrome (IBS-M). Her symptoms have not significantly changed. Her prior workup has been reassuring and consistent with IBS-M. Despite this, the patient pushes to repeat a colonoscopy, fearful that something is being missed or that she is not being offered care because of her undocumented status. How do you respond? 

Patient 3: A 36-year-old man is followed for the management of generalized anxiety disorder and functional heartburn. He was started on low-dose amitriptyline with some benefit, but follow-up has been sporadic. On further discussion, he reports financial stressors, time barriers, and difficulty scheduling a meeting with his union representative for work accommodations as he lives in a more rural community. How do you reply?

Patient 4: A 74-year-old man with Parkinson’s disease who uses a wheelchair has functional constipation that is well controlled on his current regimen. He has never undergone colon cancer screening. He occasionally notices blood in his stool, so a colonoscopy was recommended to confirm that his hematochezia reflects functional constipation complicated by hemorrhoids. He is concerned about the bowel preparation required for a colonoscopy given his limited mobility, as his insurance does not cover assistance at home. He does not have family members to help him. How can you assist him?

Social determinants of health, health disparities, and DGBIs

Social determinants of health affect all aspects of patient care, with an increasing body of published work looking at potential disparities in organ-based and structural diseases.^1,2,3,4 However, little has been done to explore their influence on disorders of gut-brain interaction or DGBIs.

From a pathophysiologic perspective, the impact of biopsychosocial stressors is particularly relevant in patients with DGBIs. As DGBIs cannot be diagnosed with a single laboratory or endoscopic test, the patient history is of the utmost importance and physician-patient rapport is paramount in their treatment. Such rapport may be more difficult to establish in patients coming from historically marginalized and minoritized communities who may be distrustful of healthcare as an institution of (discriminatory) power. 

 

Potential DGBI management pitfalls in historically marginalized or minoritized communities

For racial and ethnic minorities in the United States, disparities in healthcare take on many forms. People from racial and ethnic minority communities are less likely to receive a gastroenterology consultation and those with IBS are more likely to undergo procedures as compared to White patients with IBS.⁶ Implicit bias may lead to fewer specialist referrals, and specialty care may be limited or unavailable in some areas. Patients may prefer seeing providers in their own community, with whom they share racial or ethnic identities, which could lead to fewer referrals to specialists outside of the community.

Historical discrimination contributes to a lack of trust in healthcare professionals, which may lead patients to favor more objective diagnostics such as endoscopy or view being counseled against invasive procedures as having necessary care denied. Due to a broader cultural stigma surrounding mental illness, patients may be more hesitant to utilize neuromodulators, which have historically been used for psychiatric diagnoses, as it may lead them to conflate their GI illness with mental illness.^7,8

Since DGBIs cannot be diagnosed with a single test or managed with a single treatment modality, providing excellent care for patients with DGBIs requires clear communication. For patients with limited English proficiency (LEP), access to high-quality language assistance is the foundation of comprehensive care. Interpreter use (or lack thereof) may limit the ability to obtain a complete and accurate clinical history, which can lead to fewer referrals to specialists and increased reliance on endoscopic evaluations that may not be clinically indicated.

These language barriers affect patients on many levels – in their ability to understand instructions for medication administration, preparation for procedures, and return precautions – which may ultimately lead to poorer responses to therapy or delays in care. LEP alone is broadly associated with fewer referrals for outpatient follow-up, adverse health outcomes and complications, and longer hospital stays.⁹ These disparities can be mitigated by investing in high-quality interpreter services, providing instructions and forms in multiple languages, and engaging the patient’s family and social supports according to their preferences.

People experiencing poverty (urban and rural) face challenges across multiple domains including access to healthcare, health insurance, stable housing and employment, and more. Many patients seek care at federally qualified health centers, which may face greater difficulties coordinating care with external gastroenterologists.¹⁰

 

Insurance barriers limit access to essential medications, tests, and procedures, and create delays in establishing care with specialists. Significant psychological stress and higher rates of comorbid anxiety and depression contribute to increased IBS severity.¹¹ Financial limitations may limit dietary choices, which can further exacerbate DGBI symptoms. Long work hours with limited flexibility may prohibit them from presenting for regular follow-ups and establishing advanced DGBI care such as with a dietitian or psychologist.

Patients with disabilities face many of the health inequities previously discussed, as well as additional challenges with physical accessibility, transportation, exclusion from education and employment, discrimination, and stigma. Higher prevalence of comorbid mental illness and higher rates of intimate partner violence and interpersonal violence all contribute to DGBI severity and challenges with access to care.^12,13 Patients with disabilities may struggle to arrive at appointments, maneuver through the building or exam room, and ultimately follow recommended care plans.

 

How to approach DGBIs in historically marginalized and minoritized communities

Returning to the patients from the introduction, how would you counsel each of them?

Patient 1: We can discuss with the patient how nortriptyline and other typical antidepressants can and often are used for indications other than depression. These medications modify centrally-mediated pain signaling and many patients with functional dyspepsia experience a significant benefit. It is critical to build on the rapport that was established at the community health outreach event and to explore the patient’s concerns thoroughly.

Patient 2: We would begin by inquiring about her underlying fears associated with her symptoms and seek to understand her goals for repeat intervention. We can review the risks of endoscopy and shift the focus to improving her symptoms. If we can improve her bowel habits or her pain, her desire for further interventions may lessen. 

Patient 3: It will be important to work within the realistic time and monetary constraints in this patient’s life. We can validate him and the challenges he is facing, provide positive reinforcement for the progress he has made so far, and avoid disparaging him for the aspects of the treatment plan he has been unable to follow through with. As he reported a benefit from amitriptyline, we can consider increasing his dose as a feasible next step. 

Patient 4: We can encourage the patient to discuss with his primary care physician how they may be able to coordinate an inpatient admission for colonoscopy preparation. Given his co-morbidities, this avenue will provide him dedicated support to help him adequately prep to ensure a higher quality examination and limit the need for repeat procedures.

DGBI care in historically marginalized and minoritized communities: A call to action

Understanding cultural differences and existing disparities in care is essential to improving care for patients from historically minoritized communities with DGBIs. Motivational interviewing and shared decision-making, with acknowledgment of social and cultural differences, allow us to work together with patients and their support systems to set and achieve feasible goals.¹⁴

 

To address known health disparities, offices can take steps to ensure the accessibility of language, forms, physical space, providers, and care teams. Providing culturally sensitive care and lowering barriers to care are the first steps to effecting meaningful change for patients with DGBIs from historically minoritized communities.

Dr. Yu is based at Division of Gastroenterology and Hepatology, Boston Medical Center and Boston University, both in Boston, Massachusetts. Dr. Dimino and Dr. Vélez are based at the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, both in Boston, Massachusetts. Dr. Yu, Dr. Dimino, and Dr. Vélez do not have any conflicts of interest for this article.

Additional Online Resources

Form Accessibility 

• Intake Form Guidance for Providers
• Making Your Clinic Welcoming to LGBTQ Patients
• Transgender data collection in the electronic health record: Current concepts and issues

Language Accessibility 

• Overcoming the challenges of providing care to limited English proficient patients

Physical Accessibility 

• Access to Medical Care for Individuals with Mobility Disabilities
• Making your medical office accessible

References

1. Zavala VA, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021 Jan. doi: 10.1038/s41416-020-01038-6.

2. Kardashian A, et al. Health disparities in chronic liver disease. Hepatology. 2023 Apr. doi: 10.1002/hep.32743.

3. Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl. 2021 Jun. doi: 10.1002/lt.25996.

4. Anyane-Yeboa A, et al. The Impact of the Social Determinants of Health on Disparities in Inflammatory Bowel Disease. Clin Gastroenterol Hepatol. 2022 Nov. doi: 10.1016/j.cgh.2022.03.011.

5. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.032.

6. Silvernale C, et al. Racial disparity in healthcare utilization among patients with Irritable Bowel Syndrome: results from a multicenter cohort. Neurogastroenterol Motil. 2021 May. doi: 10.1111/nmo.14039.

7. Hearn M, et al. Stigma and irritable bowel syndrome: a taboo subject? Lancet Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/S2468-1253(19)30348-6.

8. Yan XJ, et al. The impact of stigma on medication adherence in patients with functional dyspepsia. Neurogastroenterol Motil. 2021 Feb. doi: 10.1111/nmo.13956.

9. Twersky SE, et al. The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review. Healthcare (Basel). 2024 Jan. doi: 10.3390/healthcare12030364.

10. Bayly JE, et al. Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021. Prev Med Rep. 2024 Feb. doi: 10.1016/j.pmedr.2024.102638.

11. Cheng K, et al. Epidemiology of Irritable Bowel Syndrome in a Large Academic Safety-Net Hospital. J Clin Med. 2024 Feb. doi: 10.3390/jcm13051314.

12. Breiding MJ, Armour BS. The association between disability and intimate partner violence in the United States. Ann Epidemiol. 2015 Jun. doi: 10.1016/j.annepidem.2015.03.017.

13. Mitra M, et al. Prevalence and characteristics of sexual violence against men with disabilities. Am J Prev Med. 2016 Mar. doi: 10.1016/j.amepre.2015.07.030.

14. Bahafzallah L, et al. Motivational Interviewing in Ethnic Populations. J Immigr Minor Health. 2020 Aug. doi: 10.1007/s10903-019-00940-3.

Eosinophilic esophagitis (EoE) can be considered a “young” disease, with initial case series reported only about 30 years ago. Since that time, it has become a commonly encountered condition in both emergency and clinic settings. The most recent prevalence study estimates that 1 in 700 people in the U.S. have EoE,¹ the volume of EoE-associated ED visits tripped between 2009 and 2019 and is projected to double again by 2030,² and “new” gastroenterologists undoubtedly have learned about and seen this condition. As a chronic disease, EoE necessitates longitudinal follow-up and optimization of care to prevent complications. With increasing diagnostic delay, EoE progresses in most, but not all, patients from an inflammatory- to fibrostenotic-predominant condition.³This article will review a practical approach to diagnosing EoE, including common scenarios where it can be picked-up, as well as treatment and monitoring approaches.

Diagnosis of EoE

The most likely area that you will encounter EoE is during an emergent middle-of-the-night endoscopy for food impaction. If called in for this, EoE will be the cause in more than 50% of patients.⁴ However, the diagnosis can only be made if esophageal biopsies are obtained at the time of the procedure. This is a critical time to decrease diagnostic delay, as half of patients are lost to follow-up after a food impaction.⁵ Unfortunately, although taking biopsies during index food impaction is guideline-recommended, a quality metric, and safe to obtain after the food bolus is cleared, this is infrequently done in practice.^{6, 7}

The next most likely area for EoE detection is in the endoscopy suite where 15-23% of patients with dysphagia and 5-7% of patients undergoing upper endoscopy for any indication will have EoE.⁴ Sometimes EoE will be detected “incidentally” during an open-access case (for example, in a patient with diarrhea undergoing evaluation for celiac). In these cases, it is important to perform a careful history (as noted below) as subtle EoE symptoms can frequently be identified. Finally, when patients are seen in clinic for solid food dysphagia, EoE is clearly on the differential. A few percent of patients with refractory heartburn or chest pain will have EoE causing the symptoms rather than reflux,⁴ and all patients under consideration for antireflux surgery should have an endoscopy to assess for EoE.

When talking to patients with known or suspected EoE, the history must go beyond general questions about dysphagia or trouble swallowing. Many patients with EoE have overtly or subconsciously modified their eating behaviors over many years to minimize symptoms, may have adapted to chronic dysphagia, and will answer “no” when asked if they have trouble swallowing. Instead, use the acronym “IMPACT” to delve deeper into possible symptoms.⁸ Do they “Imbibe” fluids or liquids between each bite to help get food down? Do they “Modify” the way they eat (cut food into small bites; puree foods)? Do they “Prolong” mealtimes? Do they “Avoid” certain foods that stick? Do they “Chew’ until their food is a mush to get it down? And do they “Turn away” tablets or pills? Pill dysphagia is often a subtle symptom, and sometimes the only symptom elicited.

Additionally, it may be important to ask a partner or family member (if present) about their observations. They may provide insight (e.g. “yes – he chokes with every bite but never says it bothers him”) that the patient might not otherwise provide. The suspicion for EoE should also be increased in patients with concomitant atopic diseases and in those with a family history of dysphagia or who have family members needing esophageal dilation. It is important to remember that EoE can be seen across all ages, sexes, and races/ethnicities.

Diagnosis of EoE is based on the AGREE consensus,⁹ which is also echoed in the recently updated American College of Gastroenterology (ACG) guidelines.¹⁰ Diagnosis requires three steps. First, symptoms of esophageal dysfunction must be present. This will most typically be dysphagia in adolescents and adults, but symptoms are non-specific in children (e.g. poor growth and feeding, abdominal pain, vomiting, regurgitation, heartburn).

Second, at least 15 eosinophils per high-power field (eos/hpf) are required on esophageal biopsy, which implies that an endoscopy be performed. A high-quality endoscopic exam in EoE is of the utmost importance. The approach has been described elsewhere,¹¹ but enough time on insertion should be taken to fully insufflate and examine the esophagus, including the areas of the gastroesophageal junction and upper esophageal sphincter where strictures can be missed, to gently wash debris, and to assess the endoscopic findings of EoE. Endoscopic findings should be reported using the validated EoE Endoscopy Reference Score (EREFS),¹² which grades five key features. EREFS is reproducible, is responsive to treatment, and is guideline-recommended (see Figure 1).^{6, 10} The features are edema (present=1), rings (mild=1; moderate=2; severe=3), exudates (mild=1; severe=2), furrows (mild=1; severe=2), and stricture (present=1; also estimate diameter in mm) and are incorporated into many endoscopic reporting programs. Additionally, diffuse luminal narrowing and mucosal fragility (“crepe-paper” mucosa) should be assessed.

After this, biopsies should be obtained with at least 6 biopsy fragments from different locations in the esophagus. Any visible endoscopic abnormalities should be targeted (the highest yield is in exudates and furrows). The rationale is that EoE is patchy and at least 6 biopsies will maximize diagnostic yield.¹⁰ Ideally the initial endoscopy for EoE should be done off of treatments (like PPI or diet restriction) as these could mask the diagnosis. If a patient with suspected EoE has an endoscopy while on PPI, and the endoscopy is normal, a diagnosis of EoE cannot be made. In this case, consideration should be given as to stopping the PPI, allowing a wash out period (at least 1-2 months), and then repeating the endoscopy to confirm the diagnosis. This is important as EoE is a chronic condition necessitating life-long treatment and monitoring, so a definitive diagnosis is critical.

The third and final step in diagnosis is assessing for other conditions that could cause esophageal eosinophilia.⁹ The most common differential diagnosis is gastroesophageal reflux disease (GERD). In some cases, EoE and GERD overlap or can have a complex relationship.¹³ Unfortunately the location of the eosinophilia (i.e. distal only) and the level of the eosinophil counts are not useful in making this distinction, so all clinical features (symptoms, presence of erosive esophagitis, or a hiatal hernia endoscopically), and ancillary reflex testing when indicated may be required prior to a formal EoE diagnosis. After the diagnosis is established, there should be direct communication with the patient to review the diagnosis and select treatments. While it is possible to convey results electronically in a messaging portal or with a letter, a more formal interaction, such as a clinic visit, is recommended because this is a new diagnosis of a chronic condition. Similarly, a new diagnosis of inflammatory bowel disease would never be made in a pathology follow-up letter alone. 

 

Treatment of EoE

When it comes to treatment, the new guidelines emphasize several points.¹⁰ First, there is the concept that anti-inflammatory treatment should be paired with assessment of fibrostenosis and esophageal dilation; to do either in isolation is incomplete treatment. It is safe to perform dilation both prior to anti-inflammatory treatment (for example, with a critical stricture in a patient with dysphagia) and after anti-inflammatory treatment has been prescribed (for example, during an endoscopy to assess treatment response).

Second, proton pump inhibitors (PPIs), swallowed topical corticosteroids (tCS), or dietary elimination are all acceptable first-line treatment options for EoE. A shared decision-making framework should be used for this discussion. If dietary elimination is selected,¹⁴ based on new clinical trial data, guidelines recommend using empiric elimination and starting with a less restrictive diet (either a one-food elimination diet with dairy alone or a two-food elimination with dairy and wheat elimination). If PPIs are selected, the dose should be double the standard reflux dose. Data are mixed as to whether to use twice daily dosing (i.e., omeprazole 20 mg twice daily) or once a day dosing (i.e., omeprazole 40 mg daily), but total dose and adherence may be more important than frequency.¹⁰

For tCS use, either budesonide or fluticasone can be selected, but budesonide oral suspension is the only FDA-approved tCS for EoE.¹⁵ Initial treatment length is usually 6-8 weeks for diet elimination and, 12 weeks for PPI and tCS. In general, it is best to pick a single treatment to start, and reserve combining therapies for patients who do not have a complete response to a single modality as there are few data to support combination therapy.

After initial treatment, it is critical to assess for treatment response.¹⁶ Goals of EoE treatment include improvement in symptoms, but also improvement in endoscopic and histologic features to prevent complications. Symptoms in EoE do not always correlate with underlying biologic disease activity: patients can minimize symptoms with careful eating; they may perceive no difference in symptoms despite histologic improvement if a stricture persists; and they may have minimal symptoms after esophageal dilation despite ongoing inflammation. Because of this, performing a follow-up endoscopy after initial treatment is guideline-recommended.^{10, 17} This allows assessing for endoscopic improvement, re-assessing for fibrostenosis and performing dilation if indicated, and obtaining esophageal biopsies. If there is non-response, options include switching between other first line treatments or considering “stepping-up” to dupilumab which is also an FDA-approved option for EoE that is recommended in the guidelines.^{10, 18} In some cases where patients have multiple severe atopic conditions such as asthma or eczema that would warrant dupilumab use, or if patients are intolerant to PPIs or tCS, dupilumab could be considered as an earlier treatment for EoE.

 

Long-Term Maintenance

If a patient has a good response (for example, improved symptoms, improved endoscopic features, and <15 eos/hpf on biopsy), treatment can be maintained long-term. In almost all cases, if treatment is stopped, EoE disease activity recurs.¹⁹ Patients could be seen back in clinic in 6-12 months, and then a discussion can be conducted about a follow-up endoscopy, with timing to be determined based on their individual disease features and severity.¹⁷

Patients with more severe strictures, however, may have to be seen in endoscopy for serial dilations. Continued follow-up is essential for optimal care. Just as patients can progress in their disease course with diagnostic delay, there are data that show they can also progress after diagnosis when there are gaps in care without regular follow-up.²⁰ Unlike other chronic esophageal disorders such as GERD and Barrett’s esophagus and other chronic GI inflammatory conditions like inflammatory bowel disease, however, EoE is not associated with an increased risk of esophageal cancer.^{21, 22}

Given its increasing frequency, EoE will be commonly encountered by gastroenterologists both new and established. Having a systematic approach for diagnosis, understanding how to elicit subtle symptoms, implementing a shared decision-making framework for treatment with a structured algorithm for assessing response, performing follow-up, maintaining treatment, and monitoring patients long-term will allow the large majority of EoE patients to be successfully managed.

Dr. Dellon is based at the Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill. He disclosed research funding, consultant fees, and educational grants from multiple companies.

References

1. Thel HL, et al. Prevalence and Costs of Eosinophilic Esophagitis in the United States. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.09.031.

2. Lam AY, et al. Epidemiologic Burden and Projections for Eosinophilic Esophagitis-Associated Emergency Department Visits in the United States: 2009-2030. Clin Gastroenterol Hepatol. 2023 Nov. doi: 10.1016/j.cgh.2023.04.028.

3. Schoepfer AM, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013 Dec. doi: 10.1053/j.gastro.2013.08.015.

4. Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology. 2018 Jan. doi: 10.1053/j.gastro.2017.06.067.

5. Chang JW, et al. Loss to follow-up after food impaction among patients with and without eosinophilic esophagitis. Dis Esophagus. 2019 Dec. doi: 10.1093/dote/doz056.

6. Aceves SS, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc. 2022 Aug. doi: 10.1016/j.gie.2022.05.013.

7. Leiman DA, et al. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2023 Jun. doi: 10.14309/ajg.0000000000002138.

8. Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology. 2020 Mar. doi: 10.1053/j.gastro.2019.09.052.

9. Dellon ES, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: Proceedings of the AGREE conference. Gastroenterology. 2018 Oct. doi: 10.1053/j.gastro.2018.07.009.

10. Dellon ES, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025 Jan. doi: 10.14309/ajg.0000000000003194.

11. Dellon ES. Optimizing the Endoscopic Examination in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2021 Dec. doi: 10.1016/j.cgh.2021.07.011.

12. Hirano I, et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2012 May. doi: 10.1136/gutjnl-2011-301817.

13. Spechler SJ, et al. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis. Am J Gastroenterol. 2007 Jun. doi: 10.1111/j.1572-0241.2007.01179.x.

14. Chang JW, et al. Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2023 Jul. doi: 10.1016/j.cgh.2023.03.006.

15. Hirano I, et al. Budesonide Oral Suspension Improves Outcomes in Patients With Eosinophilic Esophagitis: Results from a Phase 3 Trial. Clin Gastroenterol Hepatol. 2022 Mar. doi: 10.1016/j.cgh.2021.04.022.

16. Dellon ES, Gupta SK. A conceptual approach to understanding treatment response in eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2019 Oct. doi: 10.1016/j.cgh.2019.01.030.

17. von Arnim U, et al. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol. 2023 Sep. doi: 10.1016/j.cgh.2022.12.018.

18. Dellon ES, et al. Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med. 2022 Dec. doi: 10.1056/NEJMoa220598.

19. Dellon ES, et al. Rapid Recurrence of Eosinophilic Esophagitis Activity After Successful Treatment in the Observation Phase of a Randomized, Double-Blind, Double-Dummy Trial. Clin Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/j.cgh.2019.08.050.

20. Chang NC, et al. A Gap in Care Leads to Progression of Fibrosis in Eosinophilic Esophagitis Patients. Clin Gastroenterol Hepatol. 2022 Aug. doi: 10.1016/j.cgh.2021.10.028.

21. Syed A, et al. The relationship between eosinophilic esophagitis and esophageal cancer. Dis Esophagus. 2017 Jul. doi: 10.1093/dote/dox050.

22. Albaneze N, et al. No Association Between Eosinophilic Oesophagitis and Oesophageal Cancer in US Adults: A Case-Control Study. Aliment Pharmacol Ther. 2025 Jan. doi: 10.1111/apt.18431.







 

Eosinophilic esophagitis (EoE) can be considered a “young” disease, with initial case series reported only about 30 years ago. Since that time, it has become a commonly encountered condition in both emergency and clinic settings. The most recent prevalence study estimates that 1 in 700 people in the U.S. have EoE,¹ the volume of EoE-associated ED visits tripped between 2009 and 2019 and is projected to double again by 2030,² and “new” gastroenterologists undoubtedly have learned about and seen this condition. As a chronic disease, EoE necessitates longitudinal follow-up and optimization of care to prevent complications. With increasing diagnostic delay, EoE progresses in most, but not all, patients from an inflammatory- to fibrostenotic-predominant condition.³This article will review a practical approach to diagnosing EoE, including common scenarios where it can be picked-up, as well as treatment and monitoring approaches.

Diagnosis of EoE

The most likely area that you will encounter EoE is during an emergent middle-of-the-night endoscopy for food impaction. If called in for this, EoE will be the cause in more than 50% of patients.⁴ However, the diagnosis can only be made if esophageal biopsies are obtained at the time of the procedure. This is a critical time to decrease diagnostic delay, as half of patients are lost to follow-up after a food impaction.⁵ Unfortunately, although taking biopsies during index food impaction is guideline-recommended, a quality metric, and safe to obtain after the food bolus is cleared, this is infrequently done in practice.^{6, 7}

The next most likely area for EoE detection is in the endoscopy suite where 15-23% of patients with dysphagia and 5-7% of patients undergoing upper endoscopy for any indication will have EoE.⁴ Sometimes EoE will be detected “incidentally” during an open-access case (for example, in a patient with diarrhea undergoing evaluation for celiac). In these cases, it is important to perform a careful history (as noted below) as subtle EoE symptoms can frequently be identified. Finally, when patients are seen in clinic for solid food dysphagia, EoE is clearly on the differential. A few percent of patients with refractory heartburn or chest pain will have EoE causing the symptoms rather than reflux,⁴ and all patients under consideration for antireflux surgery should have an endoscopy to assess for EoE.

When talking to patients with known or suspected EoE, the history must go beyond general questions about dysphagia or trouble swallowing. Many patients with EoE have overtly or subconsciously modified their eating behaviors over many years to minimize symptoms, may have adapted to chronic dysphagia, and will answer “no” when asked if they have trouble swallowing. Instead, use the acronym “IMPACT” to delve deeper into possible symptoms.⁸ Do they “Imbibe” fluids or liquids between each bite to help get food down? Do they “Modify” the way they eat (cut food into small bites; puree foods)? Do they “Prolong” mealtimes? Do they “Avoid” certain foods that stick? Do they “Chew’ until their food is a mush to get it down? And do they “Turn away” tablets or pills? Pill dysphagia is often a subtle symptom, and sometimes the only symptom elicited.

Additionally, it may be important to ask a partner or family member (if present) about their observations. They may provide insight (e.g. “yes – he chokes with every bite but never says it bothers him”) that the patient might not otherwise provide. The suspicion for EoE should also be increased in patients with concomitant atopic diseases and in those with a family history of dysphagia or who have family members needing esophageal dilation. It is important to remember that EoE can be seen across all ages, sexes, and races/ethnicities.

Diagnosis of EoE is based on the AGREE consensus,⁹ which is also echoed in the recently updated American College of Gastroenterology (ACG) guidelines.¹⁰ Diagnosis requires three steps. First, symptoms of esophageal dysfunction must be present. This will most typically be dysphagia in adolescents and adults, but symptoms are non-specific in children (e.g. poor growth and feeding, abdominal pain, vomiting, regurgitation, heartburn).

Second, at least 15 eosinophils per high-power field (eos/hpf) are required on esophageal biopsy, which implies that an endoscopy be performed. A high-quality endoscopic exam in EoE is of the utmost importance. The approach has been described elsewhere,¹¹ but enough time on insertion should be taken to fully insufflate and examine the esophagus, including the areas of the gastroesophageal junction and upper esophageal sphincter where strictures can be missed, to gently wash debris, and to assess the endoscopic findings of EoE. Endoscopic findings should be reported using the validated EoE Endoscopy Reference Score (EREFS),¹² which grades five key features. EREFS is reproducible, is responsive to treatment, and is guideline-recommended (see Figure 1).^{6, 10} The features are edema (present=1), rings (mild=1; moderate=2; severe=3), exudates (mild=1; severe=2), furrows (mild=1; severe=2), and stricture (present=1; also estimate diameter in mm) and are incorporated into many endoscopic reporting programs. Additionally, diffuse luminal narrowing and mucosal fragility (“crepe-paper” mucosa) should be assessed.

After this, biopsies should be obtained with at least 6 biopsy fragments from different locations in the esophagus. Any visible endoscopic abnormalities should be targeted (the highest yield is in exudates and furrows). The rationale is that EoE is patchy and at least 6 biopsies will maximize diagnostic yield.¹⁰ Ideally the initial endoscopy for EoE should be done off of treatments (like PPI or diet restriction) as these could mask the diagnosis. If a patient with suspected EoE has an endoscopy while on PPI, and the endoscopy is normal, a diagnosis of EoE cannot be made. In this case, consideration should be given as to stopping the PPI, allowing a wash out period (at least 1-2 months), and then repeating the endoscopy to confirm the diagnosis. This is important as EoE is a chronic condition necessitating life-long treatment and monitoring, so a definitive diagnosis is critical.

The third and final step in diagnosis is assessing for other conditions that could cause esophageal eosinophilia.⁹ The most common differential diagnosis is gastroesophageal reflux disease (GERD). In some cases, EoE and GERD overlap or can have a complex relationship.¹³ Unfortunately the location of the eosinophilia (i.e. distal only) and the level of the eosinophil counts are not useful in making this distinction, so all clinical features (symptoms, presence of erosive esophagitis, or a hiatal hernia endoscopically), and ancillary reflex testing when indicated may be required prior to a formal EoE diagnosis. After the diagnosis is established, there should be direct communication with the patient to review the diagnosis and select treatments. While it is possible to convey results electronically in a messaging portal or with a letter, a more formal interaction, such as a clinic visit, is recommended because this is a new diagnosis of a chronic condition. Similarly, a new diagnosis of inflammatory bowel disease would never be made in a pathology follow-up letter alone. 

 

Treatment of EoE

When it comes to treatment, the new guidelines emphasize several points.¹⁰ First, there is the concept that anti-inflammatory treatment should be paired with assessment of fibrostenosis and esophageal dilation; to do either in isolation is incomplete treatment. It is safe to perform dilation both prior to anti-inflammatory treatment (for example, with a critical stricture in a patient with dysphagia) and after anti-inflammatory treatment has been prescribed (for example, during an endoscopy to assess treatment response).

Second, proton pump inhibitors (PPIs), swallowed topical corticosteroids (tCS), or dietary elimination are all acceptable first-line treatment options for EoE. A shared decision-making framework should be used for this discussion. If dietary elimination is selected,¹⁴ based on new clinical trial data, guidelines recommend using empiric elimination and starting with a less restrictive diet (either a one-food elimination diet with dairy alone or a two-food elimination with dairy and wheat elimination). If PPIs are selected, the dose should be double the standard reflux dose. Data are mixed as to whether to use twice daily dosing (i.e., omeprazole 20 mg twice daily) or once a day dosing (i.e., omeprazole 40 mg daily), but total dose and adherence may be more important than frequency.¹⁰

For tCS use, either budesonide or fluticasone can be selected, but budesonide oral suspension is the only FDA-approved tCS for EoE.¹⁵ Initial treatment length is usually 6-8 weeks for diet elimination and, 12 weeks for PPI and tCS. In general, it is best to pick a single treatment to start, and reserve combining therapies for patients who do not have a complete response to a single modality as there are few data to support combination therapy.

After initial treatment, it is critical to assess for treatment response.¹⁶ Goals of EoE treatment include improvement in symptoms, but also improvement in endoscopic and histologic features to prevent complications. Symptoms in EoE do not always correlate with underlying biologic disease activity: patients can minimize symptoms with careful eating; they may perceive no difference in symptoms despite histologic improvement if a stricture persists; and they may have minimal symptoms after esophageal dilation despite ongoing inflammation. Because of this, performing a follow-up endoscopy after initial treatment is guideline-recommended.^{10, 17} This allows assessing for endoscopic improvement, re-assessing for fibrostenosis and performing dilation if indicated, and obtaining esophageal biopsies. If there is non-response, options include switching between other first line treatments or considering “stepping-up” to dupilumab which is also an FDA-approved option for EoE that is recommended in the guidelines.^{10, 18} In some cases where patients have multiple severe atopic conditions such as asthma or eczema that would warrant dupilumab use, or if patients are intolerant to PPIs or tCS, dupilumab could be considered as an earlier treatment for EoE.

 

Long-Term Maintenance

If a patient has a good response (for example, improved symptoms, improved endoscopic features, and <15 eos/hpf on biopsy), treatment can be maintained long-term. In almost all cases, if treatment is stopped, EoE disease activity recurs.¹⁹ Patients could be seen back in clinic in 6-12 months, and then a discussion can be conducted about a follow-up endoscopy, with timing to be determined based on their individual disease features and severity.¹⁷

Patients with more severe strictures, however, may have to be seen in endoscopy for serial dilations. Continued follow-up is essential for optimal care. Just as patients can progress in their disease course with diagnostic delay, there are data that show they can also progress after diagnosis when there are gaps in care without regular follow-up.²⁰ Unlike other chronic esophageal disorders such as GERD and Barrett’s esophagus and other chronic GI inflammatory conditions like inflammatory bowel disease, however, EoE is not associated with an increased risk of esophageal cancer.^{21, 22}

Given its increasing frequency, EoE will be commonly encountered by gastroenterologists both new and established. Having a systematic approach for diagnosis, understanding how to elicit subtle symptoms, implementing a shared decision-making framework for treatment with a structured algorithm for assessing response, performing follow-up, maintaining treatment, and monitoring patients long-term will allow the large majority of EoE patients to be successfully managed.

Dr. Dellon is based at the Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill. He disclosed research funding, consultant fees, and educational grants from multiple companies.

References

1. Thel HL, et al. Prevalence and Costs of Eosinophilic Esophagitis in the United States. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.09.031.

2. Lam AY, et al. Epidemiologic Burden and Projections for Eosinophilic Esophagitis-Associated Emergency Department Visits in the United States: 2009-2030. Clin Gastroenterol Hepatol. 2023 Nov. doi: 10.1016/j.cgh.2023.04.028.

3. Schoepfer AM, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013 Dec. doi: 10.1053/j.gastro.2013.08.015.

4. Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology. 2018 Jan. doi: 10.1053/j.gastro.2017.06.067.

5. Chang JW, et al. Loss to follow-up after food impaction among patients with and without eosinophilic esophagitis. Dis Esophagus. 2019 Dec. doi: 10.1093/dote/doz056.

6. Aceves SS, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc. 2022 Aug. doi: 10.1016/j.gie.2022.05.013.

7. Leiman DA, et al. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2023 Jun. doi: 10.14309/ajg.0000000000002138.

8. Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology. 2020 Mar. doi: 10.1053/j.gastro.2019.09.052.

9. Dellon ES, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: Proceedings of the AGREE conference. Gastroenterology. 2018 Oct. doi: 10.1053/j.gastro.2018.07.009.

10. Dellon ES, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025 Jan. doi: 10.14309/ajg.0000000000003194.

11. Dellon ES. Optimizing the Endoscopic Examination in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2021 Dec. doi: 10.1016/j.cgh.2021.07.011.

12. Hirano I, et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2012 May. doi: 10.1136/gutjnl-2011-301817.

13. Spechler SJ, et al. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis. Am J Gastroenterol. 2007 Jun. doi: 10.1111/j.1572-0241.2007.01179.x.

14. Chang JW, et al. Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2023 Jul. doi: 10.1016/j.cgh.2023.03.006.

15. Hirano I, et al. Budesonide Oral Suspension Improves Outcomes in Patients With Eosinophilic Esophagitis: Results from a Phase 3 Trial. Clin Gastroenterol Hepatol. 2022 Mar. doi: 10.1016/j.cgh.2021.04.022.

16. Dellon ES, Gupta SK. A conceptual approach to understanding treatment response in eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2019 Oct. doi: 10.1016/j.cgh.2019.01.030.

17. von Arnim U, et al. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol. 2023 Sep. doi: 10.1016/j.cgh.2022.12.018.

18. Dellon ES, et al. Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med. 2022 Dec. doi: 10.1056/NEJMoa220598.

19. Dellon ES, et al. Rapid Recurrence of Eosinophilic Esophagitis Activity After Successful Treatment in the Observation Phase of a Randomized, Double-Blind, Double-Dummy Trial. Clin Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/j.cgh.2019.08.050.

20. Chang NC, et al. A Gap in Care Leads to Progression of Fibrosis in Eosinophilic Esophagitis Patients. Clin Gastroenterol Hepatol. 2022 Aug. doi: 10.1016/j.cgh.2021.10.028.

21. Syed A, et al. The relationship between eosinophilic esophagitis and esophageal cancer. Dis Esophagus. 2017 Jul. doi: 10.1093/dote/dox050.

22. Albaneze N, et al. No Association Between Eosinophilic Oesophagitis and Oesophageal Cancer in US Adults: A Case-Control Study. Aliment Pharmacol Ther. 2025 Jan. doi: 10.1111/apt.18431.







 

Eosinophilic esophagitis (EoE) can be considered a “young” disease, with initial case series reported only about 30 years ago. Since that time, it has become a commonly encountered condition in both emergency and clinic settings. The most recent prevalence study estimates that 1 in 700 people in the U.S. have EoE,¹ the volume of EoE-associated ED visits tripped between 2009 and 2019 and is projected to double again by 2030,² and “new” gastroenterologists undoubtedly have learned about and seen this condition. As a chronic disease, EoE necessitates longitudinal follow-up and optimization of care to prevent complications. With increasing diagnostic delay, EoE progresses in most, but not all, patients from an inflammatory- to fibrostenotic-predominant condition.³This article will review a practical approach to diagnosing EoE, including common scenarios where it can be picked-up, as well as treatment and monitoring approaches.

Diagnosis of EoE

The most likely area that you will encounter EoE is during an emergent middle-of-the-night endoscopy for food impaction. If called in for this, EoE will be the cause in more than 50% of patients.⁴ However, the diagnosis can only be made if esophageal biopsies are obtained at the time of the procedure. This is a critical time to decrease diagnostic delay, as half of patients are lost to follow-up after a food impaction.⁵ Unfortunately, although taking biopsies during index food impaction is guideline-recommended, a quality metric, and safe to obtain after the food bolus is cleared, this is infrequently done in practice.^{6, 7}

The next most likely area for EoE detection is in the endoscopy suite where 15-23% of patients with dysphagia and 5-7% of patients undergoing upper endoscopy for any indication will have EoE.⁴ Sometimes EoE will be detected “incidentally” during an open-access case (for example, in a patient with diarrhea undergoing evaluation for celiac). In these cases, it is important to perform a careful history (as noted below) as subtle EoE symptoms can frequently be identified. Finally, when patients are seen in clinic for solid food dysphagia, EoE is clearly on the differential. A few percent of patients with refractory heartburn or chest pain will have EoE causing the symptoms rather than reflux,⁴ and all patients under consideration for antireflux surgery should have an endoscopy to assess for EoE.

When talking to patients with known or suspected EoE, the history must go beyond general questions about dysphagia or trouble swallowing. Many patients with EoE have overtly or subconsciously modified their eating behaviors over many years to minimize symptoms, may have adapted to chronic dysphagia, and will answer “no” when asked if they have trouble swallowing. Instead, use the acronym “IMPACT” to delve deeper into possible symptoms.⁸ Do they “Imbibe” fluids or liquids between each bite to help get food down? Do they “Modify” the way they eat (cut food into small bites; puree foods)? Do they “Prolong” mealtimes? Do they “Avoid” certain foods that stick? Do they “Chew’ until their food is a mush to get it down? And do they “Turn away” tablets or pills? Pill dysphagia is often a subtle symptom, and sometimes the only symptom elicited.

Additionally, it may be important to ask a partner or family member (if present) about their observations. They may provide insight (e.g. “yes – he chokes with every bite but never says it bothers him”) that the patient might not otherwise provide. The suspicion for EoE should also be increased in patients with concomitant atopic diseases and in those with a family history of dysphagia or who have family members needing esophageal dilation. It is important to remember that EoE can be seen across all ages, sexes, and races/ethnicities.

Diagnosis of EoE is based on the AGREE consensus,⁹ which is also echoed in the recently updated American College of Gastroenterology (ACG) guidelines.¹⁰ Diagnosis requires three steps. First, symptoms of esophageal dysfunction must be present. This will most typically be dysphagia in adolescents and adults, but symptoms are non-specific in children (e.g. poor growth and feeding, abdominal pain, vomiting, regurgitation, heartburn).

Second, at least 15 eosinophils per high-power field (eos/hpf) are required on esophageal biopsy, which implies that an endoscopy be performed. A high-quality endoscopic exam in EoE is of the utmost importance. The approach has been described elsewhere,¹¹ but enough time on insertion should be taken to fully insufflate and examine the esophagus, including the areas of the gastroesophageal junction and upper esophageal sphincter where strictures can be missed, to gently wash debris, and to assess the endoscopic findings of EoE. Endoscopic findings should be reported using the validated EoE Endoscopy Reference Score (EREFS),¹² which grades five key features. EREFS is reproducible, is responsive to treatment, and is guideline-recommended (see Figure 1).^{6, 10} The features are edema (present=1), rings (mild=1; moderate=2; severe=3), exudates (mild=1; severe=2), furrows (mild=1; severe=2), and stricture (present=1; also estimate diameter in mm) and are incorporated into many endoscopic reporting programs. Additionally, diffuse luminal narrowing and mucosal fragility (“crepe-paper” mucosa) should be assessed.

After this, biopsies should be obtained with at least 6 biopsy fragments from different locations in the esophagus. Any visible endoscopic abnormalities should be targeted (the highest yield is in exudates and furrows). The rationale is that EoE is patchy and at least 6 biopsies will maximize diagnostic yield.¹⁰ Ideally the initial endoscopy for EoE should be done off of treatments (like PPI or diet restriction) as these could mask the diagnosis. If a patient with suspected EoE has an endoscopy while on PPI, and the endoscopy is normal, a diagnosis of EoE cannot be made. In this case, consideration should be given as to stopping the PPI, allowing a wash out period (at least 1-2 months), and then repeating the endoscopy to confirm the diagnosis. This is important as EoE is a chronic condition necessitating life-long treatment and monitoring, so a definitive diagnosis is critical.

The third and final step in diagnosis is assessing for other conditions that could cause esophageal eosinophilia.⁹ The most common differential diagnosis is gastroesophageal reflux disease (GERD). In some cases, EoE and GERD overlap or can have a complex relationship.¹³ Unfortunately the location of the eosinophilia (i.e. distal only) and the level of the eosinophil counts are not useful in making this distinction, so all clinical features (symptoms, presence of erosive esophagitis, or a hiatal hernia endoscopically), and ancillary reflex testing when indicated may be required prior to a formal EoE diagnosis. After the diagnosis is established, there should be direct communication with the patient to review the diagnosis and select treatments. While it is possible to convey results electronically in a messaging portal or with a letter, a more formal interaction, such as a clinic visit, is recommended because this is a new diagnosis of a chronic condition. Similarly, a new diagnosis of inflammatory bowel disease would never be made in a pathology follow-up letter alone. 

 

Treatment of EoE

When it comes to treatment, the new guidelines emphasize several points.¹⁰ First, there is the concept that anti-inflammatory treatment should be paired with assessment of fibrostenosis and esophageal dilation; to do either in isolation is incomplete treatment. It is safe to perform dilation both prior to anti-inflammatory treatment (for example, with a critical stricture in a patient with dysphagia) and after anti-inflammatory treatment has been prescribed (for example, during an endoscopy to assess treatment response).

Second, proton pump inhibitors (PPIs), swallowed topical corticosteroids (tCS), or dietary elimination are all acceptable first-line treatment options for EoE. A shared decision-making framework should be used for this discussion. If dietary elimination is selected,¹⁴ based on new clinical trial data, guidelines recommend using empiric elimination and starting with a less restrictive diet (either a one-food elimination diet with dairy alone or a two-food elimination with dairy and wheat elimination). If PPIs are selected, the dose should be double the standard reflux dose. Data are mixed as to whether to use twice daily dosing (i.e., omeprazole 20 mg twice daily) or once a day dosing (i.e., omeprazole 40 mg daily), but total dose and adherence may be more important than frequency.¹⁰

For tCS use, either budesonide or fluticasone can be selected, but budesonide oral suspension is the only FDA-approved tCS for EoE.¹⁵ Initial treatment length is usually 6-8 weeks for diet elimination and, 12 weeks for PPI and tCS. In general, it is best to pick a single treatment to start, and reserve combining therapies for patients who do not have a complete response to a single modality as there are few data to support combination therapy.

After initial treatment, it is critical to assess for treatment response.¹⁶ Goals of EoE treatment include improvement in symptoms, but also improvement in endoscopic and histologic features to prevent complications. Symptoms in EoE do not always correlate with underlying biologic disease activity: patients can minimize symptoms with careful eating; they may perceive no difference in symptoms despite histologic improvement if a stricture persists; and they may have minimal symptoms after esophageal dilation despite ongoing inflammation. Because of this, performing a follow-up endoscopy after initial treatment is guideline-recommended.^{10, 17} This allows assessing for endoscopic improvement, re-assessing for fibrostenosis and performing dilation if indicated, and obtaining esophageal biopsies. If there is non-response, options include switching between other first line treatments or considering “stepping-up” to dupilumab which is also an FDA-approved option for EoE that is recommended in the guidelines.^{10, 18} In some cases where patients have multiple severe atopic conditions such as asthma or eczema that would warrant dupilumab use, or if patients are intolerant to PPIs or tCS, dupilumab could be considered as an earlier treatment for EoE.

 

Long-Term Maintenance

If a patient has a good response (for example, improved symptoms, improved endoscopic features, and <15 eos/hpf on biopsy), treatment can be maintained long-term. In almost all cases, if treatment is stopped, EoE disease activity recurs.¹⁹ Patients could be seen back in clinic in 6-12 months, and then a discussion can be conducted about a follow-up endoscopy, with timing to be determined based on their individual disease features and severity.¹⁷

Patients with more severe strictures, however, may have to be seen in endoscopy for serial dilations. Continued follow-up is essential for optimal care. Just as patients can progress in their disease course with diagnostic delay, there are data that show they can also progress after diagnosis when there are gaps in care without regular follow-up.²⁰ Unlike other chronic esophageal disorders such as GERD and Barrett’s esophagus and other chronic GI inflammatory conditions like inflammatory bowel disease, however, EoE is not associated with an increased risk of esophageal cancer.^{21, 22}

Given its increasing frequency, EoE will be commonly encountered by gastroenterologists both new and established. Having a systematic approach for diagnosis, understanding how to elicit subtle symptoms, implementing a shared decision-making framework for treatment with a structured algorithm for assessing response, performing follow-up, maintaining treatment, and monitoring patients long-term will allow the large majority of EoE patients to be successfully managed.

Dr. Dellon is based at the Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill. He disclosed research funding, consultant fees, and educational grants from multiple companies.

References

1. Thel HL, et al. Prevalence and Costs of Eosinophilic Esophagitis in the United States. Clin Gastroenterol Hepatol. 2025 Feb. doi: 10.1016/j.cgh.2024.09.031.

2. Lam AY, et al. Epidemiologic Burden and Projections for Eosinophilic Esophagitis-Associated Emergency Department Visits in the United States: 2009-2030. Clin Gastroenterol Hepatol. 2023 Nov. doi: 10.1016/j.cgh.2023.04.028.

3. Schoepfer AM, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013 Dec. doi: 10.1053/j.gastro.2013.08.015.

4. Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology. 2018 Jan. doi: 10.1053/j.gastro.2017.06.067.

5. Chang JW, et al. Loss to follow-up after food impaction among patients with and without eosinophilic esophagitis. Dis Esophagus. 2019 Dec. doi: 10.1093/dote/doz056.

6. Aceves SS, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc. 2022 Aug. doi: 10.1016/j.gie.2022.05.013.

7. Leiman DA, et al. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2023 Jun. doi: 10.14309/ajg.0000000000002138.

8. Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology. 2020 Mar. doi: 10.1053/j.gastro.2019.09.052.

9. Dellon ES, et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: Proceedings of the AGREE conference. Gastroenterology. 2018 Oct. doi: 10.1053/j.gastro.2018.07.009.

10. Dellon ES, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025 Jan. doi: 10.14309/ajg.0000000000003194.

11. Dellon ES. Optimizing the Endoscopic Examination in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2021 Dec. doi: 10.1016/j.cgh.2021.07.011.

12. Hirano I, et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2012 May. doi: 10.1136/gutjnl-2011-301817.

13. Spechler SJ, et al. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis. Am J Gastroenterol. 2007 Jun. doi: 10.1111/j.1572-0241.2007.01179.x.

14. Chang JW, et al. Development of a Practical Guide to Implement and Monitor Diet Therapy for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2023 Jul. doi: 10.1016/j.cgh.2023.03.006.

15. Hirano I, et al. Budesonide Oral Suspension Improves Outcomes in Patients With Eosinophilic Esophagitis: Results from a Phase 3 Trial. Clin Gastroenterol Hepatol. 2022 Mar. doi: 10.1016/j.cgh.2021.04.022.

16. Dellon ES, Gupta SK. A conceptual approach to understanding treatment response in eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2019 Oct. doi: 10.1016/j.cgh.2019.01.030.

17. von Arnim U, et al. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol. 2023 Sep. doi: 10.1016/j.cgh.2022.12.018.

18. Dellon ES, et al. Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med. 2022 Dec. doi: 10.1056/NEJMoa220598.

19. Dellon ES, et al. Rapid Recurrence of Eosinophilic Esophagitis Activity After Successful Treatment in the Observation Phase of a Randomized, Double-Blind, Double-Dummy Trial. Clin Gastroenterol Hepatol. 2020 Jun. doi: 10.1016/j.cgh.2019.08.050.

20. Chang NC, et al. A Gap in Care Leads to Progression of Fibrosis in Eosinophilic Esophagitis Patients. Clin Gastroenterol Hepatol. 2022 Aug. doi: 10.1016/j.cgh.2021.10.028.

21. Syed A, et al. The relationship between eosinophilic esophagitis and esophageal cancer. Dis Esophagus. 2017 Jul. doi: 10.1093/dote/dox050.

22. Albaneze N, et al. No Association Between Eosinophilic Oesophagitis and Oesophageal Cancer in US Adults: A Case-Control Study. Aliment Pharmacol Ther. 2025 Jan. doi: 10.1111/apt.18431.







 

In this video, Lisa Mathew, MD, of South Denver Gastroenterology in Denver, Colorado, and Raja Taunk, MD, of Anne Arundel Gastroenterology Associates, in Annapolis, Maryland, share insights on private practice gastroenterology and offer tips on building your practice – specifically improving your referral base.

In this video, Lisa Mathew, MD, of South Denver Gastroenterology in Denver, Colorado, and Raja Taunk, MD, of Anne Arundel Gastroenterology Associates, in Annapolis, Maryland, share insights on private practice gastroenterology and offer tips on building your practice – specifically improving your referral base.

In this video, Lisa Mathew, MD, of South Denver Gastroenterology in Denver, Colorado, and Raja Taunk, MD, of Anne Arundel Gastroenterology Associates, in Annapolis, Maryland, share insights on private practice gastroenterology and offer tips on building your practice – specifically improving your referral base.